Anne-Laure Philippon

Mid-regional pro-adrenomedullin and copeptin to predict short-term prognosis of COPD exacerbations: a multicenter prospective blinded study

Background Exacerbations of COPD (ECOPD) are a frequent cause of emergency room (ER) visits. Predictors of early outcome could help clinicians in orientation decisions. In the current study, we investigated whether mid-regional pro-adrenomedullin (MR-proADM) and copeptin, in addition to clinical evaluation, could predict short-term outcomes. Patients and methods This prospective blinded observational study was conducted in 20 French centers. Patients admitted to the ER for an ECOPD were considered for inclusion. A clinical risk score was calculated, and MR-proADM and copeptin levels were determined from a venous blood sample. The composite primary end point comprised 30-day death or transfer to the intensive care unit or a new ER visit. Results A total of 379 patients were enrolled in the study, of whom 277 were eventually investigated for the primary end point that occurred in 66 (24%) patients. In those patients, the median (interquartile range [IQR]) MR-proADM level was 1.02 nmol/L (0.77–1.48) versus 0.83 nmol/L (0.63–1.07) in patients who did not meet the primary end point (P=0.0009). In contrast, copeptin levels were similar in patients who met or did not meet the primary end point (P=0.23). MR-proADM levels increased with increasing clinical risk score category: 0.74 nmol/L (0.57–0.89), 0.83 nmol/L (0.62–1.12) and 0.95 nmol/L (0.75–1.29) for the low-, intermediate- and high-risk categories, respectively (P<0.001). MR-proADM was independently associated with the primary end point (odds ratio, 1.65; 95% confidence interval [CI], 1.10–2.48; P=0.015). MR-proADM predicted the occurrence of primary end point with a sensitivity of 46% (95% CI, 33%–58%) and a specificity of 79% (95% CI, 74–84). Conclusion MR-proADM but not copeptin was significantly associated with outcomes at 30 days, even after adjustment for clinical risk category. Overall, MR-proADM, alone or combined with the clinical risk score, was a moderate strong predictor of short-term outcomes.

Effect of Systematic Physician Cross-checking on Reducing Adverse Events in the Emergency Department: The CHARMED Cluster Randomized Trial

Importance Emergency departments (ED) are environments that are at high risk for medical errors. Previous studies suggested that the proportion of medical errors may decrease when more than 1 physician is involved. Objective To reduce the proportion of medical errors by implementing systematic cross-checking between emergency physicians. Design, Setting, and Participants This cluster randomized crossover trial includes a random sample of 14 adult patients (age ≥18 years) per day during two 10-day period in 6 EDs (n = 1680 patients) in France. Interventions Systematic cross-checking between emergency physicians, 3 times a day, which included a brief presentation of one physician’s case to another, followed by the second physician’s feedback to the first. Main Outcomes and Measures Medical error in the ED, defined as an adverse event (either a near miss or a serious adverse event). The primary end point was identified using a 2-level error detection surveillance system, blinded to the strategy allocation. Results Among the 1680 included patients (mean [SD] age, 57.5 [21.7] years), 144 (8.6%) had an adverse event. There were 54 adverse events among 840 patients (6.4%) in the cross-check group compared with 90 adverse events among 840 patients (10.7%) in the standard care group (relative risk reduction [RRR], 40% [95% CI, 12% to 59%]; absolute risk reduction [ARR], 4.3%; number needed to treat [NNT], 24). There was also a significant reduction rate of near misses (RRR, 47% [95% CI, 15% to 67%]; ARR, 2.7%; NNT, 37) but not of the rate of preventable serious adverse events (RRR, 29% [95% CI, −18% to 57%]; ARR, 1.2%; NNT, 83). Conclusions and Relevance The implementation of systematic cross-checking between emergency physicians was associated with a significant reduction in adverse events, mainly driven by a reduction in near misses. Trial Registration ClinicalTrials.gov Identifier: NCT02356926

Effect of emergency physician burnout on patient waiting times

Burnout is common in emergency physicians. This syndrome may negatively affect patient care and alter work productivity. We seek to assess whether burnout of emergency physicians impacts waiting times in the emergency department. Prospective study in an academic ED. All patients who visited the main ED for a 4-month period in 2016 were included. Target waiting times are assigned by triage nurse to patients on arrival depending on their severity. The primary endpoint was an exceeded target waiting time for ED patients. All emergency physicians were surveyed by a psychologist to assess their level of burnout using the Maslach Burnout Inventory. We defined the level of burnout of the day in the ED as the mean burnout level of the physicians working that day (8:30 to the 8:30 the next day). A logistic regression model was performed to assess whether burnout level of the day was independently associated with prolonged waiting times, along with previously reported predictors. Target waiting time was exceeded in 7524 patients (59%). Twenty-six emergency physicians were surveyed. Median burnout score was 35 [Interquartile (24–49)]. A burnout level of the day higher than 35 was independently associated with an exceeded target waiting time (adjusted odds ratio 1.54, 95% confidence interval 1.39–1.70), together with previously reported predictors (i.e., day of the week, time of the day, trauma, age and daily census). Burnout of emergency physicians was independently associated with a prolonged waiting time for patients visiting the ED.

Agreement between arterial and venous lactate in emergency department patients: a prospective study of 157 consecutive patients.

