RESUMO
Background: Out-of-hospital cardiac arrest (OHCA) incidence and survival often vary within regions according to patient-related and contextual factors. This study aims to establish the overall spatial dependence of incidence, bystander cardiopulmonary resuscitation (BCPR) and 48-h survival of OHCA with their associated demographic and socioeconomic characteristics in a Swiss region. Methods: We conducted a retrospective study using data of all OHCAs recorded between 2007 and 2019 in the canton of Vaud and, more specifically, in the Lausanne area. Provision of BCPR and 48-h survival were analysed using Getis-Ord Gi statistics and OHCA incidence by local Moran's I with empirical Bayes standardised rates. Demographic and socioeconomic characteristics were compared between incidence clusters generated by local Moran's I method. Results: Significant spatial variations of OHCA incidence, BCPR and 48-h mortality were observed. Although BCPR was statistically more likely in rural areas, 48-h survival was improved in a few main cities. At the cantonal level, postcode areas with a higher incidence of OHCAs were less densely inhabited with lower salary levels, more Swiss citizens, and an older population. At city level, small area variations were detected within urban neighbourhoods. The more affected hectares with more OHCAs were less inhabited, with a better median salary, more Swiss citizens, and off-centre. Conclusions: Spatial variations associated with demographic and socioeconomic factors were observed for OHCA incidence and survival, with sparsely populated areas particularly at risk. These data suggest an unmet need for targeted prevention interventions and structural modifications of the existing prehospital system at the cantonal level.
RESUMO
Dabigatran is an oral anticoagulant that is mainly renally excreted. Despite its efficacy in preventing thromboembolic events, concerns arise regarding bleeding complications in patients with acute kidney injury. Idarucizumab is its specific antidote and reverses quickly and effectively dabigatran anticoagulation effects in situations of severe bleeding or pending surgical procedures, but its benefit beyond these two indications remains uncertain. We present a case of a woman with atrial fibrillation anticoagulated by dabigatran and admitted with Streptococcus agalactiae meningitis, acute kidney injury and dabigatran accumulation. Idarucizumab was not administered initially as she did not meet its current strict indications. However, subsequently, significant bleeding necessitated its use. A rebound increase in dabigatran concentration was associated with an intracranial hemorrhage, but the combination of additional doses of idarucizumab with hemodialysis lowered the dabigatran concentration and prevented significant rebound increases. Further investigation into the optimal management of dabigatran accumulation and acute kidney injury-associated bleeding is needed to enhance patient outcomes and safety. Early initiation of hemodialysis together with idarucizumab administration may be crucial in preventing life-threatening bleeding events in these patients.
RESUMO
BACKGROUND AND AIMS: Home treatment is considered safe in acute pulmonary embolism (PE) patients selected by a validated triage tool (e.g. simplified PE severity index score or Hestia rule), but there is uncertainty regarding the applicability in underrepresented subgroups. The aim was to evaluate the safety of home treatment by performing an individual patient-level data meta-analysis. METHODS: Ten prospective cohort studies or randomized controlled trials were identified in a systematic search, totalling 2694 PE patients treated at home (discharged within 24â h) and identified by a predefined triage tool. The 14- and 30-day incidences of all-cause mortality and adverse events (combined endpoint of recurrent venous thromboembolism, major bleeding, and/or all-cause mortality) were evaluated. The relative risk (RR) for 14- and 30-day mortalities and adverse events is calculated in subgroups using a random effects model. RESULTS: The 14- and 30-day mortalities were 0.11% [95% confidence interval (CI) 0.0-0.24, I2 = 0) and 0.30% (95% CI 0.09-0.51, I2 = 0). The 14- and 30-day incidences of adverse events were 0.56% (95% CI 0.28-0.84, I2 = 0) and 1.2% (95% CI 0.79-1.6, I2 = 0). Cancer was associated with increased 30-day mortality [RR 4.9; 95% prediction interval (PI) 2.7-9.1; I2 = 0]. Pre-existing cardiopulmonary disease, abnormal troponin, and abnormal (N-terminal pro-)B-type natriuretic peptide [(NT-pro)BNP] at presentation were associated with an increased incidence of 14-day adverse events [RR 3.5 (95% PI 1.5-7.9, I2 = 0), 2.5 (95% PI 1.3-4.9, I2 = 0), and 3.9 (95% PI 1.6-9.8, I2 = 0), respectively], but not mortality. At 30 days, cancer, abnormal troponin, and abnormal (NT-pro)BNP were associated with an increased incidence of adverse events [RR 2.7 (95% PI 1.4-5.2, I2 = 0), 2.9 (95% PI 1.5-5.7, I2 = 0), and 3.3 (95% PI 1.6-7.1, I2 = 0), respectively]. CONCLUSIONS: The incidence of adverse events in home-treated PE patients, selected by a validated triage tool, was very low. Patients with cancer had a three- to five-fold higher incidence of adverse events and death. Patients with increased troponin or (NT-pro)BNP had a three-fold higher risk of adverse events, driven by recurrent venous thromboembolism and bleeding.
