Evaluation of a training program for emergency medical service physician dispatchers to reduce emergency departments visits.

BACKGROUND: Emergency Departments (ED) have seen an increasing number of older patients who are mostly referred following a call to the Emergency Medical Services (EMS). Long waiting times in settings, which are not designed to meet older patients' needs, may increase the risk of hospital-acquired complications. Unnecessary visits should therefore be avoided as much as possible. The objective of the study was to evaluate whether a program to provide geriatric knowledge and tools to the dispatching physicians of the EMS could decrease ED referrals of older patients. METHODS: Design: Before-and-after study with two 6-month periods before and after intervention. PARTICIPANTS: All calls received by a dispatching physician of the Rhône EMS from 8 am to 6 pm concerning patients aged 75 years or above during the study period. INTERVENTION: A program consisting of training dispatching physicians in the specific care of older patients and the developing, with a multidisciplinary team, of specific tools for dispatching physicians. OUTCOME: Proportion of ED referrals of patients aged 75 years or above after a call to the EMS. RESULTS: A total of 2671 calls to the Rhône EMS were included corresponding to 1307 and 1364 patients in the pre-and post-intervention phases, respectively. There was no significant difference in the proportion of referrals to the ED between the pre-intervention (61.7%) and the post-intervention (62.8%) phases (p = 0.57). Contact of the patients with their General Practitioner (GP) in the month preceding the call was associated with a 22% reduced probability of being referred to an ED. CONCLUSIONS: No beneficial effect of the intervention was demonstrated. This strategy of intervention is probably not effective enough in such time-constraint environment. Other strategies with a specific parallel dispatching of geriatric calls by geriatricians should be tested to avoid these unnecessary ED referrals. TRIAL REGISTRATION: ClinicalTrials NCT02712450.

Emergency calls concerning older patients: Are the appropriate questions asked?

AIM: In the present study, we evaluated the triage process particularly for older patients after calls to Emergency Medical Call Centers (ECC), according to the geriatric assessment tool. METHODS: In this observational population-based cross-sectional study in the Rhône (France), we analyzed the audiotapes of all calls received by ECC concerning patients aged ≥75 years, during seven randomly selected days, over a period of 1 year. We analyzed whether information about seven key items, predefined by a panel of experts as essential for quality telephone triage of seniors, was actually collected. RESULTS: Among 4168 calls, 712 (17.1%) concerned patients >75 years (mean ± SD, age 84.6 ± 5.6 years). The mean duration of calls was 3 min 28 s. Information about living arrangements (alone or not), dependency, multiple pathologies, polymedication, ability to walk independently or with help, and hospitalization in the previous 3 months was not collected in 20%, 42%, 40%, 45%, 58% and 61% of calls, respectively. All seven geriatric items were collected for only 54 (7.8%) calls, and only three criteria collected for 277 (40%) calls. Nurse-managed calls were significantly associated with the collection of less geriatric items compared with physician-managed calls. CONCLUSION: Key information is particularly important to guide the orientation, and further management of older patients may be lacking during the telephone triage of patients in ECCs. This may represent an important level of improvement of the triage process, to address the needs of older patients better and avoid inappropriate emergency department visits. Geriatr Gerontol Int 2023; 23: 54-59.

Referral pathway of patients aged 75 years and older after a telephone triage by the French emergency medical communication center (SAMU).

OBJECTIVES: To map the referral pathways of elderly people after telephone calls to Emergency Medical Communication Centers (ECC) in France. DESIGN: Retrospective observational study. SETTING: ECC and Emergency Departments (ED) of the Rhone region in France in 2013. PARTICIPANTS: Patients aged 75 years and older who called or had calls made to the ECC on 7 non-consecutive days (n = 712). MEASUREMENTS: All calls made by/for patients aged 75 and over were analyzed. Data were collected regarding geriatric assessment and patient discharge destination after admission to an ED. RESULTS: All 4168 calls received over the 7 days were analyzed. Of these, 692 involved the care of elderly people and were included. The median call duration was 2min59 [1min57; 4min13]. Following the call, 35% of the patients remained at home, 62% were referred to ED and 3% were directly hospitalized in intensive care units. Of the patients admitted to ED, 73% had a stable clinical condition and the main reason for admission was a fall (28%). Following ED care, 56% of patients were hospitalized and 44% returned directly home. CONCLUSION: Over half the elderly patients included in this study were referred to an ED after a call to ECC. For half of them, their clinical condition was considered stable and they were discharged after the ED visit. A more appropriate assessment of clinical conditions among geriatric patients could help to improve patient triage during ECC calls, and therefore reduce ED referrals.

