Direct phone communication to primary care physician to plan discharge from hospital: feasibility and benefits.

BACKGROUND: The discharge summary is the main vector of communication at the time of hospital discharge, but it is known to be insufficient. Direct phone contact between hospitalist and primary care physician (PCP) at discharge could ensure rapid transmission of information, improve patient safety and promote interprofessional collaboration. The objective of this study was to evaluate the feasibility and benefit of a phone call from hospitalist to PCP to plan discharge. METHODS: This study was a prospective, single-center, cross-sectional observational study. It took place in an acute medicine unit of a French university hospital. The hospitalist had to contact the PCP by telephone within 72 h prior discharge, making a maximum of 3 call attempts. The primary endpoint was the proportion of patients whose primary care physician could be reached by telephone at the time of discharge. The other criteria were the physicians' opinions on the benefits of this contact and its effect on readmission rates. RESULTS: 275 patients were eligible. 8 hospitalists and 130 PCPs gave their opinion. Calls attempts were made for 71% of eligible patients. Call attempts resulted in successful contact with the PCP 157 times, representing 80% of call attempts and 57% of eligible patients. The average call completion rate was 47%. The telephone contact was perceived by hospitalist as useful and providing security. The PCPs were satisfied and wanted this intervention to become systematic. Telephone contact did not reduce the readmission rate. CONCLUSIONS: Despite the implementation of a standardized process, the feasibility of the intervention was modest. The main obstacle was hospitalists lacking time and facing difficulties in reaching the PCPs. However, physicians showed desire to communicate directly by telephone at the time of discharge. TRIAL REGISTRATION: French C.N.I.L. registration number 2108852. Registration date October 12, 2017.

Noninvasive End Tidal CO2 Is Unhelpful in the Prediction of Complications in Deliberate Drug Poisoning.

STUDY OBJECTIVE: We study the performance of capnometry in the detection of early complications after deliberate drug poisoning. METHODS: This was a prospective cohort study of self-poisoned adult patients who presented at an emergency department (ED) between April 20, 2012, and May 6, 2014. Patients who ingested at least 1 neurologic or respiratory depressant drug were included. The primary outcome was the predictive value of an end tidal CO2 (etco2) measurement greater than or equal to 50 mm Hg for the detection of early complications defined a priori by hypoxia requiring oxygen greater than or equal to 3 L/min, bradypnea less than or equal to 10 breaths/min, or ICU admission after intubation or antidote administration because of unresponsiveness to pain or respiratory arrest. Consciousness scales and clinical data were recorded at admission and every 30 minutes. Noninvasive etco2 was continuously measured for 2 hours after inclusion unless the patient was admitted to the ICU. Patients and physicians were blinded to etco2 values. RESULTS: Two hundred one patients were included, 35 of whom exhibited at least 1 complication. An etco2 measurement greater than or equal to 50 mm Hg predicted the onset of a complication, with a sensitivity of 46% (95% confidence interval [CI] 29% to 63%) and a specificity of 80% (95% CI 73% to 86%), leading to a positive predictive value of 33% (95% CI 20% to 48%) and a negative predictive value of 88% (95% CI 81% to 92%). etco2 was less able to predict complications than the Glasgow Coma Scale score at inclusion. CONCLUSION: Capnometry in isolation does not provide adequate prediction of early complications in self-poisoned patients referred to the ED. A dynamic minute-by-minute assessment of etco2 could be more predictive.

Pulmonary embolism in mechanically ventilated patients requiring computed tomography: Prevalence, risk factors, and outcome.