Assuntos
Embolia Pulmonar , Humanos , Embolia Pulmonar/mortalidade , Doença Aguda , Serviços de Assistência Domiciliar , Hemorragia/epidemiologia , Masculino , Feminino , Anticoagulantes/uso terapêutico , Anticoagulantes/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Prospectivos , Idoso , Peptídeo Natriurético Encefálico/sangue , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: The COVID-19 pandemic had a profound negative impact on the psychological wellbeing of healthcare providers (HPs), but little is known about the factors that positively predict mental health of primary care staff during these dire situations. METHODS: We conducted an online questionnaire survey among 702 emergency department workers across 10 hospitals in Switzerland and Belgium following the first COVID-19 wave in 2020, to explore their psychological vulnerability, perceived concerns, self-reported impact and level of pandemic workplace preparedness. Participants included physicians, nurses, psychologists and nondirect care employees (administrative staff). We tested for predictors of psychological vulnerability through both an exploratory cross-correlation with rigorous correction for multiple comparisons and model-based path modelling. RESULTS: Findings showed that the self-reported impact of COVID-19 at work, concerns about contracting COVID-19 at work, and a lack of personal protective equipment were strong positive predictors of Depression, Anxiety, and Stress, and low Resilience. Instead, knowledge of the degree of preparedness of the hospital/department, especially in the presence of a predetermined contingency plan for an epidemic and training sessions about protective measures, showed the opposite effect, and were associated with lower psychological vulnerability. All effects were confirmed after accounting for confounding factors related to gender, age, geographical location and the role played by HPs in the hospital/department. CONCLUSIONS: Difficult working conditions during the pandemic had a major impact on the psychological wellbeing of emergency department HPs, but this effect might have been lessened if they had been informed about adequate measures for minimizing the risk of exposure.
Assuntos
COVID-19 , Pandemias , Humanos , Pessoal de Saúde/psicologia , Hospitais , Atenção Primária à SaúdeRESUMO
OBJECTIVE: Investigate the effect of change talk (CT) within successive brief motivational interventions (BMIs) as a mechanism of change for alcohol use. METHOD: We conducted a secondary analysis of data from a randomized controlled trial in which 344 young adults (18-35 years old) admitted to a Swiss emergency department with alcohol intoxication received either BMI (N = 171) or brief advice (N = 173). Participants with a baseline audio-recorded BMI were included (N = 140; median age 23 [Q1-Q3: 20-27], 72.9% men). Up to three booster sessions by phone were offered at 1 week, 1 month, and 3 months. Percent CT and CT Average Strength were used as predictor variables. The outcome was the number of heavy drinking days (HDD) over the 30 days prior to research assessments at 1-, 3-, 6-, and 12-month follow-up. A latent growth curve modeling framework was first used to estimate predictor and outcome variable growth parameters (i.e., intercept and slope) over time, and then to regress HDD growth parameters on CT growth parameters. RESULTS: CT increased specifically from baseline to the 1-week booster session and thereafter remained stable. Higher baseline CT was associated with lower HDD at 1 month (Percent CT: b = -0.04, 95% confidence interval [-0.06, -0.01]; Average Strength: b = -0.99 [-1.67, -0.31]). An increase in CT from baseline to the 1-week booster session was related to a decrease in HDD from 1 month to 12 months (Percent CT: b = -0.08 [-0.14, -0.03]; Average Strength: b = -2.29 [-3.52, -1.07]). CONCLUSIONS: Both baseline CT and CT trajectory over the first week are meaningful predictors of HDD. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
Assuntos
Serviço Hospitalar de Emergência , Entrevista Motivacional , Humanos , Masculino , Feminino , Adulto Jovem , Adulto , Entrevista Motivacional/métodos , Adolescente , Psicoterapia Breve/métodos , Motivação , Suíça , Consumo de Bebidas Alcoólicas/terapia , Intoxicação AlcoólicaRESUMO
INTRODUCTION: Cancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE. METHODS: In the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization. RESULTS: Patients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15-21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15-9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48-42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15-9.74). CONCLUSIONS: Among patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes.