An onco-geriatric approach to select older patients for optimal treatments of pancreatic adenocarcinoma.

INTRODUCTION: Pancreatic adenocarcinoma affects mainly older patients. Surgery is indicated for localized tumors while chemotherapy alone is proposed in advanced or metastatic tumors. OBJECTIVE: To evaluate the feasibility of standard of care oncologic treatments in this population, the accuracy of the geriatric evaluation to predict the ability of patients to tolerate the recommended treatments and to identify specific geriatric prognosis factors. METHODS: We included, between 2007 and 2014, all consecutive patients over 70 years of age with a pathologically diagnosed pancreatic cancer. The patients underwent a comprehensive geriatric assessment before therapeutic decision in a multidisciplinary team meeting. We analyzed factors independently associated with all-cause mortality with Cox survival analysis. RESULTS: Seventy-three patients (median age = 77.9 years) were prospectively included. Among them, 42 patients underwent surgery whereas the 31 other patients not eligible for surgical treatment received chemotherapy (n = 22) or best supportive care alone (n = 9). Almost 62% of operated patients received adjuvant chemotherapy. In the non-surgical group, a mean of 9 cycles of palliative chemotherapy per patients were administrated. Median overall survival was 21.3 months in the surgical group and 6.1 months in the palliative group (p = 0.0001). Most of oncologic parameters were found to be independent survival predictors. Age was not associated with the survival, but a significant impact of Lawton's Instrumental Activities of Daily Living (IADL) impairment (IADL<4) (HR = 5.0, p = 0.047), Cumulative Index Rating Scale-Geriatric (CIRS-G) ≥2 (HR = 19, p = 0.035) and weight loss >10% (HR = 4.6, p = 0.03) on survival was detected. Surgery was the only factor independently predictive of survival in multivariate analysis (p < 0.001). CONCLUSION: Almost 90% of selected older pancreatic patients with cancer (64 out of 73 patients) may benefit from the same standard treatments as younger patients. IADL impairment of patients, CIRS-G ≥2, and weight loss >10% constitute survival prognostic factors which should be added to the oncological criteria in the therapeutic decision-making process.

Factors associated with Clostridium difficile infection: A nested case-control study in a three year prospective cohort.

BACKGROUND: Clostridium difficile infection (CDI) is a serious medical condition that is associated with substantial morbidity and mortality. Identification of risk factors associated with CDI and prompt recognition of patients at risk is key to successfully preventing CDI. METHODS: A 3-year prospective, observational, cohort study was conducted in a French university hospital and a nested case-control study was performed to identify risk factors for CDI. Inpatients aged 18 years or older, suffering from diarrhea suspected to be related to CDI, were asked to participate. RESULTS: A total of 945 patients were included, of which 233 cases had a confirmed CDI. CDI infection was more common in men (58.4%) (P = 0.04) compared with patients with diarrhea not related to C. difficile. Previous hospitalization (P < 0.001), prior treatment with antibiotics (P = 0.001) or antiperistaltics (P = 0.002), liver disease (P = 0.003), malnutrition (P < 0.001), and previous CDI (P < 0.001) were significantly more common in patients with CDI. Multivariate logistic regression analysis showed that exposure to antibiotics in the last 60 days (especially third generation cephalosporins and penicillins with ß-lactamase inhibitor), chronic renal or liver disease, malnutrition or previous CDI, were associated with an independent high risk of CDI. Age was not related with CDI. CONCLUSIONS: This study showed that antibiotics and some comorbid conditions were predictors of CDI. Patients at high risk of acquiring CDI at the time of admission may benefit from careful monitoring of antibiotic prescriptions and early attention to infection control issues. In future, these "high-risk" patients may benefit from novel agents being developed to prevent CDI.

Contacts between health care workers and patients in a short-stay geriatric unit during the peak of a seasonal influenza epidemic compared with a nonepidemic period.