OBJECTIVE: To estimate the rate of pulmonary embolism among mechanically ventilated patients and its association with deep venous thrombosis. DESIGN: Prospective cohort study. SETTING: Medical intensive care unit of a university-affiliated teaching hospital. INCLUSION CRITERIA: mechanically ventilated patients requiring a thoracic contrast-enhanced computed tomography scan for any medical reason. EXCLUSION CRITERIA: a diagnosis of pulmonary embolism before intensive care unit admission, an allergy to contrast agents, and age younger than 18 yrs. INTERVENTIONS: All the mechanically ventilated patients requiring a thoracic computed tomography underwent the standard imaging protocol for pulmonary embolism detection. Therapeutic anticoagulation was given immediately after pulmonary embolism diagnosis. All the included patients underwent a compression ultrasound of the four limbs within 48 hrs after the computed tomography scan to detect deep venous thrombosis. RESULTS: Of 176 included patients, 33 (18.7%) had pulmonary embolism diagnosed by computed tomography, including 20 (61%) with no clinical suspicion of pulmonary embolism. By multiple logistic regression, independent risk factors for pulmonary embolism were male gender, high body mass index, history of cancer, past medical history of deep venous thrombosis, coma, and high platelet count. Previous prophylactic anticoagulant use was not a risk factor for pulmonary embolism. Of the 176 patients, 35 (19.9%) had deep venous thrombosis by compression ultrasonography, including 20 (57.1%) in the lower limbs and 24 (68.6%) related to central venous catheters. Of the 33 pulmonary embolisms, 11 (33.3%) were associated with deep venous thrombosis. The pulmonary embolism risk was increased by lower-limb deep venous thrombosis (odds ratio 4.0; 95% confidence interval 1.6-10) but not upper-limb deep venous thrombosis (odds ratio 0.6; 95% confidence interval 0.1-2.9). Crude comparison of patients with and without pulmonary embolism shows no difference in length of stay or mortality. CONCLUSIONS: In mechanically ventilated patients who needed a computed tomography, pulmonary embolism was more common than expected. Patients diagnosed with pulmonary embolism were all treated with therapeutic anticoagulation, and their intensive care unit or hospital mortality was not impacted by the pulmonary embolism occurrence. These results invite further research into early screening and therapeutic anticoagulation of pulmonary embolism in critically ill patients.

Screening of hepatitis E in patients presenting for acute neurological disorders.

INTRODUCTION: Hepatitis E virus (HEV) infection has been reported to be associated with neurological disorders. However, the real prevalence of acute hepatitis E in those diseases is still unknown. We determined the prevalence of anti-HEV IgM antibody in a population with acute non-traumatic, non-metabolic, non-vascular neurological injury. METHOD: A registry was created in Grenoble Hospital University from 2014 to 2018 to collect data on patients with acute (<3 months) non-traumatic, non-metabolic, non-vascular neurological injuries. Acute hepatitis E was defined as anti-HEV IgM-positive serum in immunocompetent patient, and as anti-HEV IgM-positive serum or HEV RNA-positive serum in immunocompromised patients. RESULTS: One hundred fifty-nine patients were included. Anti-HEV IgM seroprevalence in our cohort of non-traumatic, non-metabolic, non-vascular neurological injuries was 6.9% (eleven patients, including 4 Parsonage-Turner syndrome (PTS) and 2 Guillain-Barré syndrome (GBS)). Elevated transaminases were observed in only 64% of hepatitis E patients and cholestasis in 64%. CONCLUSION: In this study, 6·9% of patients with acute non-traumatic, non-metabolic, non-vascular neurological injuries had a probable recent HEV infection. HEV serology should be systematically performed in this population, even in patients with normal transaminase level.

Ultrasonography helps emergency physician identify the best lumbar puncture site under the conus medullaris.

BACKGROUND: Ultrasonography - assisted lumbar puncture helps physicians identify traditional anatomical landmarks. However, it could help to overcome the anatomical dogmas and thus identify the best interspinous space under the medullary cone. METHODS: Traditional anatomical landmarks were reported on a tracing paper in patients with an indication for lumbar puncture. Then, ultrasonography was used to locate the optimal interspinous level defined as the widest subarachnoid space located below the conus medullaris. Primary endpoint was the distance between traditional and ultrasound landmarks. RESULTS: Fifty-seven patients were included. Seven emergency physicians practiced the procedure. The median absolute distance between traditional anatomical landmarks and ultrasound marking was 32 [interquartile (IQR) 27 - 37] mm. The inter-spinous space identified in the two procedures was different in 68% of the cases. CONCLUSIONS: Ultrasound not only allows us to better identify anatomical structures before lumbar puncture, but it also allows us to choose a site of puncture different from recommendations.