The Association Between Age and Admission to an Inappropriate Ward: A Cross-Sectional Survey in France.

Half of elderly patient hospitalizations are preceded by an emergency department (ED) visit. Hospitalization in inappropriate wards (IWs), which is more frequent in case of ED overcrowding and high hospital occupancy, leads to increased morbidity. Elderly individuals are the most exposed to these negative health care outcomes. Based on a nationwide cross-sectional survey involving all EDs in France, the aim of this study was to explore whether age was associated with admission to an IW after visiting an ED. Among the 4384 patients admitted in a medical ward, 4065 were admitted in the same hospital where the ED was located, among which 17.7% were admitted to an IW. Older age was associated with an increased likelihood of being admitted to an IW (OR = 1.39; 95% CI = 1.02-1.90 for patients aged 85 years and older and OR = 1.40; 95% CI = 1.02-1.91 for patients aged 75-84 years, compared with those under 45 years). ED visits during peak periods and cardio-pulmonary presenting complaint were also associated with an increased likelihood of admission to an IW. Despite their higher vulnerability, elderly patients are more likely to be admitted to an IW than younger patients. This result reinforces the need for special attention to be given to the hospitalization of this fragile population.

Temporal trends in reperfusion therapy for patients with acute ischemic stroke.

OBJECTIVES: To analyze the temporal trends in thrombolysis rates after implementation of a regional emergency network for acute ischemic stroke (AIS). METHODS: We conducted a retrospective study based on a prospective multicenter observational registry. The AIS benefited from reperfusion therapy included in 1 of the 5 primary stroke units or 1 comprehensive stroke center and 37 emergency departments were included using a standardized case report form. The population covers 3 million inhabitants. RESULTS: In total, 32,319 AIS was reported in the regional hospitalization database of which 2215 thrombolyzed AIS patients were included in the registry and enrolled in this study. The annual incidence rate of thrombolysis continuously and significantly increased from 2010 to 2018 (10.2% to 17.3%, P-trend = 0.0013). The follow-up of the onset-to-door and the door-to-needle delays over the study period showed stable rates, as did the all-cause mortality rate at 3-months (13.2%). CONCLUSION: Although access to stroke thrombolysis has increased linearly since 2010, the 3-month functional outcome has not evolved as favorably. Further efforts must focus on reducing hospital delays.

Estimating the Proportion of COVID-19 Contacts Among Households Based on Individuals With Myocardial Infarction History: Cross-sectional Telephone Survey.

BACKGROUND: Adults with cardiovascular diseases were disproportionately associated with an increased risk of a severe form of COVID-19 and all-cause mortality. OBJECTIVE: The aims of this study are to report the associated symptoms for COVID-19 cases, to estimate the proportion of contacts, and to describe the clinical signs and behaviors among individuals with and without myocardial infarction history among cases and contacts. METHODS: A 2-week cross-sectional telephone survey was conducted during the first lockdown period in France, from May 4 to 15, 2020. A total of 668 households participated, representing 703 individuals with pre-existing cardiovascular disease in the past 2 years and 849 individuals without myocardial infarction history. RESULTS: High rates of compliance with health measures were self-reported, regardless of age or risk factors. There were 4 confirmed COVID-19 cases that were registered from 4 different households. Based on deductive assumptions of the 1552 individuals, 9.73% (n=151) were identified as contacts, of whom 71.52% (108/151) were asymptomatic. Among individuals with a myocardial infarction history, 2 were COVID-19 cases, and the estimated proportion of contacts was 8.68% (61/703), of whom 68.85% (42/61) were asymptomatic. The cases and contacts presented different symptoms, with more respiratory signs in those with a myocardial infarction history. CONCLUSIONS: The telephone survey could be a relevant tool for reporting the number of contacts during a limited period and in a limited territory based on the presence of associated symptoms and COVID-19 cases in the households. This study advanced our knowledge to better prepare for future crises.

Management of decision of withholding and withdrawing life-sustaining treatments in French EDs.

BACKGROUND: Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature. STUDY OBJECTIVE: We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France. METHOD: In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process. RESULTS: There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives. CONCLUSION: The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.

Effect of Optimal Medical Therapy at Discharge in Patients With Reperfused ST-Segment Elevation Myocardial Infarction on 1-Year Mortality (from the Regional RESCUe Registry).

Several classes of medication improve survival in patients with ST-segment elevation myocardial infarction (STEMI). We sought to assess the frequency and effect of an optimal therapy upon discharge according to current international guidelines on 1-year all-cause mortality in a prospective cohort of reperfused patients with STEMI. Using data from the French Reseau Cardiologie Urgence (RESCUe) Network, we studied all patients with STEMI admitted and discharged alive from hospital between 2009 and 2013. Class I and II level guidelines were used to define the optimal therapy (OT) group. The undertreatment (UT) group comprised patients in whom at least 1 drug with a class I recommendation was missing. Multivariable Cox regression analysis with propensity score for the prescription of OT was used. Of the 5,161 patients discharged alive, 2,991 (58%) had OT. The 1-year overall survival rate was 0.99 in the OT group (95% confidence interval [CI] 0.99 to 1.00) versus 0.90 (95% CI 0.88 to 0.92) in the UT group. Patient characteristics in the UT group were worse than those in the OT group. After multivariable adjustment, the association between the OT group and mortality remained significant, with a hazard ratio of 0.12 (95% CI 0.07 to 0.22; p<0.001). Optimal secondary prevention therapy in patients with STEMI discharged alive from hospital remains independently associated with lower 1-year mortality.