Assuntos
Neoplasias , Embolia Pulmonar , Humanos , Pacientes Ambulatoriais , Embolia Pulmonar/complicações , Embolia Pulmonar/terapia , Assistência Ambulatorial , Fatores de Risco , Neoplasias/complicações , Neoplasias/terapiaRESUMO
BACKGROUND: Lower respiratory tract infections (LRTIs) are among the most frequent infections and a significant contributor to inappropriate antibiotic prescription. Currently, no single diagnostic tool can reliably identify bacterial pneumonia. We thus evaluate a multimodal approach based on a clinical score, lung ultrasound (LUS), and the inflammatory biomarker, procalcitonin (PCT) to guide prescription of antibiotics. LUS outperforms chest X-ray in the identification of pneumonia, while PCT is known to be elevated in bacterial and/or severe infections. We propose a trial to test their synergistic potential in reducing antibiotic prescription while preserving patient safety in emergency departments (ED). METHODS: The PLUS-IS-LESS study is a pragmatic, stepped-wedge cluster-randomized, clinical trial conducted in 10 Swiss EDs. It assesses the PLUS algorithm, which combines a clinical prediction score, LUS, PCT, and a clinical severity score to guide antibiotics among adults with LRTIs, compared with usual care. The co-primary endpoints are the proportion of patients prescribed antibiotics and the proportion of patients with clinical failure by day 28. Secondary endpoints include measurement of change in quality of life, length of hospital stay, antibiotic-related side effects, barriers and facilitators to the implementation of the algorithm, cost-effectiveness of the intervention, and identification of patterns of pneumonia in LUS using machine learning. DISCUSSION: The PLUS algorithm aims to optimize prescription of antibiotics through improved diagnostic performance and maximization of physician adherence, while ensuring safety. It is based on previously validated tests and does therefore not expose participants to unforeseeable risks. Cluster randomization prevents cross-contamination between study groups, as physicians are not exposed to the intervention during or before the control period. The stepped-wedge implementation of the intervention allows effect calculation from both between- and within-cluster comparisons, which enhances statistical power and allows smaller sample size than a parallel cluster design. Moreover, it enables the training of all centers for the intervention, simplifying implementation if the results prove successful. The PLUS algorithm has the potential to improve the identification of LRTIs that would benefit from antibiotics. When scaled, the expected reduction in the proportion of antibiotics prescribed has the potential to not only decrease side effects and costs but also mitigate antibiotic resistance. TRIAL REGISTRATION: This study was registered on July 19, 2022, on the ClinicalTrials.gov registry using reference number: NCT05463406. TRIAL STATUS: Recruitment started on December 5, 2022, and will be completed on November 3, 2024. Current protocol version is version 3.0, dated April 3, 2023.
