Analysis of admissions to intensive care units that could be supported on an intermediate care unit.

BACKGROUND: Only one third of European countries use intermediate care units (IMCs). An IMC makes it possible to manage patients who do not require intensive care but who need a higher level of nursing care that cannot be provided on the general ward. In Belgium, there are no national criteria for ICU admission or discharge, and no policies regarding IMC care or for differentiating ICU intensity levels. AIM/S: The aim of our study was to analyse the profile of ICU patients in Belgium on the basis of registered nursing activity in order to quantify the number of ICU days potentially transferable to an IMC. STUDY DESIGN: The study was conducted on 310 ICU beds. Patients admitted to the study were recruited during two different one-month periods in 2018 and were included into a prospective database that evaluated nursing workload carried out in 15 hospitals in the French-speaking part of Belgium. The number of ICU days that could be supported on an IMC was defined according to the Nursing Activities Score (NAS) items. RESULTS: A total of 3279 ICU patients for a total of 13 942 ICU days were included. 4987 days (35.8%) were considered as "transferable" to an IMC. The proportion of ICU days transferable to an IMC was highly variable among hospitals, ranging from 20.4% to 59.5% of all ICU days. On the day of ICU admission, 665/2142 (31.0%) of the patients were already identified as transferable to an IMC; this percentage significantly increased on day 2 (972/2066, 47.1%) and day 3 (650/1390, 46.7%). CONCLUSIONS: In Belgian ICUs, 35.8% of ICU hospital days, as per recorded NAS, do not necessitate intensive monitoring. These 35.8% of days of ICU hospitalization could be supported on an IMC. RELEVANCE FOR CLINICAL PRACTICE: In this study, a significant number of days spent in the ICU could be supported on an IMC, this could alleviate the workload of nurses and reduce the occupancy rate of intensive care units.

Unexpected carboxyhemoglobin half-life during cardiopulmonary resuscitation: a case report.

BACKGROUND: Cardiac arrest (CA) following CO poisoning (CO-induced CA) exposes patients to an extremely high risk of mortality and remains challenging to treat effectively. Terminal carboxyhemoglobin elimination half-life (COHbt1/2) is critically affected by ventilation, oxygen therapy, and cardiac output, which are severely affected conditions in cases of CA. CASE PRESENTATION: Asystole occurred in an 18-year-old woman after unintentional exposure to CO in her bathroom. Cardiopulmonary resuscitation (CPR) was started immediately, including mechanical ventilation with a fraction of inspired oxygen (FiO2) of 1.0 and external chest compressions with a LUCAS® device. CPR was stopped after 101 min, as it was unsuccessful. During this period, we calculated a COHbt1/2 of 40.3 min using a single compartmental model. CONCLUSIONS: This result suggests that prolongation of CPR time needed to back COHb at 10%, a level more compatible with successful return of spontaneous circulation (ROSC), could be compatible with a realistic CPR time. Calculating COHbt1/2 during CPR may help with decision-making regarding the optimal duration of resuscitation efforts and further with HBO2 or ECLS. Further evidence-based data are needed to confirm this result.

SARS-CoV-2 Seroprevalence among Healthcare Workers after the First and Second Pandemic Waves.

