Effect of the 1-h bundle on mortality in patients with suspected sepsis in the emergency department: a stepped wedge cluster randomized clinical trial.

PURPOSE: The efficacy of the 1-h bundle for emergency department (ED) patients with suspected sepsis, which includes lactate measurement, blood culture, broad-spectrum antibiotics administration, administration of 30 mL/kg crystalloid fluid for hypotension or lactate ≥ 4 mmol/L, remains controversial. METHODS: We carried out a pragmatic stepped-wedge cluster-randomized trial in 23 EDs in France and Spain. Adult patients with Sepsis-3 criteria or a quick sequential organ failure assessment (SOFA) score ≥ 2 or a lactate > 2 mmol/L were eligible. The intervention was the implementation of the 1-h sepsis bundle. The primary outcome was in-hospital mortality truncated at 28 days. Secondary outcomes included volume of fluid resuscitation at 24 h, acute heart failure at 24 h, SOFA score at 72 h, intensive care unit (ICU) length of stay, number of days on mechanical ventilation or renal replacement therapy, vasopressor free days, unnecessary antibiotic administration, and mortality at 28 days. 1148 patients were planned to be analysed; the study period ended after 873 patients were included. RESULTS: 872 patients (mean age 66, 42% female) were analyzed: 387 (44.4%) in the intervention group and 485 (55.6%) in the control group. Median SOFA score was 3 [1-5]. Median time to antibiotic administration was 40 min in the intervention group vs 113 min in the control group (difference - 73 [95% confidence interval (CI) - 93 to - 53]). There was a significantly higher rate, volume, and shorter time to fluid resuscitation within 3 h in the intervention group. There were 47 (12.1%) in-hospital deaths in the intervention group compared to 61 (12.6%) in the control group (difference in percentage - 0.4 [95% CI - 5.1 to 4.2], adjusted relative risk (aRR) 0.81 [95% CI 0.48 to 1.39]). There were no differences between groups for other secondary endpoints. CONCLUSIONS: Among patients with suspected sepsis in the ED, the implementation of the 1-h sepsis bundle was not associated with significant difference in in-hospital mortality. However, this study may be underpowered to report a statistically significant difference between groups.

Effect of early ultrasound-guided femoral nerve block on preoperative opioid consumption in emergency patients with hip fracture: a randomized trial.

BACKGROUND AND IMPORTANCE: Ultrasound-guided femoral nerve block (FNB) could be used as part of a multimodal preoperative pain management for patients with hip fracture. Evidence of the effects of its early implementation in the emergency room as an immediate alternative to intravenous morphine titration is sparse. OBJECTIVE: To investigate the effect of an early ultrasound-guided FNB performed by emergency physicians on preoperative opioid consumption, compared to standard pain management. DESIGN, SETTING, AND PARTICIPANTS: This open randomized controlled trial was conducted in the Emergency Department of a French hospital with patients with neck or trochanteric femoral fracture who had a pain score ≥7 out of 10 points at triage. INTERVENTION: Patients were randomized to receive an initial analgesia with an early ultrasound-guided FNB or with standard pain management. The continuation of pain treatment followed standardized pain control guidelines until hospital discharge in both groups. OUTCOME MEASURE AND ANALYSIS: The primary outcome was preoperative opioid consumption truncated 48h after triage time, and converted in morphine milligram intravenous equivalents (MME). Secondary outcomes were time to pain relief, time for regaining walk, opioid consumption and occurrence of opioid and FNB adverse effects during the hospital stay. Exploratory outcomes included ease and duration of the procedure. MAIN RESULTS: We randomized 35 patients: 17 to standard pain management and 18 to ultrasound-guided FNB, among whom 30 patients completed the protocol. The median of preoperative opioid consumption was reduced by 60% in the ultrasound-guided FNB group compared to standard group [6 MME (3-9) vs. 15 MME (11-18)], with a consumption difference of 9 MME (95% CI: 3-14, P  < 0.001). Throughout hospital stay, opioid consumption was reduced by 56% in the ultrasound-guided FNB group compared to standard group, with a consumption difference of 11.5 MME (95% CI: 0.5-22).Times to pain relief and for regaining walk did not differ between groups. Opioid adverse events occurrence were reduced by 40% (95% CI: 5.1-74.9) in the ultrasound-guided FNB group compared to standard group. No adverse effects of FNB have been detected. CONCLUSION: Early ultrasound-guided FNB resulted in reducing preoperative opioid consumption, without delaying time to pain relief.