Assuntos
Pneumonia , Infecções Respiratórias , Adulto , Humanos , Pró-Calcitonina , Qualidade de Vida , Suíça , Infecções Respiratórias/diagnóstico por imagem , Infecções Respiratórias/tratamento farmacológico , Pneumonia/diagnóstico por imagem , Pneumonia/tratamento farmacológico , Pulmão/diagnóstico por imagem , Antibacterianos/efeitos adversos , Ultrassonografia , Serviço Hospitalar de Emergência , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Women may receive suboptimal pain management compared with men, and this disparity might be related to gender stereotypes. OBJECTIVES: To assess the influence of patient gender on the management of acute low back pain. DESIGN: We assessed pain management by 231 physicians using an online clinical vignette describing a consultation for acute low back pain in a female or male patient. The vignette was followed by a questionnaire that assessed physicians' management decisions and their gender stereotypes. METHODS: We created an online clinical vignette presenting a patient with acute low back pain and assessed the influence of a patient's gender on pain management. We investigated gender-related stereotyping regarding pain care by emergency physicians using the Gender Role Expectation of Pain questionnaire. RESULTS: Both male and female physicians tended to consider that a typical man was more sensitive to pain, had less pain endurance, and was more willing to report pain than a typical woman. These stereotypes did not translate into significant differences in pain management between men and women. However, women tended to be referred less often for imaging examinations than men and were also prescribed lower doses of ibuprofen and opioids. The physician's gender had a modest influence on management decisions, female physicians being more likely to prescribe ancillary examinations. CONCLUSION: We observed gender stereotypes among physicians. Our findings support the hypothesis that social characteristics attributed to men and women influence pain management. Prospective clinical studies are needed to provide a deeper understanding of gender stereotypes and their impact on clinical management.
Assuntos
Dor Lombar , Humanos , Masculino , Feminino , Dor Lombar/terapia , Estudos Prospectivos , Manejo da Dor/métodos , Serviço Hospitalar de Emergência , Inquéritos e QuestionáriosRESUMO
It is currently unknown whether thrombin generation is associated with venous thromboembolism (VTE) recurrence, major bleeding, or mortality in the elderly. Therefore, our aim was to prospectively study the association between thrombin generation and VTE recurrence, major bleeding, and mortality in elderly patients with acute VTE. Consecutive patients aged ≥65 years with acute VTE were followed for 2 years, starting from 1 year after the index VTE. Primary outcomes were VTE recurrence, major bleeding, and mortality. Thrombin generation was assessed in 551 patients 1 year after the index VTE. At this time, 59% of the patients were still anticoagulated. Thrombin generation was discriminatory for VTE recurrence, but not for major bleeding and mortality in non-anticoagulated patients. Moreover, peak ratio (adjusted subhazard ratio 4.09, 95% CI, 1.12-14.92) and normalized peak ratio (adjusted subhazard ratio 2.18, 95% CI, 1.28-3.73) in the presence/absence of thrombomodulin were associated with VTE recurrence, but not with major bleeding and mortality after adjustment for potential confounding factors. In elderly patients, thrombin generation was associated with VTE recurrence, but not with major bleeding and/or mortality. Therefore, our study suggests the potential usefulness of thrombin generation measurement after anticoagulation completion for VTE to help identify among elderly patients those at higher risk of VTE recurrence.
RESUMO
OBJECTIVE: Research suggests that therapeutic communication could enhance patient comfort during medical procedures. Few studies have been conducted in clinical settings, with adequate blinding. Our hypothesis was that a positive message could lead to analgesia and anxiolysis, and that this effect would be enhanced by an empathetic interaction with the nurse performing the procedure, compared with an audio-taped message. This study aimed to modulate the contents and delivery vector of a message regarding peripheral intravenous catheter (PIC) placement in the emergency department (ED). METHODS: This study was a 2 + 2 randomized controlled trial registered on ClinicalTrials.gov (NCT03502655). A positive versus standard message was delivered through audio tape (double-blind) in the first phase ( N = 131) and through the nurse placing the catheter (single-blind) in the second phase ( N = 120). RESULTS: By design, low practitioner empathic behavior was observed in the first phase (median, 1 of 5 points). In the second phase, higher empathic behavior was observed in the positive than in the standard message (median, 2 versus 3, p < .001). Contrary to our hypothesis, the intervention did not affect pain or anxiety reports due to PIC placement in either phase (all p values > .2). CONCLUSIONS: The positive communication intervention did not impact pain or anxiety reports after PIC. There might have been a floor effect, with low PIC pain ratings in a context of moderate pain due to the presenting condition. Hence, such a therapeutic communication intervention might not be sufficient to modulate a mild procedural pain in the ED.