Background: The Grand Hôpital de Charleroi is a large non-academic Belgian hospital that treated a large number of COVID-19 inpatients. In the context of this pandemic, all professions-combined healthcare workers (HCWs), and not only direct caregivers, are a frontline workforce in contact with suspected and confirmed COVID-19 cases and seem to be a high-risk group for exposure. The aim of our study was to estimate the prevalence of anti-SARS-CoV-2 antibodies in HCWs in our hospital after the first and second pandemic waves and to characterize the distribution of this seroprevalence in relation to various criteria. Methods: At the end of the two recruitment periods, a total of 4008 serological tests were performed in this single-center cross-sectional study. After completing a questionnaire including demographic and personal data, possible previous COVID-19 diagnostic test results and/or the presence of symptoms potentially related to COVID-19, the study participants underwent blood sampling and serological testing using DiaSorin's LIAISON® SARS-CoV-2 S1/S2 IgG test for the first phase and LIAISON® SARS-CoV-2 TrimericS IgG test for the second phase of this study. Results: In total, 302 study participants (10.72%) in the first round of the study and 404 (33.92%) in the second round were positive for SARS-CoV-2-IgG antibodies. The prevalence of seropositivity observed after the second wave was 3.16 times higher than after the first wave. We confirmed that direct, prolonged, and repeated contact with patients or their environment was a predominant seroconversion factor, but more unexpectedly, that this was the case for all HCWs and not only caregivers. Finally, the notion of high-risk contact seemed more readily identifiable in one's workplace than in one's private life. Conclusions: Our study confirmed that HCWs are at a significantly higher risk of contracting COVID-19 than the general population, and suggests that repeated contacts with at-risk patients, regardless of the HCWs' professions, represents the most important risk factor for seroconversion (Clinicaltrials.gov number, NCT04723290).

Correlation between hypoxaemia and lung ultrasound score in patients presenting to an emergency department with interstitial syndrome: a prospective physiological study.

Objective: To assess for the presence of a correlation between lung ultrasound score (LUSS) and ratio between arterial partial pressure of oxygen (PaO2) and the fraction of inspired oxygen (FiO2) in patients presenting to an emergency department (ED) with interstitial syndrome (IS). Design: Prospective, multicentre, physiological study. Setting: Four Belgian hospitals: one tertiary academic centre and three secondary centres. Participants: A convenience sample of adult patients who presented to an ED with acute dyspnoea and needed an arterial blood gas (ABG) analysis (those with a LUSS < 2 were secondarily excluded). Main outcome measure: Correlation between PaO2/FIO2 and LUSS determined using Pearson correlation. Results: In total, 162 adult patients were included. A statistically significant negative linear correlation between PaO2/FIO2 and LUSS was found (correlation coefficient, -0.4860 [95% CI, -0.5956 to -0.3587]; P < 0.0001). Conclusions: Our data provide evidence of a statistically significant negative linear correlation between PaO2/FIO2 and LUSS for ED patients with lung IS. Given the representativeness of PaO2/FIO2 for hypoxaemia and the fact that hypoxaemia indicates IS severity, our findings suggest that LUSS could contribute to the evaluation of IS severity. If confirmed by future studies that include patient follow-up, a noninvasive approach using LUSS could decrease the need for ABG analysis in patients who do not require repeated measurement of ABG values other than PaO2, and thereby improve patient comfort.

Factors to improve quality for older patients in the emergency department: a qualitative study of patient trajectory.

BACKGROUND: Managing older people in the emergency department remains a challenge. We aimed to identify the factors influencing the care quality of older patients in the emergency department, to fine-tune future interventions for older people, considering the naturalistic context of the ED. METHODS: This is a qualitative study of some 450 h of observations performed in three emergency departments selected for their diverse contexts. We performed seventy observations of older patient trajectories admitted to the emergency department. Themes were extracted from the material using an inductive reasoning approach, to highlight factors positively or negatively influencing management of patient's trajectories, in particular those presenting with typically geriatric syndromes. RESULTS: Four themes were developed: no geriatric flow routine; risk of discontinuity of care; unmet basic needs and patient-centered care; complex older patients are unwelcome in EDs. CONCLUSIONS: The overall process of care was based on an organ- and flow-centered paradigm, which ignored older people's specific needs and exposed them to discontinuity of care. Their basic needs were neglected and, when their management slowed the emergency department flow, older people were perceived as unwelcome. Findings of our study can inform the development of interventions about the influence of context and organizational factors.

Overlooked guide wire: a multicomplicated Swiss Cheese Model example. Analysis of a case and review of the literature.