Misdiagnosis of thrombotic microangiopathy in the emergency department: a multicenter retrospective study.

To estimate the rate of inappropriate diagnosis in patients who visited the ED with thrombotic microangiopathy (TMA) and to assess the factors and outcomes associated with emergency department (ED) misdiagnosis. Retrospective multicenter study of adult patients admitted to the intensive care unit (ICU) for TMA from 2012 to 2021 who had previously attended the ED for a reason related to TMA. Patient characteristics and outcomes were compared in a univariate analysis based on whether a TMA diagnosis was mentioned in the ED or not. Forty patients were included. The diagnosis of TMA was not mentioned in the ED in 16 patients (40%). Patients for whom the diagnosis was mentioned in the ED had more frequently a request for schistocytes research, and therefore had more often objectified schistocytes. They also had more frequently a troponin dosage in the ED (even if the difference was not significant), an ECG performed or interpreted, and were admitted more quickly in the ICU (0 [0-0] vs 2 [0-2] days; P = 0.002). Hemoglobin levels decreased significantly in both groups, and creatinine levels increased significantly in the misdiagnosis group between ED arrival and ICU admission. In patients with a final diagnosis of TTP, the time to platelets durable recovery was shorter for those in whom the diagnosis was mentioned in the ED without reaching statistical significance (7 [5-11] vs 14 [5-21] days; P = 0.3).

Intensified screening for SARS-CoV-2 in 18 emergency departments in the Paris metropolitan area, France (DEPIST-COVID): A cluster-randomized, two-period, crossover trial.

BACKGROUND: Asymptomatic and paucisymptomatic infections account for a substantial portion of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmissions. The value of intensified screening strategies, especially in emergency departments (EDs), in reaching asymptomatic and paucisymptomatic patients and helping to improve detection and reduce transmission has not been documented. The objective of this study was to evaluate in EDs whether an intensified SARS-CoV-2 screening strategy combining nurse-driven screening for asymptomatic/paucisymptomatic patients with routine practice (intervention) could contribute to higher detection of SARS-CoV-2 infections compared to routine practice alone, including screening for symptomatic or hospitalized patients (control). METHODS AND FINDINGS: We conducted a cluster-randomized, two-period, crossover trial from February 2021 to May 2021 in 18 EDs in the Paris metropolitan area, France. All adults visiting the EDs were eligible. At the start of the first period, 18 EDs were randomized to the intervention or control strategy by balanced block randomization with stratification, with the alternative condition being applied in the second period. During the control period, routine screening for SARS-CoV-2 included screening for symptomatic or hospitalized patients. During the intervention period, in addition to routine screening practice, a questionnaire about risk exposure and symptoms and a SARS-CoV-2 screening test were offered by nurses to all remaining asymptomatic/paucisymptomatic patients. The primary outcome was the proportion of newly diagnosed SARS-CoV-2-positive patients among all adults visiting the 18 EDs. Primary analysis was by intention-to-treat. The primary outcome was analyzed using a generalized linear mixed model (Poisson distribution) with the center and center by period as random effects and the strategy (intervention versus control) and period (modeled as a weekly categorical variable) as fixed effects with additional adjustment for community incidence. During the intervention and control periods, 69,248 patients and 69,104 patients, respectively, were included for a total of 138,352 patients. Patients had a median age of 45.0 years [31.0, 63.0], and women represented 45.7% of the patients. During the intervention period, 6,332 asymptomatic/paucisymptomatic patients completed the questionnaire; 4,283 were screened for SARS-CoV-2 by nurses, leading to 224 new SARS-CoV-2 diagnoses. A total of 1,859 patients versus 2,084 patients were newly diagnosed during the intervention and control periods, respectively (adjusted analysis: 26.7/1,000 versus 26.2/1,000, adjusted relative risk: 1.02 (95% confidence interval (CI) [0.94, 1.11]; p = 0.634)). The main limitation of this study is that it was conducted in a rapidly evolving epidemiological context. CONCLUSIONS: The results of this study showed that intensified screening for SARS-CoV-2 in EDs was unlikely to identify a higher proportion of newly diagnosed patients. TRIAL REGISTRATION: Trial registration number: ClinicalTrials.gov NCT04756609.

Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department : A Retrospective Analysis.

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.

Effectiveness and reliability of the four-step STANDING algorithm performed by interns and senior emergency physicians for predicting central causes of vertigo.

BACKGROUND: For emergency physicians (EPs), acute vertigo is a challenging complaint and learning a reliable clinical approach is needed. STANDING is a four-step bedside algorithm that requires (1) identifying spontaneous nystagmus with Frenzel glasses or, alternatively, a positional nystagmus; (2) characterizing the nystagmus direction; (3) assessing the vestibuloocular reflex (head impulse test); and (4) assessing the gait. The objective was to determine its accuracy for diagnosing central vertigo when using by naïve examiners as such as interns and its agreement with senior EPs. METHODS: This was a prospective 1-year diagnostic cohort study among patients with vertigo, vestibulovisual symptoms, or postural symptoms seen by 20 interns trained in the four-step examination. The algorithm was performed first by an intern and second by a senior EP and categorized as either worrisome when indicating a central diagnosis and benign or inconclusive when indicating a peripheral diagnosis. The reference test was diffusion-weighted brain magnetic resonance imaging. RESULTS: Among 312 patients included, 57 had a central diagnosis including 33 ischemic strokes (10.5%). The main etiology was benign paroxysmal positional vertigo (32.7%). The likelihood ratios were 4.63 and 10.33 for a worrisome STANDING, 0.09 and 0.01 for a benign STANDING, and 0.21 and 0.35 for an inconclusive STANDING, for interns and senior EPs, respectively. The algorithm showed sensitivities of 84.8% (95% CI 75.6%-93.9%) and 89.8% (95% CI 82.1%-97.5%), negative predictive values of 96.2% (95% CI 93.7%-98.6%) and 97.5% (95% CI 95.5%-99.5%), specificities of 88.9% (95% CI 85.1%-92.8%) and 91.3% (95% CI 87.8%-94.8%), and positive predictive values of 64.1% (95% CI 53.5%-74.8%) and 70.7% (95% CI 60.4%-81.0%), respectively. The agreement between interns and senior EPs was very substantial (B-statistic coefficient: 0.77) and almost perfect for each step: (1) 0.87, (2) 0.98, (3) 0.95, and (4) 0.99. CONCLUSIONS: With a single training session, the algorithm reached high accuracy and reliability for ruling out central causes of vertigo in the hands of both novices and experienced EPs. A future multicenter randomized controlled trial should further its impact on unnecessary neuroimaging use and patient's satisfaction.

Head computed tomography for elderly patients with acute altered mental status in the emergency setting: value for decision-making and predictors of abnormal findings.

OBJECTIVE: This study evaluated the impact of head computed tomography (CT) on clinical decision-making about older adults with acute altered mental status (AMS) in the emergency department in terms of CT's diagnostic yield, emergency department length of stay, and changes in medical strategy. It also attempted to find predictors of an acute imaging abnormality. METHODS: This was a 1-year, retrospective, single-center observational study of patients aged ≥75 years who underwent noncontrast head CT because of an isolated episode of AMS. The acute positive CT findings were ischemic strokes, hemorrhages, tumors, demyelinating lesions, hydrocephalus, and intracranial infections. RESULTS: A total of 594 CTs were performed, of which 38 (6.4%) were positive. The main etiology of AMS was sepsis (29.1%). Changes in medical strategy were more common in patients with a positive CT, and the major changes were ordering additional neuro exams (odds ratio [OR], 95.3; 95% confidence interval [CI], 38.4-233.8; P<0.001), adjusting treatments (OR, 12.2; 95% CI, 5.0-29.5; P<0.001), and referral to a neurologic unit (OR, 7.3; 95% CI, 3.0-17.5; P<0.01). Three factors were significantly associated with a positive outcome: Glasgow Coma Scale <13 (OR, 8.5; 95% CI, 2.3-28.9; P<0.001), head wound (OR, 3.1; 95% CI, 1.1-8.2; P=0.025), and dehydration (OR, 0.3; 95% CI, 0.1-0.4; P=0.021). For elderly patients with a Glasgow Coma Scale ≥13 and no head wound or clinical dehydration, the probability of a positive CT was 0.02 (95% CI, 0.01-0.04). Considering only those patients, the diagnostic yield fell to 1.7%. CONCLUSION: In elderly patients, the causes of AMS are primarily extracerebral. Randomized clinical trials are needed to validate a clinical pathway for selecting patients who require emergent neuroimaging.