Five-year evolution of reperfusion strategies and early mortality in patients with ST-segment elevation myocardial infarction in France.

AIM: To assess 5-year evolutions in reperfusion strategies and early mortality in patients with ST-segment elevation myocardial infarction. METHODS AND RESULTS: Using data from the French RESCUe network, we studied patients with ST-segment elevation myocardial infarction treated in mobile intensive care units between 2009 and 2013. Among 2418 patients (median age 62 years; 78.5% male), 2119 (87.6%) underwent primary percutaneous coronary intervention and 299 (12.4%) pre-hospital thrombolysis (94.0% of whom went on to undergo percutaneous coronary intervention). Use of primary percutaneous coronary intervention increased from 78.4% in 2009 to 95.9% in 2013 ( Ptrend<0.001). Median delays included: first medical contact to percutaneous coronary intervention centre 48 minutes; first medical contact to balloon inflation 94 minutes; and percutaneous coronary intervention centre to balloon inflation 43 minutes. Times from symptom onset to first medical contact and first medical contact to thrombolysis remained stable during 2009-2013, but times from symptom onset to first balloon inflation, and first medical contact to percutaneous coronary intervention centre to first balloon inflation decreased ( P<0.001). Among patients with known timings, 2146 (89.2%) had a first medical contact to percutaneous coronary intervention centre delay ⩽90 minutes, while 260 (10.8%) had a longer delay, with no significant variation over time. Primary percutaneous coronary intervention use increased over time in both delay groups, but was consistently higher in the ⩽90 versus >90 minutes delay group (83.0% in 2009 to 97.7% in 2013; Ptrend<0.001 versus 34.1% in 2009 to 79.2% in 2013; Ptrend<0.001). In-hospital (4-6%) and 30-day (6-8%) mortalities remained stable from 2009 to 2013. CONCLUSION: In the RESCUe network, the use of primary percutaneous coronary intervention increased from 2009 to 2013, in line with guidelines, but there was no evolution in early mortality.

Prehospital high-dose tirofiban in patients undergoing primary percutaneous intervention. The AGIR-2 study.

BACKGROUND: Compared with administration in the catheterization laboratory, early treatment with glycoprotein IIb/IIIa inhibitors provides benefits to patients with ST-segment elevation myocardial infarction who undergo primary percutaneous intervention. Whether this benefit is maintained on top of a 600 mg loading dose of clopidogrel is unknown. METHODS: In a multicentre, controlled, randomized study, 320 patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention received a high-dose bolus of tirofiban given either in the ambulance (prehospital group) or in the catheterization laboratory. The primary endpoint was a TIMI flow grade 2-3 of the infarct-related vessel at initial angiography. Secondary endpoints included ST-segment resolution 1h after percutaneous coronary intervention and peak serum troponin I concentration. RESULTS: Tirofiban was administered 48 (95% confidence interval 21.4-75.0) min earlier in the prehospital group. At initial angiography, the combined incidence of TIMI 2-3 flow was 39.7% in the catheterization-laboratory group and 44.2% in the prehospital group (p=0.45). No difference was found on postpercutaneous intervention angiography or peak troponin concentration. Complete ST-segment resolution 60 min after the start of intervention was 55.4% in the catheterization-laboratory group and 52.6% in the prehospital group (p=0.32). CONCLUSION: Prehospital initiation of high-dose bolus tirofiban did not improve significantly initial TIMI 2 or 3 flow of the infarct-related artery or complete ST-segment resolution after coronary intervention compared with initiation of tirofiban in the catheterization laboratory (NCT00538317).

A five-step protocol for withholding and withdrawing of life support in an emergency department: an observational study.

OBJECTIVE: The objective of the study was to describe a five-step protocol for withholding and withdrawing of life support (WH/WDLS) in an emergency department (ED) for terminally ill patients. DESIGN AND SETTING: An observational study was conducted in ED of a general hospital. PATIENTS: A total of 98 patients were admitted over a 1-year period. INTERVENTIONS: The healthcare team chose a pattern of treatment limitation on the basis of a five-step protocol for every patient, which comprised five groups: group 1: there was no limitation of care, group 2: do not resuscitate order was followed, group 3: administration of therapies without treating an acute organ failure, group 4: active withdrawal of all therapies except mechanical ventilation and group 5: active withdrawal of mechanical ventilation. All the patients received comfort care. The opinions of the patients and their families were collected. MEASUREMENTS AND RESULTS: Ninety-eight patients were included in the study (1.5% of admissions). Mean age was 82+/-13 years. An acute organ failure was observed at admission in 80 patients. Severe chronic disease was noted in 93 patients. Among the 98 patients, there were 14 patients in group 2, 65 in group 3, six in group 4 and 13 in group 5. The time interval between admission and WH/WDLS decision was 117+/-77 min and ED stay was 239+/-136 min. The outcome was death in ED (n=21), admission to a medical ward (n=71) or an intensive care unit (n=six). On day 30, 16 patients were still alive. CONCLUSION: This five-step protocol could improve collaboration in the WH/WDLS decision-making process, while facilitating dialogue and transmission of information between staff and families.