Objectives: Central venous catheter (CVC) implementation is now usual in emergency department. The most common complications are misplacement, bleeding, pleural perforation, thrombosis and sepsis. Forgetting a guide wire in the patient's body after catheterization is an underestimated complication of this procedure; only 76 cases are described. Even if the majority of patients remained asymptomatic, severe complications can happened even years later. This article's aim is to identify the sequence of elements that led to the event occurrence and to suggest recommendations of good practice to minimize complications related to central catheter placement.Method: After reviewing all the complications related to central venous catheterization and their frequencies, we analyse from a case report and a review of the literature the sequence of elements that led to the medical error. We use an Ishikawa diagram to show our results and the links between them.Results: Our Ishikawa diagram shows that material, human resources, procedural and radiological involvement factors are the main elements on which we can act to reduce the complications rate after central venous catheterization. We advocate for the establishment of standardized procedures before, during and after the technical gesture.Conclusions: Because of human nature, errors will always be possible when taking care of a patient. However, we propose good practice recommendations to avoid the repetition of a forgetting guide wire after central venous catheterization.

Climate Change Impacts on Disaster and Emergency Medicine Focusing on Mitigation Disruptive Effects: an International Perspective.

In recent decades, climate change has been responsible for an increase in the average temperature of the troposphere and of the oceans, with consequences on the frequency and intensity of many extreme weather phenomena. Climate change’s effects on natural disasters can be expected to induce a rise in humanitarian crises. In addition, it will surely impact the population’s long-term general health, especially among the most fragile. There are foreseeable health risks that both ambulatory care organizations and hospitals will face as global temperatures rise. These risks include the geographic redistribution of infectious (particularly zoonotic) diseases, an increase in cardiac and respiratory illnesses, as well as a host of other health hazards. Some of these risks have been detailed for most developed countries as well as for some developing countries. Using these existing risk assessments as a template, organizational innovations as well as implementation strategies should be proposed to mitigate the disruptive effects of these health risks on emergency departments and by extension, reduce the negative impact of climate change on the populations they serve.

[Suturing a child's wound, humanising care in the emergency department]. / La suture de la plaie d'un enfant, réflexion pour l'humanisation des soins aux urgences.

The humanisation of the care pathway constitutes an objective for all caregivers. A visit to the emergency department by a child requiring a suture is a simple and frequent situation which highlights the different stages of the care. Several of these stages can be anticipated in the waiting room, in particular the exchanging of information with the patient and the family, which helps to improve the parent-child-professional relationship.

Prehospital paediatric emergencies in Belgium: an epidemiologic study.

OBJECTIVES: In Belgium, emergency medical services (EMS) are staffed with a medical team if mandatory according to the regulation authority procedures. Children are involved in interventions, but no extensive data are available in the country. We analysed the characteristics of the children involved in EMS to gain better knowledge of the pathologies and the needs of these patients. MATERIALS AND METHODS: A retrospective review of all patients under 16 years of age dealt with by our EMS team during a 2-year period. RESULTS: During the 2010-2011 period, our EMS performed 229 paediatric missions. Most of the patients (76.0%) presented medical conditions. Seizure was the most common diagnosis (34.1%), including febrile convulsions in 55.1% of the cases. Five patients (2.2%) suffered a cardiac arrest. All of them died despite advanced life support. Two more patients died before or just after admission to the emergency room. In the subgroup of patients admitted to our hospital, 26.6% needed drug administration and 43.2% were discharged home after emergency room management. CONCLUSION: Prehospital paediatric emergencies are rarely life-threatening conditions and seldom need advanced medical interventions. However, the outcome of real life-threatening conditions is poor, therefore emphasizing the need for better trained teams.

Changes in the clinical features of older patients admitted from the emergency department.

Demographic changes and healthcare reforms may impact the profile of hospitalized older persons. In this study, we sought to compare the characteristics of two prospective cohorts recruited at a ten-year interval (1999, n=253-2009, n=355). They included older patients (≥75 years) admitted through the emergency department for at least 48 h in acute non-geriatric wards in the same university hospital. The exclusion criteria were patients who were admitted directly to the intensive care unit, who were dependent for all 6 Activities of Daily Living (ADL), who had recently suffered from a major stroke, or whose with a life expectancy of less than 3 months. Median age was higher in 2009 than in 1999 (83 vs. 81; p=0.020), with a higher proportion of those aged 85 years and over (p=0.026). Patients in the 2009 cohort were less likely to live in a nursing home (p=0.018), more dependent for the basic ADL (p<0.001), more independent for the instrumental ADL (p<0.001). They were more likely to have fallen in the previous year (p<0.001). They took more medications (p<0.001). Their length-of-stay was shorter (p<0.001), but they were more likely to be discharged to a rehabilitation center (p<0.001). They underwent more early re-admissions (p=0.020) and similar 3-month functional decline (p=0.614). In conclusion, within a decade, the social, functional and medical characteristics of older patients admitted to hospital have changed significantly. In view of the high consumption of in-patient services by this population, hospitals must adapt to these rapid changes.

