RESUMO
Frequent users of the emergency department (ED) who contribute to ED overcrowding are a well-known public health issue. An integrative and multidisciplinary approach through case management (CM) is the intervention of choice to reduce the number of ED visits. This strategy seems to work particularly well among patients with psychiatric comorbidities and could also be implemented in the prehospital setting in collaboration with emergency medical services and primary care physicians. The actual implementation of CM has however not yet progressed. Ongoing studies aimed at proving the economic and medical efficiency of CM could lead to a wider implementation in the future.
Les grands consommateurs des services d'urgences (GCSU) qui participent à l'engorgement de ces services sont un enjeu de santé publique bien connu. Une approche intégrative et pluridisciplinaire sous forme de case management (CM) est l'approche de prédilection afin de diminuer le nombre de consultations aux urgences. Cette stratégie semble particulièrement bien fonctionner chez des GCSU avec comorbidités psychiatriques et pourrait être également mise en place dès la phase préhospitalière par les services d'ambulances et les médecins généralistes. L'implémentation concrète du CM peine pourtant à progresser. Des études en cours visant à en prouver l'efficacité économique et médicale pourraient favoriser une mise en place plus large dans un futur proche.
Assuntos
Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Humanos , Administração de Caso , Estudos Interdisciplinares , ConhecimentoRESUMO
Background: Prompt recognition of sepsis is critical to improving patients' outcomes. We compared the performance of NEWS and qSOFA scores as sepsis detection tools in patients admitted to the emergency department (ED) with suspicion of sepsis. Methodology: A single-center 12-month retrospective study comparing NEWS using the recommended cut-off of ≥5 and qSOFA as sepsis screening tools in a cohort of patients transported by emergency medical services (EMS) to the Lausanne University Hospital (LUH). We used the Sepsis-3 consensus definition. The primary study endpoint was the detection of sepsis. Secondary endpoints were ICU admission and 28-day all-cause mortality. Results: Among 886 patients admitted to ED by EMS for suspected infection, 556 (63%) had a complete set of vital parameters panel enabling the calculation of NEWS and qSOFA scores, of whom 300 (54%) had sepsis. For the detection of sepsis, the sensitivity of NEWS > 5 was 86% and that of qSOFA ≥ 2 was 34%. Likewise, the sensitivities of NEWS ≥ 5 for predicting ICU admission and 28-day mortality were higher than those of qSOFA ≥ 2 (82% versus 33% and 88% versus 37%). Conversely, the specificity of qSOFA ≥ 2 for sepsis detection was higher than that of NEWS ≥ 5 (90% versus 55%). The negative predictive value of NEWS > 5 was higher than that of qSOFA ≥ 2 (77% versus 54%), while the positive predictive value of qSOFA ≥ 2 was higher than that of NEWS ≥ 5 (80% versus 69%). Finally, the accuracy of NEWS ≥ 5 was higher than that of qSOFA ≥ 2 (72% versus 60%). Conclusions: The sensitivity of NEWS ≥ 5 was superior to that of qSOFA ≥ 2 to identify patients with sepsis in the ED and predict ICU admission and 28-day mortality. In contrast, qSOFA ≥ 2 had higher specificity and positive predictive values than NEWS ≥ 5 for these three endpoints.
RESUMO
BACKGROUND: Basic life support (BLS) is the first link in the chain of survival and should be performed by every lay rescuer. Although international studies have suggested that BLS knowledge was poor among the overall population, Swiss data are scarce. Our objective in this study was to evaluate BLS knowledge among Swiss conscripts, a semi-representative sample of Swiss young adults, during the recruitment process and to identify potential characteristics related to performance. METHODS: A short online voluntary anonymous survey was proposed to Swiss conscripts called to duty in the six national recruiting centres of the Swiss Armed Forces during an 8-month period (2 February 2019 to 27 September 2019). The survey was available in three official languages (French, German, and Italian). Considered outcome was BLS knowledge evaluated on a Likert scale from 1 (very bad) to 6 (excellent). Univariate and multivariate ordinal logistic regression analyses were performed to assess the relationship between BLS knowledge and participants' characteristics. RESULTS: Among the 19,247 conscripts called to service during the study period, 737 replied to the survey. Among them, 735 were included in the analyses (mean age 19.8 years [± 2.1]). Of these, 144 (20%) had never received any BLS training. The BLS knowledge survey was completely answered by 670 participants (91%). 157 participants (23%) reached a BLS knowledge score ≥5. Out of 695 answers, 142 (20%) did not know the Swiss emergency phone number. Out of 670 answers, 364 (54%) believed that CPR could worsen the health status of a person in cardiac arrest, whereas 413 (62%) agreed that BLS training should be mandatory in secondary school. German as native language (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.0-.8)], receipt of BLS training (OR 3.1, 95% CI 2.0-4.8), and female gender were associated with a higher BLS knowledge score. Time since the last BLS training of ≥3 years (OR 0.5, 95% CI 0.4-0.7) and unemployment (OR 0.3, 95% CI 0.1-0.9) were associated with a lower BLS knowledge score. We found substantial agreement between conscripts' scores and their self-assessments (weighted kappa with 74% agreement). DISCUSSION AND CONCLUSION: Knowledge of the emergency phone number and BLS principles was poor among Swiss conscripts participating in the study. However, their awareness and motivation is high. The effect of training during boot camp should be evaluated in further studies. Focusing on BLS training is essential and should be promoted in educational and professional contexts.