Effect of Systematic Physician Cross-checking on Reducing Adverse Events in the Emergency Department: The CHARMED Cluster Randomized Trial.

Importance: Emergency departments (ED) are environments that are at high risk for medical errors. Previous studies suggested that the proportion of medical errors may decrease when more than 1 physician is involved. Objective: To reduce the proportion of medical errors by implementing systematic cross-checking between emergency physicians. Design, Setting, and Participants: This cluster randomized crossover trial includes a random sample of 14 adult patients (age ≥18 years) per day during two 10-day period in 6 EDs (n = 1680 patients) in France. Interventions: Systematic cross-checking between emergency physicians, 3 times a day, which included a brief presentation of one physician's case to another, followed by the second physician's feedback to the first. Main Outcomes and Measures: Medical error in the ED, defined as an adverse event (either a near miss or a serious adverse event). The primary end point was identified using a 2-level error detection surveillance system, blinded to the strategy allocation. Results: Among the 1680 included patients (mean [SD] age, 57.5 [21.7] years), 144 (8.6%) had an adverse event. There were 54 adverse events among 840 patients (6.4%) in the cross-check group compared with 90 adverse events among 840 patients (10.7%) in the standard care group (relative risk reduction [RRR], 40% [95% CI, 12% to 59%]; absolute risk reduction [ARR], 4.3%; number needed to treat [NNT], 24). There was also a significant reduction rate of near misses (RRR, 47% [95% CI, 15% to 67%]; ARR, 2.7%; NNT, 37) but not of the rate of preventable serious adverse events (RRR, 29% [95% CI, -18% to 57%]; ARR, 1.2%; NNT, 83). Conclusions and Relevance: The implementation of systematic cross-checking between emergency physicians was associated with a significant reduction in adverse events, mainly driven by a reduction in near misses. Trial Registration: ClinicalTrials.gov Identifier: NCT02356926.

Can transcutaneous carbon dioxide pressure be a surrogate of blood gas samples for spontaneously breathing emergency patients? The ERNESTO experience.

BACKGROUND: It is known that the arterial carbon dioxide pressure (PaCO2) is useful for emergency physicians to assess the severity of dyspnoeic spontaneously breathing patients. Transcutaneous carbon dioxide pressure (PtcCO2) measurements could be a non-invasive alternative to PaCO2 measurements obtained by blood gas samples, as suggested in previous studies. This study evaluates the reliability of a new device in the emergency department (ED). METHODS: We prospectively included patients presenting to the ED with respiratory distress who were breathing spontaneously or under non-invasive ventilation. We simultaneously performed arterial blood gas measurements and measurement of PtcCO2 using a sensor placed either on the forearm or the side of the chest and connected to the TCM4 CombiM device. The agreement between PaCO2 and PtcCO2 was assessed using the Bland-Altman method. RESULTS: Sixty-seven spontaneously breathing patients were prospectively included (mean age 70 years, 52% men) and 64 first measurements of PtcCO2 (out of 67) were analysed out of the 97 performed. Nineteen patients (28%) had pneumonia, 19 (28%) had acute heart failure and 19 (28%) had an exacerbation of chronic obstructive pulmonary disease. Mean PaCO2 was 49 mm Hg (range 22-103). The mean difference between PaCO2 and PtcCO2 was 9 mm Hg (range -47 to +54) with 95% limits of agreement of -21.8 mm Hg and 39.7 mm Hg. Only 36.3% of the measurement differences were within 5 mm Hg. CONCLUSIONS: Our results show that PtcCO2 measured by the TCM4 device could not replace PaCO2 obtained by arterial blood gas analysis.

Relation between pulse oximetry plethysmographic waveform amplitude induced by passive leg raising and cardiac index in spontaneously breathing subjects.

INTRODUCTION: Previous studies suggested that variation of pulse oximetric plethysmographic (POP) waveform amplitude (Delta POP) could predict fluid responsiveness in mechanically ventilated patients. Our objective was to correlate the variations of Delta POP and the variations of cardiac index (CI) induced by passive leg raising (PLR) in spontaneously breathing volunteers. METHODS: We studied 26 spontaneously breathing volunteers using a pulse oximeter attached to the middle finger. We assessed hemodynamic variables, including Delta POP (%) (POP(max) - POP(min))/[(POP(max) + POP(min))/2] and CI determined by transthoracic echocardiography at baseline (eg, semirecumbent position), during PLR at 60 degrees, and back to baseline. RESULTS: Cardiac index significantly increased from 2.2 to 2.5 L/min x m(2) (P < .01) at 60 degrees PLR. Conversely, Delta POP significantly decreased from 22% to 15% (P < .01) at 60 degrees PLR. There was a weak correlation between CI and Delta POP variations at 60 degrees PLR (r = 0.40; P < .01). The area under curve of the receiver operating characteristic curve for Delta POP as a predictor of an increase of CI of 15% was not significant (0.67 +/- 0.10; P = .16). CONCLUSION: The variation of Delta POP induced by PLR is not an accurate predictor of increase in CI.