Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial.

Importance: The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population. Objective: To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice. Design, Setting, and Participants: Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015. Interventions: Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants). Main Outcomes and Measures: The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months. Results: One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly different between groups. Conclusions and Relevance: Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU. Trial Registration: clinicaltrials.gov Identifier: NCT01508819.

[Evaluation of a new information tool in an Emergency Department] / Évaluation d'un nouvel outil d'information dans un service d'Urgence.

Aims : emergency Departments represent unique and complex entities that must be understood by the public. Objectives : to increase, by setting up screens, the number of information integrated by the patients during their waiting before medical care. Method : Cohort, before/after implementation of information screens, prospective, evaluative, monocentric study. Patients were interviewed on the location of the hospital, the organization of the Emergency Department, their legal rights. The primary endpoint was the quality of the information received by the patient from arrival until the beginning of medical care. Distributions of the responses were compared between groups using Wilcoxon and Fisher tests. All tests were performed bilaterally at alpha risk of 5 %. Results : 267 questionnaires have been collected ; 128 in the first period, 139 in the second one. The main endpoint was statistically significant (p = 0,049). Knowledge of the type of hosted population (40 % vs 23 %), the notion of property of the medical record (83 % vs 53 %), the identification of the staff (46 % vs 18 %) was significantly increased by watching the screens. Conclusion : this study showed that the screens had a positive impact on the information to the patients and accompanying persons.

[Proposal of HIV, HBV and HCV targeted screening: short period feasibility study in a free-access outpatient medical structure]. / Faisabilité du dépistage ciblé VIH, VHB, VHC dans une structure de soins ambulatoires avec un système de permanence d'accès aux soins de santé intégré

OBJECTIVES: In France, patients coming from sub-Saharan Africa, French Indies and French Guiana are frequently missed HIV, HBV and HCV diagnosis, despite high prevalence of these infections. METHODS: Targeted proposal of HIV, HBV and HCV screening, using sensitive enzyme immunoassays, to any adult patient originating of the above mentioned areas, with/without medical insurance, consulting for a medical issue in outpatients' department. Monocentric prospective study in a hospital in Paris during 28 consecutive days in 2010. RESULTS: Among the 272 eligible patients, 166 were tested (patients' acceptance: 61%). 180/272 (66%) alleged being tested previously for HIV, women (66/87, 76%) more frequently than men (114/185, 62%), P=0.02. Patients' acceptance seemed higher in patients mentioning no previous test than in patients reporting previous test. Among the patients who refused being tested, reporting a previous negative HIV test, more than a quarter has been tested more than 1 year ago. Among the 166 tested patients, 120 (72%) came back to get their results, men (89/113, 79%) more frequently than women (31/53, 58.5%), P=0.009; recently metropolitan patients more frequently than longer metropolitan patients, P=0.01; patients without any job more frequently than patients with a job, P=0.01. Three (1.8%) HIV tests returned positive; HBsAg was positive in 13 (7.8%) patients; 54 patients (32.7%) had a negative hepatitis B screening (anti-HBcAb+HBsAg+anti-HBsAb), attesting to sensitivity to this infection, only 18 patients (10.9%) showed isolated anti-HBsAb at protective levels. Eighty-one patients (49.1%) exhibited anti-HBcAb, confirming the high prevalence of HBV infection in the areas the patients came from. Six patients (3.6%) had anti-HCVAb. There was no co-infection. CONCLUSION: Targeted HIV, HBV and HCV screening to patients coming from high prevalence areas in outpatients' department appears a very cost-effective strategy.