Capnography as a diagnostic tool for pulmonary embolism: a meta-analysis.

STUDY OBJECTIVE: Multiple studies have evaluated capnography for the diagnosis of pulmonary embolism; accordingly, we conduct a meta-analysis of these trials. METHODS: We performed a systematic search from 1990 to 2011, using MEDLINE, EMBASE, and the Cochrane Library, including studies evaluating capnography as a diagnostic tool alone or in conjunction with other tests. After study quality evaluation, we calculated the pooled sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. RESULTS: We included 14 trials with 2,291 total subjects, with a 20% overall prevalence of pulmonary embolism. The pooled diagnostic accuracy for capnography was sensitivity 0.80 (95% confidence interval [CI] 0.76 to 0.83), specificity 0.49 (95% CI 0.47 to 0.51), negative likelihood ratio 0.32 (95% CI 0.23 to 0.45), positive likelihood ratio 2.43 (95% CI 1.70 to 3.46), and diagnostic odds ratio 10.4 (95% CI 6.33 to 17.1). The area under the summary receiver operating characteristic curve was 0.84. To reach pulmonary embolism posttest probabilities less than 1%, 2%, or 5%, pulmonary embolism prevalence or pretest probability had to be less than 3%, 5%, or 10% respectively. Because of interstudy differences in dead space measurements methodologies, the best cutoff in alveolar dead space or end tidal CO2 conferring the best negative likelihood ratio could not be evaluated. CONCLUSION: Pooled data suggest a potential diagnostic role for capnography when the pulmonary embolism pretest probability is 10% or less, perhaps after a positive D-dimer test result.

Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism.

STUDY OBJECTIVE: The assessment of clinical probability (as low, moderate, or high) with clinical decision rules has become a cornerstone of diagnostic strategy for patients with suspected pulmonary embolism, but little is known about the use of physician gestalt assessment of clinical probability. We evaluate the performance of gestalt assessment for diagnosing pulmonary embolism. METHODS: We conducted a retrospective analysis of a prospective observational cohort of consecutive suspected pulmonary embolism patients in emergency departments. Accuracy of gestalt assessment was compared with the Wells score and the revised Geneva score by the area under the curve (AUC) of receiver operating characteristic curves. Agreement between the 3 methods was determined by κ test. RESULTS: The study population was 1,038 patients, with a pulmonary embolism prevalence of 31.3%. AUC differed significantly between the 3 methods and was 0.81 (95% confidence interval [CI] 0.78 to 0.84) for gestalt assessment, 0.71 (95% CI 0.68 to 0.75) for Wells, and 0.66 (95% CI 0.63 to 0.70) for the revised Geneva score. The proportion of patients categorized as having low clinical probability was statistically higher with gestalt than with revised Geneva score (43% versus 26%; 95% CI for the difference of 17%=13% to 21%). Proportion of patients categorized as having high clinical probability was higher with gestalt than with Wells (24% versus 7%; 95% CI for the difference of 17%=14% to 20%) or revised Geneva score (24% versus 10%; 95% CI for the difference of 15%=13% to 21%). Pulmonary embolism prevalence was significantly lower with gestalt versus clinical decision rules in low clinical probability (7.6% for gestalt versus 13.0% for revised Geneva score and 12.6% for Wells score) and non-high clinical probability groups (18.3% for gestalt versus 29.3% for Wells and 27.4% for revised Geneva score) and was significantly higher with gestalt versus Wells score in high clinical probability groups (72.1% versus 58.1%). Agreement between the 3 methods was poor, with all κ values below 0.3. CONCLUSION: In our retrospective study, gestalt assessment seems to perform better than clinical decision rules because of better selection of patients with low and high clinical probability.