Assuntos
Dor Processual , Humanos , Método Simples-Cego , Dor , Ansiedade/terapia , Comunicação , Serviço Hospitalar de EmergênciaRESUMO
Medical students and professional healthcare providers often underestimate patients' pain, together with decreased neural responses to pain information in the anterior insula (AI), a brain region implicated in self-pain processing and negative affect. However, the functional significance and specificity of these neural changes remains debated. Across two experiments, we recruited university medical students and emergency nurses to test the role of healthcare experience on the brain reactivity to other's pain, emotions, and beliefs, using both pictorial and verbal cues. Brain responses to self-pain was also assessed and compared with those to observed pain. Our results confirmed that healthcare experience decreased the activity in AI in response to others' suffering. This effect was independent from stimulus modality (pictures or texts), but specific for pain, as it did not generalize to inferences about other mental or affective states. Furthermore, representational similarity and multivariate pattern analysis revealed that healthcare experience impacted specifically a component of the neural representation of others' pain that is shared with that of first-hand nociception, and related more to AI than to other pain-responsive regions. Taken together, our study suggests a decreased propensity to appraise others' suffering as one's own, associated with a reduced recruitment of pain-specific information in AI. These findings provide new insights into neural mechanisms leading to pain underestimation by caregivers in clinical settings.
Assuntos
Emoções , Empatia , Humanos , Emoções/fisiologia , Dor/psicologia , Encéfalo/fisiologia , Mapeamento Encefálico , Imageamento por Ressonância MagnéticaRESUMO
BACKGROUND: We aimed to evaluate the quality of life (QoL), using patient-reported outcome measures (PROMs), in elderly patients with venous thromboembolism (VTE) and to explore whether VTE complications (recurrence, bleeding, or postthrombotic syndrome) had an impact on later QoL. METHODS: We used data from the SWIss venous Thromboembolism COhort of older patients(SWITCO65+), a prospective multicenter cohort of patients aged ≥65 years with acute, symptomatic VTE. Primary outcome was changes in QoL up to 24 months, assessed using generic (36-Item Short-Form Health Survey), with physical (PCS) and mental component score (MCS), and disease-specific (Venous Insufficiency Epidemiological and Economic Study [VEINES]-QoL, [VEINES-Sym], and Pulmonary Embolism QoL) PROMs. PROM scores ranged from 0 to 100 points, higher scores indicating a better QoL. Longitudinal latent class analysis was used to group patients with similar PCS trajectories. Repeated-measures linear regression analyses were used to assess effects of VTE complications on changes in QoL scores. RESULTS: In 923 patients (median age, 75; male, 54%), 140 (15%) patients died, 97 (11%) experienced recurrent VTE, and 106 (12%) major bleeding during follow-up. Compared with patients with higher PCS trajectories, patients with lower PCS trajectories were more likely to be older, female, sicker, and less physically active. On average, generic and disease-specific QoL scores improved over time (+11% in PCS, +3% in MCS, +6% in VEINES QoL, and +16% in Pulmonary Embolism QoL at 3 months). VTE complications were always associated with significantly lower QoL scores (for VTE recurrence: PCS adjusted difference -2.57, 95% CI, -4.47 to -0.67). CONCLUSION: Although QoL following VTE tended to improve over time, patients with VTE-related complications had lower QoL than patients without complications.