BACKGROUND: Patterns of contacts between health care workers and patients during seasonal epidemics are unknown. Our study objective was to compare the number and duration of contacts between health care workers and patients during a nonepidemic period versus a community influenza epidemic, and to identify supercontactors. METHODS: Our observational study was conducted in a short-stay geriatric unit of a university hospital. Contacts between individuals were recorded by active radio frequency identification devices. Contact patterns were compared between 2 periods according to contact number and duration. Each care period lasted 5 days in the nonepidemic and influenza epidemic periods. RESULTS: The study included 21 medical doctors, 43 nurses, and 56 patients. In total, 3,200 contacts (61.4%; 152,700 seconds) were recorded during the nonepidemic period, with 2,013 contacts (38.6%; 92,740 seconds) in the epidemic period (P = .007). More cumulative contacts occurred during the nonepidemic period between nurses and patients (n = 2,638 [82%] vs n = 1,599 [79%]), but not between patients (n = 56 [18%] vs n = 414 [21%]). Contact duration between nurses and patients lasted longer during the nonepidemic period (P = .04). During the epidemic period, 6 nurses (15%) considered to be supercontactors accounted for 44.3% of the total number of contacts with patients. CONCLUSION: The pattern of contacts between individuals differed according to the presence or not of the community influenza peak that might have influenced the risk of nosocomial influenza.

Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial.

BACKGROUND: In France, for patients aged 75 or older, it has been estimated that the hospital readmission rate within 30 days is 14 %, a quarter being avoidable. Some evidence suggests that interventions "bridging" the transition from hospital to home and involving a designated professional (usually nurses) are the most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a care transition program from hospital to home for elderly admitted to short-stay units. METHODS: This is a multicentre, stepped-wedge cluster randomised trial. The program will be implemented at three times of the transition: 1) during the patient's stay in hospital: development of a discharge plan, creation of a transitional care file, and notification of the primary care physician about inpatient care and hospital discharge by the transition nurse; 2) on the day of discharge: meeting between the transition nurse and the patient to review the follow-up recommendations; and 3) for 4 weeks after discharge: follow-up by the transition nurse. The primary outcome is the 30-day unscheduled hospital readmission or emergency visit rate after the index hospital discharge. The patients enrolled will be aged 75 or older, hospitalized in an acute care geriatric unit, and at risk of hospital readmission or an emergency visit after returning home. In all, 630 patients will be included over a 14-month period. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: Our study makes it possible to evaluate the specific effect of a bridging intervention involving a designated professional intervening before, during, and after hospital discharge. The strengths of the study design are methodological and practical. It permits the estimation of the intervention effect using between- and within-cluster comparisons; the study of the fluctuations in unscheduled hospital readmission or emergency visit rates; the participation of all clusters in the intervention condition; the implementation of the intervention in each cluster successively. TRIAL REGISTRATION: This study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02421133 ). Registered 9 March 2015.

Combining high-resolution contact data with virological data to investigate influenza transmission in a tertiary care hospital.

OBJECTIVE: Contact patterns and microbiological data contribute to a detailed understanding of infectious disease transmission. We explored the automated collection of high-resolution contact data by wearable sensors combined with virological data to investigate influenza transmission among patients and healthcare workers in a geriatric unit. DESIGN: Proof-of-concept observational study. Detailed information on contact patterns were collected by wearable sensors over 12 days. Systematic nasopharyngeal swabs were taken, analyzed for influenza A and B viruses by real-time polymerase chain reaction, and cultured for phylogenetic analysis. SETTING: An acute-care geriatric unit in a tertiary care hospital. PARTICIPANTS: Patients, nurses, and medical doctors. RESULTS: A total of 18,765 contacts were recorded among 37 patients, 32 nurses, and 15 medical doctors. Most contacts occurred between nurses or between a nurse and a patient. Fifteen individuals had influenza A (H3N2). Among these, 11 study participants were positive at the beginning of the study or at admission, and 3 patients and 1 nurse acquired laboratory-confirmed influenza during the study. Infectious medical doctors and nurses were identified as potential sources of hospital-acquired influenza (HA-Flu) for patients, and infectious patients were identified as likely sources for nurses. Only 1 potential transmission between nurses was observed. CONCLUSIONS: Combining high-resolution contact data and virological data allowed us to identify a potential transmission route in each possible case of HA-Flu. This promising method should be applied for longer periods in larger populations, with more complete use of phylogenetic analyses, for a better understanding of influenza transmission dynamics in a hospital setting.

Detection of hospital outbreaks of influenza-like illness based on excess of incidence rates compared to the community.

The risk of nosocomial influenza-like illness (noso-ILI) compared with that of community-acquired ILI was calculated during 3 influenza seasons (2004-2007) at a 1100-bed university hospital with a total of 21,519 hospitalized patients. Outbreaks of noso-ILI occurred in each season, although a protective effect against noso-ILI was also identified for other wards.