Clinical and operational impact of rapid point-of-care SARS-CoV-2 detection in an emergency department.

STUDY OBJECTIVE: Rapid point-of-care (POC) SARS-CoV-2 detection with Abbott ID NOW™ COVID-19 test has been implemented in our Emergency Department (ED) for several months. We aimed to evaluate the operational impact and potential benefits of this innovative clinical pathway. METHODS: We conducted a prospective, descriptive, interventional, non-randomized study, before-after trial with the comparison of patient cohorts from two consecutive periods of seven weeks (observational pre-POC period vs interventional POC period). RESULTS: In 2020, throughout weeks 37 to 50, 3333 patients were assessed for eligibility and among them 331 (9.9%) were positive for SARS-CoV-2 infections. Among the included patients, 136 (9.2%) were positive for SARS-CoV-2 infection in the pre-POC period and 195 (10.5%) in the POC period. Among positive patients for SARS-CoV-2 related infection in-hospital mortality rate was similar between the two groups but the hospitalization rate was higher in the POC group (81.6% vs. 65.4%; p < 0.001). More patients in the POC period were able to leave the ED within 6 h. We examined rates of antibiotic, anticoagulant, and corticosteroid prescriptions among patients tested for SARS-CoV-2 in the ED. Only the rate of prescribed anticoagulants was found to be higher in the POC period (40% vs. 24.2%; p < 0.003). CONCLUSION: We demonstrated that COVID-19 point-of-care testing speeds up clinical decision-making, improving use of recommended treatments for COVID-19, such as anticoagulants. Moreover, it improves the boarding time and significantly shortened the length of stay in the ED for patients requiring outpatient care.

Prospective evaluation of ID NOW COVID-19 assay used as point-of-care test in an emergency department.

BACKGROUND: Rapid testing for COVID-19 has been clearly identified as an essential component of the strategy to control the SARS-CoV-2 epidemic, worldwide. The ID NOW COVID-19 assay is a simple, user-friendly, rapid molecular biology test based on nicking and extension amplification reaction (NEAR). OBJECTIVES: The aim of this study was to evaluate the ID NOW COVID-19 assay when used as a point-of-care test (POCT) in our Emergency Department (ED). TYPE OF STUDY: This prospective study enrolled 395 consecutive patients; paired nasopharyngeal swabs were collected from each study participant. The first swab was tested with the ID NOW COVID-19 assay at the point-of-care by ED nurses. The second swab was diluted in viral transport medium (VTM) and sent to the clinical microbiology department for analysis by both the RT-PCR Simplexa test COVID-19 Direct assay as the study reference method, and the ID NOW COVID-19 assay performed in the laboratory. RESULTS: Nasopharyngeal swabs directly tested with the ID NOW COVID-19 assay yielded a sensitivity, specificity, PPV and NPV of 98.0%, 97.5%, 96.2% and 98.7%, respectively, in comparison with the RT-PCR study reference assay. When the ID NOW COVID-19 assay was performed in the laboratory using the VTM samples, the sensitivity decreased to 62.5% and the NPV to 79.7%. Three false negative test results were reported with the ID NOW COVID-19 assay when performed using undiluted swabs directly in the ED; these results were obtained from patients with elevated CT values (> 30). CONCLUSION: We demonstrated that the ID NOW COVID-19 assay, performed as a point of care test in the ED using dry swabs, provides a rapid and reliable alternative to laboratory-based RT-PCR methods.

Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study.

BACKGROUND: Diagnosing stroke in dizzy patients remains a challenge in emergency medicine. The accuracy of the neuroophthalmologic examination HINTS performed by emergency physicians (EPs) is unknown. Our objective was to determine the accuracy of the HINTS examination performed by trained EPs for diagnosing central cause of acute vertigo and unsteadiness and to compare it with another bedside clinical tool, STANDING, and with the history-based score ABCD2. METHODS: This was a prospective diagnostic cohort study among patients with isolated vertigo and unsteadiness seen in a single emergency department (ED). Trained EPs performed HINTS and STANDING tests blinded to attending physicians. ABCD2 ≥ 4 was used as the threshold and was calculated retrospectively. The criterion standard was diffusion-weighted brain magnetic resonance imaging (MRI). Peripheral diagnoses were established by a normal MRI, and etiologies were further refined by an otologic examination. RESULTS: We included 300 patients of whom 62 had a central lesion on neuroimaging including 49 strokes (79%). Of the 238 peripheral diagnoses, 159 were vestibulopathies, mainly benign paroxysmal positional vertigo (40%). HINTS and STANDING tests reached high sensitivities at 97% and 94% and NPVs at 99% and 98%, respectively. The ABCD2 score failed to predict half of central vertigo cases and had a sensitivity of 55% and a NPV of 87%. The STANDING test was more specific and had a better positive predictive value (PPV; 75% and 49%, respectively; positive likelihood ratio [LR+] = 3.71, negative likelihood ratio [LR-] = 0.09) than the HINTS test (67% and 44%, respectively; LR+ = 2.96, LR- = 0.04). The ABCD2 score was specific (82%, LR+ = 3.04, LR- = 0.56) but had a very low PPV (44%). CONCLUSIONS: In the hands of EPs, HINTS and STANDING tests outperformed ABCD2 in identifying central causes of vertigo. For diagnosing peripheral disorders, the STANDING algorithm is more specific than the HINTS test. HINTS and STANDING could be useful tools saving both time and costs related to unnecessary neuroimaging use.

Antibiotic prescribing and outcomes in cancer patients with febrile neutropenia in the emergency department.

INTRODUCTION: The benefit of reducing the time of antibiotic initiation in the emergency department (ED) for neutropenic patients is controversial and the research on the impact of antibiotic adherence to international guidelines in the ED is scarce. We aimed to investigate the effect of antibiotic timing and appropriateness on outcomes in patients with febrile neutropenia (FN) and to assess the performance of the MASCC risk-index to risk-stratify such patients in the ED. METHODS: We prospectively identified patients with FN who presented to our ED and assessed their Multinational Association of Supportive Care in Cancer (MASCC) risk-index. The time to parenteral antibiotic initiation and the appropriateness of the antibiotic regimen according to international guidelines were retrospectively abstracted. The performance of the MASCC risk-index in predicting the absence of complication was assessed with sensitivity, specificity and the area under the receiver operating characteristics curve (AUC). We investigated the effect of the time to antibiotic initiation and the appropriateness of the antibiotic regimen on the outcome (ICU admission or death) by logistic regression analyses. RESULTS: We included 249 patients. Median age was 60 years and 67.9% had hematological malignancies, 26 (10.4%) were admitted to the ICU and 23 (9.8%) died during hospital stay. Among the 173 patients at low risk according to the MASCC risk-index, 56 (32.4%) presented at least one complication including 11 deaths. The MASCC risk-index had a sensitivity and a specificity of 0.78% and 0.43%, respectively, in predicting the absence of complication and the AUC was 0.67. The time to antibiotic initiation in the ED was not associated with the outcome after adjusting for performance status and shock-index. Conversely, an inadequate ED antibiotic regimen was associated with higher ICU admission or death during hospital stay (OR = 3.50; 95% CI = 1.49 to 8.28). CONCLUSION: An inadequate ED antibiotic regimen in patients with FN was significantly associated with higher ICU admission or death during hospital stay.