Jennifer Truchot

Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial

Importance The safety of the pulmonary embolism rule-out criteria (PERC), an 8-item block of clinical criteria aimed at ruling out pulmonary embolism (PE), has not been assessed in a randomized clinical trial. Objective To prospectively validate the safety of a PERC-based strategy to rule out PE. Design, Setting, and Patients A crossover cluster–randomized clinical noninferiority trial in 14 emergency departments in France. Patients with a low gestalt clinical probability of PE were included from August 2015 to September 2016, and followed up until December 2016. Interventions Each center was randomized for the sequence of intervention periods. In the PERC period, the diagnosis of PE was excluded with no further testing if all 8 items of the PERC rule were negative. Main Outcomes and Measures The primary end point was the occurrence of a thromboembolic event during the 3-month follow-up period that was not initially diagnosed. The noninferiority margin was set at 1.5%. Secondary end points included the rate of computed tomographic pulmonary angiography (CTPA), median length of stay in the emergency department, and rate of hospital admission. Results Among 1916 patients who were cluster-randomized (mean age 44 years, 980 [51%] women), 962 were assigned to the PERC group and 954 were assigned to the control group. A total of 1749 patients completed the trial. A PE was diagnosed at initial presentation in 26 patients in the control group (2.7%) vs 14 (1.5%) in the PERC group (difference, 1.3% [95% CI, −0.1% to 2.7%]; P = .052). One PE (0.1%) was diagnosed during follow-up in the PERC group vs none in the control group (difference, 0.1% [95% CI, −∞ to 0.8%]). The proportion of patients undergoing CTPA in the PERC group vs control group was 13% vs 23% (difference, −10% [95% CI, −13% to −6%]; P < .001). In the PERC group, rates were significantly reduced for the median length of emergency department stay (mean reduction, 36 minutes [95% CI, 4 to 68]) and hospital admission (difference, 3.3% [95% CI, 0.1% to 6.6%]). Conclusions and Relevance Among very low-risk patients with suspected PE, randomization to a PERC strategy vs conventional strategy did not result in an inferior rate of thromboembolic events over 3 months. These findings support the safety of PERC for very low-risk patients presenting to the emergency department. Trial Registration clinicaltrials.gov Identifier: NCT02375919

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

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.

Serious game versus online course for pretraining medical students before a simulation-based mastery learning course on cardiopulmonary resuscitation: A randomised controlled study

BACKGROUND Although both recorded lectures and serious games have been used to pretrain health professionals before simulation training on cardiopulmonary resuscitation, they have never been compared. OBJECTIVE The aim of this study was to compare an online course and a serious game for pretraining medical students before simulation-based mastery learning on the management of sudden cardiac arrest. DESIGN A randomised controlled trial. Participants were pretrained using the online course or the serious game on day 1 and day 7. On day 8, each participant was evaluated repeatedly on a scenario of cardiac arrest until reaching a minimum passing score. SETTING Department of Simulation in Healthcare in a French medical faculty. PARTICIPANTS Eighty-two volunteer second-year medical students participated between June and October 2016 and 79 were assessed for primary outcome. INTERVENTIONS The serious game used was Staying Alive, which involved a 3D realistic environment, and the online course involved a PowerPoint lecture. MAIN OUTCOME MEASURES The median total training time needed for students to reach the minimum passing score on day 8. This same outcome was also assessed 4 months later. RESULTS The median training time (interquartile range) necessary for students to reach the minimum passing score was similar between the two groups: 20.5 (15.8 to 30.3) minutes in the serious game group versus 23 (15 to 32) minutes in the online course group, P = 0.51. Achieving an appropriate degree of chest compression was the most difficult requirement to fulfil for students in both groups. Four months later, the median training time decreased significantly in both groups, but no correlation was found at an individual level with the training times observed on day 8. CONCLUSION The serious game used in this study was not superior to an online course to pretrain medical students in the management of a cardiac arrest. The absence of any correlation between the performances of students evaluated during two training sessions separated by 4 months suggests that some elements in the management of cardiac arrest such as compression depth can only be partially learned and retained after a simulation-based training. TRIAL REGISTRATION ClinicalTrials.gov-NCT02758119.

Proceedings of the 23rd Annual Meeting of the Society in Europe for Simulation Applied to Medicine

Introduction & Aims Medical simulation is an important technique to provide education as well as clinical evaluation with physical examination. Simulation is now regarded as a strategy to improve safety of learning (to patient and student) and quality in real medical practice. The aim of this study was to evaluate students’ confidence levels in detection of heart and respiratory murmurs with Harvey the Cardiopulmonary Patient Simulator compared to real patients with cardiopulmonary disorders. Methods Three hundred and eighty 3 year medical students underwent prestudy multiple-choice question test (MCQ) to assess their confidence of cardiopulmonary examination and to detect cardiopulmonary murmurs. Three hundred and eleven students successfully passed (>51% test score). They were divided in two groups: G1 (n=155) firstly examine patients with cardiopulmonary disorders pneumonia with crackles (CR), bronchial asthma with wheezes (WZ), typical mitral stenosis (MS) and aortic stenosis (AS) and then participate in the Harvey simulation (the same scenarios). G2 (n=156) firstly participate in the Harvey simulation and then examine real patients. At the end, all the students completed the post-study MCQ to assess their confidence in detecting murmurs. Statistical analysis was performed using Statistica 10.0. Data was presented as M±SD. For comparison of frequency we used x2-criterion. Mann-Whitney and multiple logistic regression analysis were performed. P <0.05 was considered statistically significant. Results & Discussion 311 students completed all surveys. There was no difference in mean pre-study score between groups (58% vs 63%, p>0.05). After completing the first activity there were no differences in detecting CR and WZ between groups (74% vs 72%, 80 vs 78%, p>0.05 respectively), but there was significantly higher confidence in detecting MS and AS in G2 (50 vs 72%, x2= 15,1, p<0.001 and 82% vs 94%, x2= 11,2, p<0.001). After completing second activity, significant increase of confidence level in detection of MS, especially in G1 was observed (for detail information see Table 1). The mean score of post-study MCQ increase in both groups, but was higher in G2 (82 vs 90%, x2= 3,9, p<0.05).