Assuntos
Embolia Pulmonar , Insuficiência Venosa , Tromboembolia Venosa , Idoso , Humanos , Masculino , Feminino , Qualidade de Vida , Tromboembolia Venosa/diagnóstico , Estudos Prospectivos , Hemorragia , Embolia Pulmonar/diagnóstico , Medidas de Resultados Relatados pelo PacienteRESUMO
BACKGROUND: Research has not identified which patients optimally benefit from brief Motivational Interviewing (bMI) for heavy drinking when delivered to young adults in the Emergency Department (ED). METHODS: We conducted secondary analyses of data from a randomized controlled trial in which 344 young adults (18-35 years) presenting to the ED with alcohol intoxication received either bMI or Brief Advice (BA, control group). We used Latent Class Analysis to derive participants' profiles from baseline characteristics (i.e., sex, age, severity of alcohol use disorder, attribution of ED admission to alcohol use, importance, and confidence to change, cognitive discrepancy, anxiety, depression, and trait reactance). We then conducted a moderation analysis to assess the number of heavy drinking days at short-term (1-month) and long-term (12-month) follow-up using negative binomial regressions with interactions between the intervention and derived classes. RESULTS: Fit statistics indicated that a 4-class solution best fit the data. Class 3 (high severity, importance and discrepancy, and low confidence and anxiety) benefitted more from bMI than BA at short- and long-term follow-up than Class 1 (younger; lowest severity, importance, discrepancy, reactance, anxiety and depression, and highest confidence). Class 2 (older; highest severity, importance, discrepancy, reactance, anxiety and depression, and lowest confidence) also benefitted more from bMI than BA than did Class 1 at short-term follow-up. In these significant contrasts, Class 1 benefitted more from BA than bMI. There were no significant interactions involving Class 4 (more likely to be women; low severity; high levels of anxiety, depression, and reactance). CONCLUSIONS: This study identified the patient profiles that benefitted more from bMI than BA among nontreatment-seeking young adults who present intoxicated to the ED. The findings have implications for intervention design and argue for the importance of research aimed at developing intervention content tailored to patient profiles.
RESUMO
BACKGROUND: Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). OBJECTIVE: To measure any resulting change in CTPA use for suspected PE. DESIGN: Retrospective analysis. SETTING: 26 European EDs in 6 countries. PATIENTS: Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019. MEASUREMENTS: The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models. RESULTS: 8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, -8.9% [CI, -17.1% to -0.3%]) were observed. LIMITATION: Data were limited to 7 days every 2 months. CONCLUSION: Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed. PRIMARY FUNDING SOURCE: None specific for this study.
Assuntos
Embolia Pulmonar , Tomografia Computadorizada por Raios X , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Estudos Retrospectivos , Embolia Pulmonar/diagnóstico por imagem , Serviço Hospitalar de Emergência , AngiografiaRESUMO
AIMS: Frequent users of the emergency department (FUED; five ED visits or more per year) often have negative experiences in health care settings, potentially aggravating their health problems. Scarce research has explored FUED experiences in health care in Europe, none in Switzerland. Thus, this study aimed to conduct an in-depth exploration of FUED experiences in health care settings in Switzerland. METHODS: Semi-structured interviews were conducted among 20 FUED (75% female; mean age = 40.6, SD = 12.8). Qualitative data were subject to inductive content analysis. RESULTS: Five main themes emerged from the analysis. The main findings documented that FUED experiences in health care were mostly negative, leading to negative emotions, dissatisfaction and a loss of confidence in the system, although some positive experiences were reported as well. The relationship with health care workers was perceived as playing a key role in FUED experiences. CONCLUSION: The findings indicate that FUED often have negative experiences in the health care system in Switzerland. The relationship with the health care staff is reported as a decisive ingredient of the experience in health care. Future research is needed to develop awareness-raising interventions for health care staff to improve FUED experiences in health care.
RESUMO
BACKGROUND: The diagnostic strategy for pulmonary embolism (PE) includes a D-dimer test when PE probability is low or intermediate, but false-positive D-dimer results are frequent and can result in an unnecessary computed tomography pulmonary angiogram. The PE rule-out criteria (PERC) rule excludes PE without D-dimer testing when pretest probability is <15%. The aim of this study was to assess the safety of the PERC rule strategy in patients included in the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry. METHODS: This retrospective cohort study used data from the RIETE registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the failure rate of the PERC strategy, represented by the proportion of PERC-negative (PERC-N) patients with a PE included in the registry. Secondary outcomes were a comparison of the clinical characteristics, treatment strategy, and outcome of PERC-N versus PERC-positive (PERC-P) patients at 3 months. RESULTS: From 2001 to 2021, a total of 49,793 patients with acute PE were enrolled in the RIETE registry. We included 48,903 in the final analysis after exclusion of 890 patients with an undetermined PERC status. Only 346 patients were PERC-N with a failure rate of 0.7% (95% confidence interval 0.6%-0.8%). PERC-N patients presented more frequently with chest pain but less often with dyspnea, syncope, or hypotension. They also had subsegmental or segmental PE more frequently, were more often treated with direct oral anticoagulants, and received mechanical or pharmacological thrombolysis less often. In addition, PERC-N patients had a lower incidence of recurrent deep vein thrombosis, major bleeding, and death attributed to PE during the 3-month follow-up. CONCLUSIONS: A low failure rate of the PERC rule was observed in the RIETE registry, thus supporting its use to safely identify patients with an unlikely probability of PE.