Ventilation-associated pneumonia after intubation in the prehospital or the emergency unit.

The aim of the study was to evaluate the prevalence and the risk factors of ventilation-associated pneumonia (VAP) for out-of-hospital or in the emergency department intubated patients. This was a retrospective descriptive study. All intubated adults subsequently admitted to the ICU over 1-year period were included. Among 75 patients, 15 patients developed VAP (20%; 95% CI 12-31%). A multivariate analysis revealed three variables independently associated with VAP: cardiorespiratory arrest as the reason of intubation (P=0.001), out-of-hospital as the location of intubation (P=0.011), and clinical macroaspiration as clinical characteristic at the time of intubation (P=0.024). Death rate was 17% and was not significantly higher for patients with VAP (P=0.9; 95% CI 0.32-4.95%). Emergency care workers should be aware of the potential 20% occurrence of VAP when they intubate and ventilate a patient. Preventive strategies, which have been proven effective in ICUs, should be implemented in the emergency setting.

Lactic acidosis following intentional overdose by inhalation of salmeterol and fluticasone.

Salmeterol, a long-acting ß2-adrenergic receptor agonist used for the treatment of asthma and chronic obstructive pulmonary disease, has an adverse effects profile that is similar to that of salbutamol and other ß2-agonists. We report a sympathomimetic syndrome with metabolic acidosis and hyperlactatemia after intentional inhalation of salmeterol in a suicide attempt. A 16-year-old female patient was admitted to the emergency department approximately 2 hours after having inhaled 60 puffs of a combination of salmeterol xinafoate 25 µg and fluticasone propionate 50 µg. She presented in an anxious state with complaints of palpitations and chest pain. The electrocardiogram demonstrated sinus tachycardia and ST-segment depression in the inferior and anterolateral leads. Laboratory findings showed hypokalemia, hypophosphatemia, and lactic acidosis. Cardiac troponin I and creatine kinase MB remained within the normal range. Treatment was supportive and included intravenous fluids and cautious potassium supplementation. The next day, electrocardiographic and laboratory findings returned to normal. We hypothesize that stimulation of ß2-adrenergic receptors by inhalation of salmeterol caused this patient's lactic acidosis. This observation is consistent with the hypothesis that the hyperlactatemia observed during asthma attacks is due in part to the administration of high doses of ß2-agonists. Salmeterol overdose by inhalation appears to be sufficient to cause lactic acidosis.

Performance of the Pulmonary Embolism Rule-out Criteria (the PERC rule) combined with low clinical probability in high prevalence population.

INTRODUCTION: PERC rule was created to rule out pulmonary embolism (PE) without further exams, with residual PE risk<2%. Its safety is currently not confirmed in high PE prevalence populations even when combined with low clinical probability assessed by revised Geneva score (RGS). As PERC rule and RGS are 2 similar explicit rules with many redundant criteria, we hypothesized that the combination of PERC rule with gestalt clinical probability could resolve this limitation. METHODS: We collected prospectively documented clinical gestalt assessments and retrospectively calculated PERC rules and RGS from a prospective study of PE suspected patients. We analyzed performance of combinations of negative PERC with low clinical probability assessed by both methods in high overall PE prevalence population. RESULTS: Among the final study population (n = 959), the overall PE prevalence was 29.8%. Seventy-four patients (7.7%) were classified as PERC negative and among them, 4 patients (5.4%) had final diagnosis of PE. When negative PERC was combined with low pretest probability assessed by RGS or gestalt assessment, PE prevalence was respectively 6.2% and 0%. This last combination reaches threshold target of 2% and unnecessary exams could easily have been avoided in this subgroup (6%). However, it confidence interval was still wide (0%; CI 0-5). CONCLUSIONS: PERC rule combined with low gestalt probability seems to identify a group of patients for whom PE could easily be ruled out without additional test. A larger study is needed to confirm this result and to ensure safety.

