A retrospective study of complaint letters sent to a Swiss Emergency Department between 2009 and 2014.

OBJECTIVE: Patient complaints are a valuable resource for monitoring and improving patient safety and quality of care. The purpose of this study was to analyze the complaint letters received at a Swiss academic emergency department (ED) over six years. METHODS: A retrospective study of all complaint letters sent to a Swiss academic ED between 2009 and 2014 was conducted. The following data were extracted: epidemiology items, reasons for complaints, hospital responses, follow-up, and severity of the events mentioned in the complaints. All complaint letters related to adult patients evaluated in the ED between 2009 and 2014 were included and a qualitative evaluation was performed based on a systematic taxonomy. Context, patient characteristics, mode of resolution and clinical severity of the related adverse event were evaluated. RESULTS: A total number of 156 complaints were recorded, corresponding to an annual complaint rate of 5.5 to 8.8 per 10,000 visits. The complaints concerned mostly three domains (clinical care, management and patient or caregiver relationship) with a slight predominance for organisation and logistics (39%) compared with 31.4% for standard of care and 29.6% for communication/relational complaints. The majority of complaints were sent within one month of the ED visit. Most complaints were resolved with written apologies or explanations. The consequences of 73.5% of the events in question were considered minor or negligible, 19% moderate, and 6.5% major. Only 1% (two cases) was related to situations with catastrophic consequences. CONCLUSION: Complaint incidence in our ED was low and remained stable over the six-year observation period. Most of the complaints pertained to incidents that entailed negligible or minor consequences. As most complaints were due to inadequate communication, interventions targeting improvement of the doctor/patient communication are required.

[Complications of body piercing]. / Complications liées aux piercings.

The trend of body piercing has grown in popularity in the past decade within the general population and especially among young adults. Complications of body piercing include local inflammation and infections, but severe complications are also possible and largely underestimated. People are usually not aware of the risks before making a piercing, and their medical history, medication and comorbidities are largely neglected by the people who realise the piercing. This article presents a review of the complications that a primary care physician may observe, for a patient who wishes to make a piercing, or presents complications due to the implementation of such a device.

Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study.

BACKGROUND: Prehospital oligoanalgesia is prevalent among trauma victims, even when the emergency medical services team includes a physician. We investigated if not only patients' characteristics but physicians' practice variations contributed to prehospital oligoanalgesia. METHODS: Patient records of conscious adult trauma victims transported by our air rescue helicopter service over 10 yr were reviewed retrospectively. Oligoanalgesia was defined as a numeric rating scale (NRS) >3 at hospital admission. Multilevel logistic regression analysis was used to predict oligoanalgesia, accounting first for patient case-mix, and then physician-level clustering. The intraclass correlation was expressed as the median odds ratio (MOR). RESULTS: A total of 1202 patients and 77 physicians were included in the study. NRS at the scene was 6.9 (1.9). The prevalence of oligoanalgesia was 43%. Physicians had a median of 5.7 yr (inter-quartile range: 4.2-7.5) of post-graduate training and 27% were female. In our multilevel analysis, significant predictors of oligoanalgesia were: no analgesia [odds ratio (OR) 8.8], National Advisory Committee for Aeronautics V on site (OR 4.4), NRS on site (OR 1.5 per additional NRS unit >4), female physician (OR 2.0), and years of post-graduate experience [>4.0 to ≤5.0 (OR 1.3), >3.0 to ≤4.0 (OR 1.6), >2.0 to ≤3.0 (OR 2.6), and ≤2.0 yr (OR 16.7)]. The MOR was 2.6, and was statistically significant. CONCLUSIONS: Physicians' practice variations contributed to oligoanalgesia, a factor often overlooked in analyses of prehospital pain management. Further exploration of the sources of these variations may provide innovative targets for quality improvement programmes to achieve consistent pain relief for trauma victims.

[Fruits and vegetables: can they be dangerous?]. / Fruits et légumes: peuvent-ils être dangereux?

Fruits, vegetables and spices are found in our everyday food consumption. However, some contain potentially toxic substances, particularly when consumed in large amounts. These risks may be greater for certain susceptible individuals and may depend on how the ingredients are prepared. Food poisoning is generally speaking self-limiting, but may be life threatening. This article discusses the possible toxic effects of certain common foodstuffs, as described in the current medical literature.