Assuntos
Embolia Pulmonar , Tromboembolia Venosa , Trombose Venosa , Humanos , Estudos Retrospectivos , Trombose Venosa/diagnóstico , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/terapia , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiologia , Sistema de RegistrosRESUMO
BACKGROUND: Previous research revealed the vulnerability of frequent users of emergency department (FUED) because of concomitant medical, psychological and social issues. Case management (CM) provides FUED with effective medical and social support, however, the heterogeneity of this population has highlighted the need to explore the specific needs of FUED subpopulations. In response, this study aimed to explore qualitatively the lived experience of migrant and non-migrant FUED in the healthcare system to identify unmet needs. METHODS: Adult migrant and non-migrant FUED (≥ 5 visits in the ED in the past 12 months) were recruited in a Swiss university hospital to collect qualitative data on their experience within the Swiss health system. Participants were selected based on predefined quotas for gender and age. Researchers conducted one-on-one semistructured interviews until reaching data saturation. Inductive conventional content analysis was used to analyse qualitative data. RESULTS: In total, 23 semistructured interviews were conducted (11 migrant FUED and 12 non-migrant FUED). Four main themes emerged from the qualitative analysis: (1) self-evaluation of the Swiss healthcare system; (2) orientation within the healthcare system; (3) relationship with caregivers and (4) perception of own health. While both groups were overall satisfied with the healthcare system and care provided, migrant FUED reported language and financial barriers to access it. Both groups expressed overall satisfaction over their relationship with healthcare professionals, although migrant FUED reported a feeling of illegitimacy to consult the ED based on social status, whereas non-migrant FUED felt more often the need to justify their use of the ED. Finally, migrant FUED perceived their own health to be affected by their status. CONCLUSION: This study highlighted difficulties specific to subpopulations of FUED. For migrant FUED, these included access to care and impact of migrant status on own health. Adapting CM to the specific needs of migrant FUED could help reduce their vulnerability.
Assuntos
Serviço Hospitalar de Emergência , Migrantes , Adulto , Humanos , Suíça , Pesquisa Qualitativa , Idioma , Atenção à SaúdeRESUMO
BACKGROUND: Effective management of frequent users of emergency departments (FUED) remains challenging. Case management (CM) has shown to improve patient quality of life while reducing ED visits and associated costs. However, little data is available on FUED's perception of CM outside of North America to further improve CM implementation. OBJECTIVES: Explore the FUED's perspectives about CM in Switzerland. DESIGN, SETTING & PARTICIPANTS: Semi-structured qualitative interviews eliciting FUED's experiences of CM were conducted among 20 participants (75% female; mean age = 40.6, SD = 12.8) across 6 hospital ED. OUTCOMES MEASURES & ANALYSIS: Inductive content analysis. MAIN RESULTS: Most participants were satisfied with the CM program. In particular, FUEDs identified the working relationship with the case manager (cm) as key for positive outcomes, and also valued the holistic evaluation of their needs and resources. Overall, patients reported increased motivation and health literacy, as well as facilitated interactions within the healthcare system. Conversely, a small number of participants reported negative views on CM (ie, stigmatization, lack of concrete outcomes). Barriers identified were cm's lack of time, COVID-19's negative impact on CM organization, as well as lack of clarity on the objectives of CM. FUED perceived CM as useful, in particular establishing a working relationship with the cm. Our results suggest that CM can be further improved by (1) professionals remaining non-judgmental toward FUED, (2) making sure the aims and objectives of the CM are understood by the participants, and (3) allowing more time for the cm to carry out their work.