Five years of hospital based surveillance of influenza-like illness and influenza in a short-stay geriatric unit.

BACKGROUND: Data on influenza in the healthcare setting are often based on retrospective investigations of outbreaks and a few studies described influenza during several consecutive seasons.The aim of the present work is to report data on influenza like illness (ILI) and influenza from 5-year prospective surveillance in a short-stay geriatrics unit. FINDINGS: A short stay geriatrics unit underwent 5 years of ILI surveillance from November 2004 to March 2009, with the aim of describing ILI in a non-outbreak context. The study was proposed to patients who presented ILI, defined as fever >37.8°C or cough or sore throat. Among 1,353 admitted patients, 115 presented an ILI, and 34 had hospital-acquired ILI (HA-ILI). Influenza was confirmed in 23 patients, 13 of whom had been vaccinated. Overall attack rates were 2.78% and 0.02% for HA-ILI and HA-confirmed influenza respectively, during the 5 seasons. CONCLUSIONS: This 5-year surveillance study supports the notion that influenza infections are common in hospitals, mostly impacting the elderly hospitalized in short-stay units. It highlights the need for appropriate control measures to prevent HA-ILI in geriatric units and protect elderly patients.

Estimating potential infection transmission routes in hospital wards using wearable proximity sensors.

BACKGROUND: Contacts between patients, patients and health care workers (HCWs) and among HCWs represent one of the important routes of transmission of hospital-acquired infections (HAI). A detailed description and quantification of contacts in hospitals provides key information for HAIs epidemiology and for the design and validation of control measures. METHODS AND FINDINGS: We used wearable sensors to detect close-range interactions ("contacts") between individuals in the geriatric unit of a university hospital. Contact events were measured with a spatial resolution of about 1.5 meters and a temporal resolution of 20 seconds. The study included 46 HCWs and 29 patients and lasted for 4 days and 4 nights. 14,037 contacts were recorded overall, 94.1% of which during daytime. The number and duration of contacts varied between mornings, afternoons and nights, and contact matrices describing the mixing patterns between HCW and patients were built for each time period. Contact patterns were qualitatively similar from one day to the next. 38% of the contacts occurred between pairs of HCWs and 6 HCWs accounted for 42% of all the contacts including at least one patient, suggesting a population of individuals who could potentially act as super-spreaders. CONCLUSIONS: Wearable sensors represent a novel tool for the measurement of contact patterns in hospitals. The collected data can provide information on important aspects that impact the spreading patterns of infectious diseases, such as the strong heterogeneity of contact numbers and durations across individuals, the variability in the number of contacts during a day, and the fraction of repeated contacts across days. This variability is however associated with a marked statistical stability of contact and mixing patterns across days. Our results highlight the need for such measurement efforts in order to correctly inform mathematical models of HAIs and use them to inform the design and evaluation of prevention strategies.

Influenza vaccination of healthcare workers in acute-care hospitals: a case-control study of its effect on hospital-acquired influenza among patients.

BACKGROUND: In acute-care hospitals, no evidence of a protective effect of healthcare worker (HCW) vaccination on hospital-acquired influenza (HAI) in patients has been documented. Our study objective was to ascertain the effectiveness of influenza vaccination of HCW on HAI among patients. METHODS: A nested case-control investigation was implemented in a prospective surveillance study of influenza-like illness (ILI) in a tertiary acute-care university hospital. Cases were patients with virologically-confirmed influenza occurring ≥ 72 h after admission, and controls were patients with ILI presenting during hospitalisation with negative influenza results after nasal swab testing. Four controls per case, matched per influenza season (2004-05, 2005-06 and 2006-07), were randomly selected. Univariate and multivariate conditional logistic regression models were fitted to assess factors associated with HAI among patients. RESULTS: In total, among 55 patients analysed, 11 (20%) had laboratory-confirmed HAI. The median HCW vaccination rate in the units was 36%. The median proportion of vaccinated HCW in these units was 11.5% for cases vs. 36.1% for the controls (P = 0.11); 2 (20%) cases and 21 (48%) controls were vaccinated against influenza in the current season (P = 0.16). The proportion of ≥ 35% vaccinated HCW in short-stay units appeared to protect against HAI among patients (odds ratio = 0.07; 95% confidence interval 0.005-0.98), independently of patient age, influenza season and potential influenza source in the units. CONCLUSIONS: Our observational study indicates a shielding effect of more than 35% of vaccinated HCW on HAI among patients in acute-care units. Investigations, such as controlled clinical trials, are needed to validate the benefits of HCW vaccination on HAI incidence in patients.