Head-to-head comparison of the prohormone proBNP1-108 with BNP and Nt-proBNP in patients admitted to emergency department.

OBJECTIVES: B-type natriuretic peptide (BNP) and amino-terminal proBNP (Nt-proBNP) are derived from a common precursor, the proBNP(1-108) (proBNP), synthesized by cardiomyocytes. We determined proBNP concentrations in patients admitted to ED and suspected of CHF. DESIGN AND METHODS: One hundred fifty six consecutive patients admitted to ED were included. ProBNP, BNP and Nt-proBNP levels were determined at admission. RESULTS: In this ED population, assays for proBNP, BNP and Nt-proBNP were positively and significantly correlated. Circulating levels of proBNP were higher in patients admitted to ED for CHF than in patients admitted to ED other reasons. Applying receiver operating characteristic curve (ROC) analysis for the diagnosis of CHF, the area under the curve (AUC) was 0.92 for proBNP. CONCLUSIONS: Our study demonstrated that proBNP testing, the precursor of BNP and Nt-proBNP, appears as a relevant tool to assist the diagnosis of CHF in patients admitted to ED.

Noninvasive ventilation use in French out-of-hospital settings: a preliminary national survey.

OBJECTIVE: The objective of our study was to describe noninvasive ventilation (NIV) practices (pressure support ventilation and continuous positive airway pressure) in French out-of-hospital mobile intensive care units (SMUR) and their compliance with national consensus guidelines. METHOD: Online inquiry into practices of NIV among managers of French SMUR. Analyzed data include types of NIV devices and use of NIV. RESULTS: Upon 218 SMUR referenced within the SAMU de France database, 118 questionnaires (54%) were processed. Noninvasive ventilation equipment: 91% of the SMUR with at least one type of NIV device (continuous positive airway pressure only=82%; pressure support ventilation only=59%; both=50%) but frequently not with recommended devices. Use of NIV: for acute cardiogenic pulmonary edema, practices were compliant with recommendations in 80% of cases, although there was still room for improvement. For other pathologies, practices were very heterogeneous, not always properly assessed, and frequently not compliant with recommendations. CONCLUSION: To conclude, NIV use in the out-of-hospital setting in France seems to meet current recommendations for acute cardiogenic pulmonary edema but not for other pathologies. This could be improved by the use of written procedures, conduction of further studies, and promotion of compliance through education.

Mondor disease: a case report in ED.

Mondor disease is a form of superficial thrombophlebitis affecting the subcutaneous veins, specifically of the anterolateral thoracoabdominal wall. Clinical presentation is commonly a subcutaneous, tender, painful cordlike induration, usually founded in the breast or axilla. It affects typically middle-aged women. A 36-year-old patient was admitted to the emergency department to a chest discomfort and to discovery of a palpable, nonerythematous, and painful cordlike structure running from the inferior pole of her left breast to the left iliac pit. She had no history of trauma, injury, or intensive physical activity. Ultrasonography confirmed thrombosis of the thoracoepigastric vein. A thrombophilic workup performed 2 years ago was normal. The patient was treated by enoxaparin 1 mg/kg per day for 30 days. Evolution was favorable. The etiology of Mondor disease remains unclear. Predisposing factors are mainly trauma, excessive physical activity, surgery, infections. Ultrasonography is used to confirm the diagnosis. Coagulation tests should be performed to exclude hypercoagulability condition. In the past, symptomatic approach with anti-inflammatory drugs was proposed. Recent guidelines suggest prophylactic or intermediate doses of low-molecular-weight heparin for at least 4 weeks. Although uncommon, Mondor disease has to be recognized to avoid useless diagnosis testing and to deliver a specific treatment.

Diagnosing destabilized heart failure in the emergency setting: current and future biomarker tests.

Acute or destabilized heart failure (DHF) is characterized by new or worsening signs and symptoms of heart failure leading to admission to an emergency department. Biomarkers may support the diagnosis, the prognosis and the management of DHF patients. The aim of this review article is to discuss and evaluate the clinical usefulness of both recognized and potential new biomarker tests for use in heart failure.