Assuntos
COVID-19 , Administração de Caso , Humanos , Feminino , Adulto , Masculino , Qualidade de Vida , Atenção à Saúde , Serviço Hospitalar de EmergênciaRESUMO
STUDY OBJECTIVE: We aimed to assess the analgesic and anxiolytic efficacy of distraction, a nonpharmacologic intervention provided by 3-dimensional (3D) virtual reality (VR) compared with that provided by 2-dimensional (2D) VR during minor emergency department (ED) procedures. METHODS: This randomized controlled study conducted in the ED of a teaching hospital included patients aged more than or equal to 18 years undergoing minor procedures. The patients watched the same computer-generated VR world either in 3D in a head-mounted display (intervention) or in 2D on a laptop screen (control). Our main outcomes were pain and anxiety during the procedure, assessed on a 100-mm visual analog scale. Secondary outcomes included the impression of telepresence in the computer-generated world assessed using the Igroup Presence Questionnaire, and the prevalence and intensity of cybersickness measured on a 100-mm visual analog scale. RESULTS: The final analysis included 117 patients. The differences in median procedural pain and anxiety levels between the 2D and 3D VR groups were not significant: -3 mm (95% confidence interval [CI] -14 to 8) and -4 mm (95% CI -15 to 3), respectively; the difference in telepresence was 2.0 point (95% CI 0 to 2.0), and the proportion difference of cybersickness was -4% (95% CI -22 to 14), with an intensity difference of -5 mm (95% CI -9 to 3). CONCLUSION: During minor procedures in adult patients in the ED, distraction by viewing a 3D virtual world in a head-mounted VR display did not result in lower average levels of procedural pain and anxiety than that by 2D viewing on a screen despite a higher sense of telepresence. There were no significant differences in the prevalence and intensity of cybersickness between the 2 groups.
Assuntos
Ansiolíticos , Dor Processual , Realidade Virtual , Adulto , Humanos , Dor Processual/prevenção & controle , Analgésicos , Ansiedade/prevenção & controle , Serviço Hospitalar de EmergênciaRESUMO
Importance: Heavy drinking among young adults is a major public health concern. Brief motivational interventions in the emergency department have shown promising but inconsistent results. Objective: To test whether young adults receiving a newly developed brief motivational intervention reduce their number of heavy drinking days and alcohol-related problems over 1 year compared with participants receiving brief advice. Design, Setting, and Participants: This randomized clinical trial was conducted at an emergency department of a tertiary care university hospital in Lausanne, Switzerland. Recruitment ran from December 2016 to August 2019. Follow-up was conducted after 1, 3, 6, and 12 months. All adults aged 18 to 35 years presenting for any cause and presenting with alcohol intoxication were eligible (N = 2108); 1764 were excluded or refused participation. Follow-up rate was 79% at 12 months and 89% of participants provided follow-up data at least once and were included in the primary analyses. Statistical analysis was performed from September 2020 to January 2021. Interventions: The novel intervention was based on motivational interviewing and comprised in-person discussion in the emergency department and up to 3 booster telephone calls. The control group received brief advice. Main Outcomes and Measures: Primary outcomes were the number of heavy drinking days (at least 60 g of ethanol) over the previous month and the total score on the Short Inventory of Problems (0-45, higher scores indicating more problems) over the previous 3 months. Hypotheses tested were formulated before data collection. Results: There were 344 young adults included (median [IQR] age: 23 [20-28] years; 84 women [24.4%]). Among the 306 participants providing at least 1 follow-up point, a statistically significant time × group interaction was observed (ß = -0.03; 95% CI, -0.05 to 0.00; P = .02), and simple slopes indicated an increase of heavy drinking days over time in the control (ß = 0.04; 95% CI, 0.02 to 0.05; P < .001) but not in the intervention group (ß = 0.01; 95% CI, -0.01 to 0.03; P = .24). There was no effect on the Short Inventory of Problems score (ß = -0.01; 95% CI, -0.03 to 0.02; P = .71). Conclusions and Relevance: This randomized clinical trial found that a brief motivational intervention implemented in the emergency department provided beneficial effects on heavy drinking, which accounts for a substantial portion of mortality and disease burden among young adults. Trial Registration: ISRCTN registry: 13832949.