Influenza vaccine effectiveness among adult patients in a University of Lyon hospital (2004-2009).

The aim of this study was to estimate influenza vaccine effectiveness (IVE) against laboratory-confirmed influenza among hospitalized patients. A case-control investigation was based on the prospective surveillance of influenza-like illness (ILI) during five flu seasons. We compared influenza-positive cases and influenza-negative controls. Unadjusted overall IVE was 62% (95% confidence interval 24% to 81%). We found that IVE was lower during the 2004-05 flu season (11%; 95% CI -232% to 76%) when the vaccine and circulating viruses were mismatched. Expansion of the study to other hospitals could provide IVE estimates earlier in the season, for different age groups and emerging virus strains.

Impact of a multifaceted program to prevent postoperative delirium in the elderly: the CONFUCIUS stepped wedge protocol.

BACKGROUND: Postoperative delirium is common in the elderly and is associated with a significant increase in mortality, complications, length of hospital stay and admission in long care facility. Although several interventions have proved their effectiveness to prevent it, the Cochrane advises an assessment of multifaceted intervention using rigorous methodology based on randomized study design. Our purpose is to present the methodology and expected results of the CONFUCIUS trial, which aims to measure the impact of a multifaceted program on the prevention of postoperative delirium in elderly. METHOD/DESIGN: Study design is a stepped wedge cluster randomized trial within 3 surgical wards of three French university hospitals. All patients aged 75 and older, and admitted for scheduled surgery will be included. The multifaceted program will be conducted by mobile geriatric team, including geriatric preoperative consultation, training of the surgical staff and implementation of the Hospital Elder Life Program, and morbidity and mortality conference related to delirium cases. The primary outcome is based on postoperative delirium rate within 7 days after surgery. This program is planned to be implemented along four successive time periods within all the surgical wards. Each one will be affected successively to the control arm and to the intervention arm of the trial and the order of program introduction within each surgical ward will be randomly assigned. Based on a 20% reduction of postoperative delirium rate (ICC = 0.25, α = 0.05, ß = 0.1), three hundred sixty patients will be included i.e. thirty patients per service and per time period. Endpoints comparison between intervention and control arms of the trial will be performed by considering the cluster and time effects. DISCUSSION: Better prevention of delirium is expected from the multifaceted program, including a decrease of postoperative delirium, and its consequences (mortality, morbidity, postoperative complications and length of hospital stay) among elderly patients. This study should allow better diagnosis of delirium and strengthen the collaboration between surgical and mobile geriatric teams. Should the program have a substantial impact on the prevention of postoperative delirium in elderly, it could be extended to other facilities. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01316965.

Risk of influenza-like illness in an acute health care setting during community influenza epidemics in 2004-2005, 2005-2006, and 2006-2007: a prospective study.

BACKGROUND: The person-to-person transmission of influenza-like illness (ILI) and influenza has been described mostly in long-term care units. Studies in acute hospital settings are rare and mostly retrospective. METHODS: We prospectively estimated the relative risk (RR) of hospital-acquired (HA) ILI during hospitalization according to in-hospital exposures to contagious individuals. Surveillance of ILI and laboratory-confirmed influenza was undertaken at Edouard Herriot Hospital (1100 beds) during 3 influenza seasons. A total of 21 519 patients and 2153 health care workers (HCWs) from 2004 to 2007 were included. The RR of HA-ILI in patients was calculated according to exposure to other contagious patients and HCWs. RESULTS: For patients exposed to at least 1 contagious HCW compared with those with no documented exposure in the hospital, the RR of HA-ILI was 5.48 (95% confidence interval [CI], 2.09-14.37); for patients exposed to at least 1 contagious patient, the RR was 17.96 (95% CI, 10.07-32.03); and for patients exposed to at least 1 contagious patient and 1 contagious HCW, the RR was 34.75 (95% CI, 17.70-68.25). CONCLUSIONS: Hospitalized patients exposed to potentially infectious patients and HCWs with ILI inside the hospital are at greater risk for HA-ILI. Such results identify priorities regarding preventive measures for seasonal or pandemic influenza.