[Access to thrombolysis in stroke: place of the rescue system and of the primary care physician]. / Accès à la thrombolyse lors d'AVC: rôle des secours préhospitaliers et des médecins de premier recours.

Thrombolysis is the most effective treatment improving the outcome of patients suffering from acute stroke. Moreover, its effectiveness increases when administrated as quick as possible after the onset of the first symptoms. Prehospital selection of patients and their immediate transfer to stroke center are the principal factors allowing the practice of thrombolysis within the authorized time frame. On the basis of regional Swiss French data, it seems that patients evaluated by emergency physician and their direct transfer in an acute stroke unit reduces delays and allows for a higher thrombolysis rate.

[Hospitalisation criteria for the acute abdominal pain patient seen at home or in an ambulatory setting]. / L'orientation du patient souffrant d'un syndrome douloureux abdominal aigu a domicile.

Dealing at patient's home with an acute abdominal pain may be particularly challenging for the primary care physician. In such a clinical situation, the part of laboratory and radiological investigations is increasing in the diagnostic process. The decision to keep the patient at home based on a clinical evaluation alone may represent a great medical responsibility for the physician. Emergency departments (ED) are of course in charge of investigating such patients with a wide panel of investigation techniques. But these structures are chronically overcrowded resulting frequently in long and difficult periods of waiting. Based on a literature review, a description of useful clinical symptoms and signs is summarized and should help the decision process for the orientation of the patient.

[Access to prehospital medical care: organization and utility of the chain of survival]. / Accès aux soins d'urgence: organisation et utilité de la chaîne des secours.

In order to be effective, access to prehospital care must be integrated into a system described as "the chain of survival". This system is composed of 5 essential phases: 1) basic help by witnesses; 2) call for help; 3) basic life support; 4) professional rescue and transport to the appropriate institution and 5) access to emergency ward and hospital management. Each phase is characterized by a specific organization, dedicated skills and means in order to increase the level of care brought to the patient. This article describes the organization, the utility and the specificity of the chain of survival allowing access to prehospital medical care in the western part of Switzerland.

[Emergency department overcrowding: a legitimate reason to refuse access to urgent care for non-urgent patients?]. / Engorgement des centres d'urgences: une raison légitime de refuser l'accès aux patients non urgents?

Non-urgent cases represent 30-40% of all ED consults; they contribute to overcrowding of emergency departments (ED), which could be reduced if they were denied emergency care. However, no triage instrument has demonstrated a high enough degree of accuracy to safely rule out serious medical conditions: patients suffering from life-threatening emergencies have been inappropriately denied care. Insurance companies have instituted financial penalties to discourage the use of ED as a source of non-urgent care, but this practice mainly restricts access for the underprivileged. More recent data suggest that in fact most patients consult for appropriate urgent reasons, or have no alternate access to urgent care. The safe reduction of overcrowding requires a reform of the healthcare system based on patients' needs rather than access barriers.

[Preventive medicine in emergency centres: an opportunity of partnership for emergency physicians and primary care physicians]. / Les urgences: une opportunité d'accès a des interventions préventives en partenariat avec les médecins de premier recours?

Whereas preventive interventions for primary care physicians are now well established, the preventive interventions in emergency departments have been only partially and recently evaluated. Emergency departments probably represent however an opportunity for preventive medicine. Indeed, the population, sometimes vulnerable, consulting emergency departments, frequently presents risks factors and risks behaviours. Moreover, the concept of "teachable moment" and the studies recently performed seem to confirm this hypothesis. This article review the currently preventive interventions recommended in emergency departments and discuss the rationale to implement preventive medicine in emergency departments and the limits of this process.

[Access of elderly patients in the emergency department: demographic evolution and ethical perspectives]. / Accès des patients agés aux urgences: evolution démographique et perspectives médico-ethiques.

Due to actual demographic evolution, emergency departments have to face a dramatic increase in admissions of elderly people. The peculiar medical and socio-demographic characteristics of these old patients emphasize the need of specific decision processes and resources allocation. An individual-based approach, related to significant ethical values, should allow better diagnostic and therapeutic attitudes. Such a way to admit, evaluate and treat older patients implies an active collaboration with patients and their relatives, but also with all medical interveners, including in particular primary care physicians.

