Organizational innovation under constraints: The case of covid patients' flow management in Parisian hospitals.

The COVID crisis has put hospitals under great stress over the past 2 years and some institutions came close to their breaking points. This has often forced decision makers and the entire institutions to change their practices and the organization of the hospitals in order to continue operating despite limited resources. It has also led some hospitals to develop and implement organizational innovations. This article is based on a qualitative case study analyzing the case of a crisis unit that has implemented various innovative medical and organizational actions in order to manage the flow of resuscitation Covid patients in a large group of hospitals in Paris. This team has implemented a new evaluation scale of resuscitation needs in order to better manage quantitatively and qualitatively the patients' flow; it has defined medical criteria to select the patients eligible for transfer; it has organized one hundred patients transfers to other hospitals' intensive care units, in and out of the region, involving private hospitals and private ambulances for a new collaboration. The case allows us to understand innovation in the midst of an extreme situation, when material and human resources are highly constrained, and with very strong time pressure. We highlight the importance of implementing flexible organizational processes and staffing the crisis team with physicians and nurses with specific and complementary skills and experience in flow management and crisis situations.

[Dealing with the bleeding patient, being effective with (almost) nothing]. / Face au patient hémorragique, être efficace avec (quasiment) rien.

The practice of pre-hospital care, whether you are a professional rescuer, a nurse, a doctor or a simple citizen, sometimes exposes you to the management of a patient who presents an acute hemorrhage. The prognosis is quickly life-threatening if the safety, assessment, life-saving gestures and activation of the rescue chain are not carried out. A basic, inexpensive first aid kit can further reduce morbidity and mortality. Training first responders in life-saving techniques is a public health issue.

Terror in Paris: Incidence and risk factors for infections related to high-energy ammunition injuries.

BACKGROUND: We aimed to assess the incidence and the risk factors for secondary wound infections associated to high-energy ammunition injuries (HEAI) in the cohort of civilian casualties from the 2015 terrorist attacks in Paris. METHODS: This retrospective multi-centric study included casualties presenting at least one HEAI who underwent surgery during the first 48 h following hospital admission. HEAI-associated infection was defined as a wound infection occurring within the initial 30 days following trauma. Risk factors were assessed using univariate and multivariate analysis. RESULTS: Among the 200 included victims, the rate of infected wounds was 11.5%. The median time between admission and the surgical revision for secondary wound infection was 11 days [IQR 9-20]. No patient died from an infectious cause. Infections were polymicrobial in 44% of the cases. The major risk factors for secondary wound infection were ISS (p < 0.001), SAPS II (p < 0.001), MGAP (p < 0.001), haemorrhagic shock (p = 0.003), use of vasopressors (p < 0.001), blood transfusion (p < 0.001), abdominal penetrating trauma (p = 0.003), open fracture (p = 0.01), vascular injury (p = 0.001), duration of surgery (p = 0.009), presence of surgical material (p = 0.01). In the multivariate analysis, the SAPS II score (OR 1.07 [1.014-1.182], p = 0.019) and the duration of surgery (OR 1.005 [1.000-1.012], p = 0.041) were the only risk factors identified. CONCLUSION: We report an 11.5% rate of secondary wound infection following high-energy ammunition injuries. Risk factors were an immediately severe condition and a prolonged surgery.

Assessment of the mass casualty triage during the November 2015 Paris area terrorist attacks: towards a simple triage rule.

BACKROUND: Triage is key in the management of mass casualty incidents. OBJECTIVE: The objective of this study was to assess the prehospital triage performed during the 2015 Paris area terrorist attack. DESIGN SETTING AND PARTICIPANT: This was a retrospective cohort study that included all casualties of the attacks on 13 November 2015 in Paris area, France, that were admitted alive at the hospital within the first 24 h after the events. Patients were triaged as absolute emergency or relative emergency by a prehospital physician or nurse. This triage was then compared to the one of an expert panel that had retrospectively access to all prehospital and hospital files. OUTCOMES MEASURES AND ANALYSIS: The primary endpoints were the rate of overtriage and undertriage, defined as number of patients misclassified in one triage category, divided by the total number of patients in this triage category. MAIN RESULT: Among 337 casualties admitted to the hospital, 262 (78%) were triaged during prehospital care, with, respectively, 74 (28%) and 188 (72%) as absolute and relative emergencies. Among these casualties, the expert panel classified 96 (37%) patients as absolute emergencies and 166 (63%) as relative emergency. The rate of undertriage and overtriage was 36% [95% confidence interval (CI), 27-47%] and 8% (95% CI, 4-13%), respectively. Among undertriaged casualties, 8 (23%) were considered as being severely undertriaged. Among overtriaged casualties, 10 (77%) were considered as being severely overtriaged. CONCLUSION: A simple prehospital triage for trauma casualties during the 13 November terrorist attack in Paris could have been performed triaged in 78% of casualties that were admitted to the hospital, with a 36% rate of undertriage and 8% of overtriage. Qualitative analysis of undertriage and overtriage indicate some possibilities for further improvement.

Blood product needs and transfusion timelines for the multisite massive Paris 2015 terrorist attack: A retrospective analysis.

OBJECTIVE: Hemorrhage is the leading cause of death after terrorist attack, and the immediacy of labile blood product (LBP) administration has a decisive impact on patients' outcome. The main objective of this study was to evaluate the transfusion patterns of the Paris terrorist attack victims, November 13, 2015. METHODS: We performed a retrospective analysis including all casualties admitted to hospital, aiming to describe the transfusion patterns from admission to the first week after the attack. RESULTS: Sixty-eight of 337 admitted patients were transfused. More than three quarters of blood products were consumed in the initial phase (until November 14, 11:59 PM), where 282 packed red blood cell (pRBC) units were transfused along with 201 plasma and 25 platelet units, to 55 patients (16% of casualties). Almost 40% of these LBPs (134 pRBC, 73 plasma, 8 platelet units) were transfused within the first 6 hours after the attack. These early transfusions were massive transfusion (MT) for 20 (6%) of 337 patients, and the average plasma/red blood cell ratio was 0.8 for MT patients who received 366 (72%) of 508 LBPs.The median time from admission to pRBC transfusion was 57 (25-108) minutes and 208 (52-430) minutes for MT and non-MT patients, respectively. These same time intervals were 119 (66-202) minutes and 222 (87-381) minutes for plasma and 225 (131-289) minutes and 198 (167-230) minutes for platelets. CONCLUSION: Our data suggest that improving transfusion procedures in mass casualty setting should rely more on shortening the time to bring LBP to the bedside than in increasing the stockpile. LEVEL OF EVIDENCE: Epidemiological study, Therapeutic IV.

Analysis of the medical response to November 2015 Paris terrorist attacks: resource utilization according to the cause of injury.

PURPOSE: The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma. METHODS: This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24 h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds. RESULTS: 337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [n = 107 (57%); median 744 min]; general [n = 27 (15%); 90 min]; vascular [n = 19 (10%); median 53 min]; thoracic [n = 19 (10%); 646 min]; and neurosurgery [n = 4 (2%); 198 min]. CONCLUSION: The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack. FUNDING: Assistance Publique-Hôpitaux de Paris.