Introduction In the emergency department (ED), lactate is routinely used for risk stratification. Whether venous or arterial lactate measured on blood gas is interchangeable is not known. We hypothesized that venous lactate can be used instead of arterial lactate for the evaluation of acute patients in the ED. Patients and methods This was a prospective single-center study. All patients requiring a lactate measurement were enrolled and we simultaneously drew arterial and venous blood. We followed up all patients to hospital discharge. Our primary aim was to evaluate agreements between the two measurements using Bland and Altman plots with the report of bias (mean difference) and limits of agreements. We also aimed to determine the rate of misclassification (defined as one measurement<1.8 mmol/l and the other>2.2). Our secondary aim was to evaluate their respective prognostic value to predict in-hospital death or admission in the ICU longer than 72 h. Results The mean age of the 132 analyzed patients was 62 years (SD: 18 years), and 59% were men. The mean difference (bias) between arterial and venous lactate was −0.6 mmol/l (limits of agreement: −1.7 to 0.6 mmol/l). The rate of misclassification was 8% (95% confidence interval: 3–2%). Both methods present similar performances for the prediction of poor outcomes, with an area under the receiving operator characteristic curves of 0.67 for both. Results were similar when focused only on septic patients. Conclusion Venous and arterial lactates do not agree well, and there is a high misclassification rate. Venous lactate does not appear to be interchangeable with arterial sampling.

A 1-h simulation-based course on basic life support durably enhances confidence among medical students.

movements altered the tension on the tube. Instead, a semirigid cervical collar was applied (Laerdal Medical, Stavanger, Norway). A short length of endotracheal tube tape was tied to the Minnesota tube a few inches from the patient’s nose and this was then looped around the lower part of the collar and tied under tension (Fig. 1). The interhospital retrieval continued without evidence of further bleeding, and during handover at the receiving hospital, there appeared to be no alteration in the position of the Minnesota tube or loosening of the traction.

Temporal trends in nitrate utilization for acute heart failure in elderly emergency patients: A single-centre observational study.

BACKGROUND We previously conducted a pilot study that reported the safety of isosorbide dinitrate boluses for elderly emergency patients with acute heart failure syndrome. AIMS To assess the temporal trend in the rate of elderly patients treated with isosorbide dinitrate, and to evaluate subsequent outcome differences. METHODS This was a single-centre study. We compared patients aged>75 years who attended the emergency department with a primary diagnosis of acute pulmonary oedema in the years 2007 and 2014. The primary endpoint was the rate of patients who received isosorbide dinitrate boluses in the emergency department. Secondary endpoints included in-hospital mortality, need for intensive care and length of stay. RESULTS We analysed 368 charts, 232 from patients included in 2014 (63%) and 136 in 2007 (37%). The mean age was 85±6 years in both groups. There was a significant rise in the rate of patients treated with isosorbide dinitrate between 2007 and 2014: 97 patients (42%) in 2014 vs. 24 patients (18%) in 2007 (P<0.01). Comparing the two periods, we report similar in-hospital mortality rates (8% vs. 11%; P=0.5), rates of admission to the intensive care unit (13% vs. 17%; P=0.3) and lengths of stay (10 days in both groups). CONCLUSION We observed a significant rise in the rate of elderly patients treated with isosorbide dinitrate boluses for acute heart failure. However, we did not observe any significant improvement in outcomes.

End tidal carbon dioxide monitoring in acute asthma: a prospective pilot study in emergency department patients.

BACKGROUND The peak expiratory flow rate (PEFR) is the gold standard for monitoring asthmatic patients. However, its measurement requires understanding and active participation. End tidal carbon dioxide (EtCO2) may be considered an accurate surrogate for PaCO2, a severity marker in acute asthma. We studied the use of EtCO2 as a monitoring tool in acute asthma. PATIENTS AND METHODS This was a prospective study that included consecutive patients admitted to our emergency department for acute asthma exacerbation. Data were collected at first medical contact (T0) and after 1 h of treatment (T60). The primary endpoint was the change in EtCO2; the secondary endpoints included changes in the EtCO2Q angle value, plateau T time, and change in EtCO2 values for the patients with a PEFR ratio less than 50% after treatment. RESULTS Fifty-five patients were included and 36 waveforms were analysed. The mean age was 37 years and 26 (47%) were women. The median initial PEFR was 200 [interquartile range (IQR): 150-240]; the median EtCO2 at T0 and T60 was 35 (IQR: 30-38) and 34 (IQR: 29-37). There was no significant change in EtCO2 after treatment. There was no significant change in the Q angle and the T time after treatment. At T60, 20 (36%) patients had a PEFR ratio less than 50%. Change in EtCO2 from T60 to T0 was associated with a PEFR ratio less than 50%. CONCLUSION After 1 h of treatment, there was no significant change in EtCO2. A decrease in EtCO2 seems to be associated with a higher risk of PEFR ratio less than 50% after treatment.

External validation of a clinical decision rule: we need events in a population in order to rule them out!

We respond to the Lorton et al. article on external validation of the PECARN study. With an event rate of only 0.6%, we believe that their study failed to confirm the safety of this rule. Such a low number of events should call for caution when interpreting the results of diagnostic tests.

Weaker compressions after night shift? The WeCAN manikin study

To assess whether the quality of chest compressions (CC) differs before and after a night shift. We carried out a cluster randomized study in three Emergency Departments and three ICUs in Paris, France. Physicians were assessed on a control day and immediately following after a night shift. The primary endpoint was the proportion of CC with a depth greater than 50 mm. We analyzed 67 participants. The proportion of CC with a depth greater than 50 mm was similar on a control day and after a night shift [52% in both groups, mean difference of 0 (95% confidence interval: −17 to 17)]. Other indicators of CC quality were unchanged after a night shift, except for the mean depth of CC (51 vs. 48 mm, P=0.01). We report in our sample that the quality of CC after a night shift is not inferior to a control day.