[An efficient example of a Swiss pre-hospital chain of survival: the state of Vaud model]. / La chaîne des secours: le modèle vaudois.

The state of Vaud model of the pre-hospital chain of survival is an example of an efficient way to deal with pre-hospital emergencies. It revolves around a centrally located dispatch center managing emergencies according to specific key words, allowing dispatchers to send out resources among which we find general practitioners, ambulances, physician staffed fast response cars or physician staffed helicopters and specific equipment. The Vaud pre-hospital chain of survival has been tailored according to geographical, demographical and political necessities. It undergoes constant reassessment and needs continuous adaptations to the ever changing demographics and epidemiology of pre-hospital medicine.

An evaluation of the Swiss staging model for hypothermia using case reports from the literature.

BACKGROUND: Core body temperature is used to stage and guide the management of hypothermic patients, however obtaining accurate measurements of core temperature is challenging, especially in the pre-hospital context. The Swiss staging model for hypothermia uses clinical indicators to stage hypothermia. The proposed temperature range for clinical stage 1 is <35-32 °C (95-90 °F), for stage 2, <32-28 °C (<90-82 °F) for stage 3, <28-24 °C (<82-75 °F), and for stage 4 below 24 °C (75 °F). However, the evidence relating these temperature ranges to the clinical stages needs to be strengthened. METHODS: Medline was used to retrieve data on as many cases of accidental hypothermia (core body temperature <35 °C (95 °F)) as possible. Cases of therapeutic or neonatal hypothermia and those with confounders or insufficient data were excluded. To evaluate the Swiss staging model for hypothermia, we estimated the percentage of those patients who were correctly classified and compared the theoretical with the observed ranges of temperatures for each clinical stage. The number of rescue collapses was also recorded. RESULTS: We analysed 183 cases; the median temperature for the sample was 25.2 °C (IQR 22-28). 95 of the 183 patients (51.9%; 95% CI = 44.7%-59.2%) were correctly classified, while the temperature was overestimated in 36 patients (19.7%; 95% CI = 13.9%-25.4%). We observed important overlaps among the four stage groups with respect to core temperature, the lowest observed temperature being 28.1 °C for Stage 1, 22 °C for Stage 2, 19.3 °C for Stage 3, and 13.7 °C for stage 4. CONCLUSION: Predicting core body temperature using clinical indicators is a difficult task. Despite the inherent limitations of our study, it increases the strength of the evidence linking the clinical hypothermia stage to core temperature. Decreasing the thresholds of temperatures distinguishing the different stages would allow a reduction in the number of cases where body temperature is overestimated, avoiding some potentially negative consequences for the management of hypothermic patients.

Accuracy of the Michigan Alcoholism Screening Test for screening of alcoholism in patients of a medical department.

To measure the applicability and validity of the Michigan Alcoholism Screening Test in a medical hospital department situated in the French-speaking part of Switzerland, the test was administered to 300 patients. The results of the test were validated in relation to the clinical diagnosis of alcohol abuse or alcoholism through a concordance analysis. The applicability rate was 89% and the agreement between test and clinical diagnosis was good, especially in young men. Positive and negative predictive values of the test were 0.69 and 0.92, respectively. These results suggest, therefore, that the Michigan Alcoholism Screening Test could be considered as a standardized, valuable, and transcultural screening and research instrument.

Depressive symptoms as a predictor of 6-month outcomes and services utilization in elderly medical inpatients.

BACKGROUND: Depressive symptoms have been associated with higher mortality in hospitalized elderly persons, but few data are available associating depressive symptoms with other outcomes. OBJECTIVE: To determine the association between depressive symptoms and the risk of hospital readmission, nursing home admission, and death as well as inpatient services utilization during a 6-month follow-up period in a cohort of elderly medical inpatients. METHODS: We enrolled 401 patients, 75 years and older, admitted to the internal medicine service of an academic hospital in Lausanne, Switzerland. Data on demographic, medical, physical, social, and mental status were collected on admission. Depressive symptoms were defined as a score of 6 or higher on the Geriatric Depression Scale short form. Follow-up data were gathered from the centralized billing system (hospital and nursing home admissions) and from proxies (in cases of death). RESULTS: In bivariate analysis, depressive symptoms were associated with an increased risk of hospital readmission, nursing home placement, and death. After adjustment for demographic, socioeconomic, and functional status and comorbidity, depressive symptoms remained associated with an increased risk of hospital readmission (adjusted hazard ratio, 1.50; 95% confidence interval, 1.03-2.17; P =.03). In addition, depressive symptoms were associated with increased average costs of both acute and rehabilitation services, resulting in higher overall costs of inpatient services. ($175.70 vs $126.00; P<.001). This association remained after adjusting for differences in functional status, comorbidity, and living situation, although it was just short of statistical significance (P =.07). CONCLUSIONS: Elderly medical inpatients with depressive symptoms were more likely than those without to be readmitted and had higher inpatient services utilization during the follow-up period, independent of functional and health status. These results emphasize the need for interventions directed at improving management of depressive symptoms, given the low recognition and treatment rates of this problem in elderly populations.

Screening for excessive alcohol drinking. Comparative value of carbohydrate-deficient transferrin, gamma-glutamyltransferase, and mean corpuscular volume.

BACKGROUND: Screening medical patients for excessive alcohol drinking is important because minimal intervention by physicians is effective in reducing excessive consumption. Screening tests, such as biologic markers of alcohol consumption, should therefore be investigated to assess their validity to detect alcohol drinking. METHOD: Levels of carbohydrate-deficient transferrin (CDT), gamma-glutamyltransferase (GGT), and mean corpuscular volume (MCV) were determined in 1202 consecutive patients (20 to 75 years old) seen at the medical emergency ward (n = 552) and the primary care center (n = 650) of a city and teaching hospital. Each eligible patient was administered a CAGE questionnaire (an acronym for questions regarding cutting down on drinking, annoyance at others' concern about drinking, feeling guilty about drinking, and using alcohol as an eye-opener in the morning), and for each CAGE-positive patient (score > or = 2) as well as for a random sex-matched sample of CAGE-negative patients, standardized data about the recent level of alcohol drinking, morbidities, drug therapy, and smoking were recorded. The operating characteristics of CDT, GGT, and MCV were determined according to alcohol consumption and the CAGE test. Sensitivities, specificities, and receiver operating characteristic curves were computed to compare the tests at different cutoff values. RESULTS: Levels of CDT were elevated in 21% of men and 7% of women. According to recent alcohol consumption in men (> 60 g/d), the respective sensitivity and specificity of the tests were 0.58 and 0.82 for CDT, 0.69 and 0.65 for GGT, and 0.27 and 0.91 for MCV. Overall, receiver operating characteristic curves demonstrated similar performance of the three tests for screening of excessive alcohol drinking or alcohol abuse. However, in young men (< 40 years of age) and in smokers, CDT was superior to GGT or MCV. CONCLUSIONS: The study suggests that CDT determination may be a useful test for screening programs of excessive alcohol drinking in young male medical patients.

Prevalence of victims of violence admitted to an emergency department.

OBJECTIVE: To collect data on the consultation frequency and demographic profile of victims of violence attending an emergency department (ED) in Switzerland. METHODS: We undertook screening of all admitted adult patients (>16 years) in the ED of the CHUV, Lausanne, Switzerland, over a 1 month period, using a modified version of the Partner Violence Screen questionnaire. Exclusionary criteria were: life threatening injury (National Advisory Committee on Aeronautics score > or =4), or inability to understand or speak French, to give oral informed consent, or to be questioned without a family member or accompanying person being present. Data were collected on history of physical and/or psychological violence during the previous 12 months, the type of violence experienced by the patient, and if violence was the reason for the current consultation. Sociodemographic data were obtained from the registration documents. RESULTS: The final sample consisted of 1602 patients (participation rate of 77.2%), with a refusal rate of 1.1%. Violence during the past 12 months was reported by 11.4% of patients. Of the total sample, 25% stated that violence was the reason for the current consultation; of these, 95% of patients were confirmed as victims of violence by the ED physicians. Patients reporting violence were more likely to be young and separated from their partner. Men were more likely to be victims of public violence and women more commonly victims of domestic violence. CONCLUSIONS: Based on this monthly prevalence rate, we estimate that over 3000 adults affected by violence consult our ED per annum. This underlines the importance of the problem and the need to address it. Health services organisations should establish measures to improve quality of care for victims. Guidelines and educational programmes for nurses and physicians should be developed in order to enhance providers' skills and basic knowledge of all types of violence, how to recognise and interact appropriately with victims, and where to refer these patients for follow up care in their local networks.

[Prehospital medical care organization during the 2003 G8 summit: a new concept of Mobile Medical Squadrons (MMS)]. / Organisation des secours extrahospitaliers lors du sommet 2003 du G8: nouveau concept de poste médical mobile (PMM).

OBJECTIVE: The occurrence of the 2003 G8 summit in Evian and the threat of major civil riots or even terrorist attacks in the Swiss neighbourhood forced us to imagine a new system of rescue and medical care in case of numerous victims. Previous occurrences of the G8 in Europe or America have demonstrated the need of flexible and mobile structures, able to respond quickly to crowd movements, unlike the usual static structure of rescue systems designed for major accidents. METHODS: We developed a new concept of Mobile Medical Squadrons (MMS) consisting of several vehicles and medical care and rescue human resources. In our concept, each MMS consisted of 3 emergency doctors, 5 paramedics and 9 first-aid workers. They were designed to handle 15 patients, with a large autonomy in terms of rescue, medical care, evacuation and medical authority. The equipment included medical, resuscitation, simple decontamination, evacuation and communication materials. RESULTS: The MMS were dispatched four times during the G8 summit following civil riots. They took care of 12 injured patients. CONCLUSION: The concept of MMS as a reinforcement of the existing rescue and health care resources appears as a new flexible, a modular and useful concept for the medical management of collective prehospital emergency situations. Its use is suggested instead of the traditional static concept of rescue systems designed for major accidents.

[After your heart arrest, would you like to test a medicinal elixir?]. / Après votre arrêt cardiaque, vous prendrez bien un peu d'élixir de (sur)vie?

So far, cardiac arrest is still associated with high mortality or severe neurological disability in survivors. At the tissue level, cardiac arrest results into an acute condition of generalized hypoxia. A better understanding of the pathophysiology of ischemia-reperfusion and of the inflammatory response that develops after cardiac arrest could help to design novel therapeutic strategies in the future. It seems unlikely that a single drug, acting as a <>, might be able to improve survival or neurological prognosis. Lessons learned from pathophysiological mechanisms rather indicate that combined therapies, involving thrombolysis, neuroprotective agents, antioxidants and anti-inflammatory molecules, together with temperature cooling, might represent helpful strategies to improve patient's outcome after cardiac arrest.

Acute opiate overdose: characteristics of 190 consecutive cases.

AIMS: To characterize the population of drug users consulting the Emergency Room (ER) of a university hospital with acute opiate overdose (AOO) and to assess rate of referral to specialized treatment programme. DESIGN: Survey of a 12-month sample of AOO patients. MEASUREMENTS: Medical and psychosocial features of the drug users, details of emergency treatment and referral by a mobile resuscitation team (SMUR) and the ER of our hospital (CHUV-Lausanne, Switzerland). In addition fatal AOO cases were collected by the Institute of Forensic Medicine (IFM) during the same period. FINDINGS: One hundred and eighty-four cases of AOO (134 patients) were treated. The files of the IFM detailed six additional deceased cases. This population of drug users was characterized by an over-representation of men (73%), by young age (27.4 years), by a high rate of multi-drugs use (90%) and by a high rate of multiple previous overdoses (2.6). Average length of stay was 20.1 hours but 41% of cases stayed less than 8 hours. Only one patient was readmitted within an 8-hour period. When discharged, 78% returned home. Unexpectedly, 67% of patients were not referred to any therapeutic programme for drug addiction. CONCLUSION: This study shows the low mortality of AOO when treated but also demonstrates the need to improve psychosocial evaluation and referral of drug addicts admitted with AOO.