Risk factors and effect of dyspnea inappropriate treatment in adults' emergency department: a retrospective cohort study.

Dyspnea is a frequent symptom in adults' emergency departments (EDs). Misdiagnosis at initial clinical examination is common, leading to early inappropriate treatment and increased in-hospital mortality. Risk factors of inappropriate treatment assessable at early examination remain undescribed herein. The objective of this study was to identify clinical risk factors of dyspnea and inappropriate treatment in patients admitted to ED. This is an observational retrospective cohort study. Patients over the age of 15 who were admitted to adult EDs of the University Hospital of Toulouse (France) with dyspnea were included from 1 July to 31 December 2019. The primary end-point was dyspnea and inappropriate treatment was initiated at ED. Inappropriate treatment was defined by looking at the final diagnosis of dyspnea at hospital discharge and early treatment provided. Afterward, this early treatment at ED was compared to the recommended treatment defined by the International Guidelines for Acute Heart Failure, bacterial pneumonia, chronic obstructive pulmonary disease, asthma or pulmonary embolism. A total of 2123 patients were analyzed. Of these, 809 (38%) had inappropriate treatment in ED. Independent risk factors of inappropriate treatment were: age over 75 years (OR, 1.46; 95% CI, 1.18-1.81), history of heart disease (OR, 1.32; 95% CI, 1.07-1.62) and lung disease (OR, 1.47; 95% CI, 1.21-1.78), SpO2 <90% (OR, 1.64; 95% CI, 1.37-2.02), bilateral rale (OR, 1.25; 95% CI, 1.01-1.66), focal cracklings (OR, 1.32; 95% CI, 1.05-1.66) and wheezing (OR, 1.62; 95% CI, 1.31-2.03). In multivariate analysis, under-treatment significantly increased in-hospital mortality (OR, 2.13; 95% CI, 1.29-3.52) compared to appropriate treatment. Over-treatment nonsignificantly increased in-hospital mortality (OR, 1.43; 95% CI, 0.99-2.06). Inappropriate treatment is frequent in patients admitted to ED for dyspnea. Patients older than 75 years, with comorbidities (heart or lung disease), hypoxemia (SpO2 <90%) or abnormal pulmonary auscultation (especially wheezing) are at risk of inappropriate treatment.

Impact of emergency department length of stay on in-hospital mortality: a retrospective cohort study.

BACKGROUND AND IMPORTANCE: Emergency Department (ED) workload may lead to ED crowding and increased ED length of stay (LOS). ED crowding has been shown to be associated with adverse events and increasing mortality. We hypothesised that ED-LOS is associated with mortality. OBJECTIVE: To study the relationship between ED-LOS and in-hospital mortality. DESIGN: Observational retrospective cohort study. SETTINGS AND PARTICIPANTS: From 1 January 2015 to 30 September 2018, all visits by patients aged 15 or older to one of the two ED at Toulouse University Hospital were screened. Patients admitted to the hospital after ED visits were included. Visits followed by ED discharge, in-ED death or transfer to ICU or another hospital were not included. OUTCOME MEASURE AND ANALYSIS: The primary outcome was 30-day in-hospital mortality. ED-LOS was defined as time from ED registration to inpatient admission. ED-LOS was categorised according to quartiles [<303 min (Q1), between 303 and 433 minutes (Q2), between 434 and 612 minutes (Q3) and >612 min (Q4)]. A multivariable logistic regression tested the association between ED-LOS and in-hospital mortality. MAIN RESULTS: A total of 49 913 patients were admitted to our hospital after ED visits and included in the study. ED-LOS was not independently associated with in-hospital mortality. Compared to ED-LOS < 303 min (Q1, reference), odd-ratios (OR) [95% CI] of in-hospital mortality for Q2, Q3, and Q4 were respectively 0.872 [0.747-1.017], 0.906 [0.777-1.056], and 1.137 [0.985-1.312]. Factors associated to in-hospital mortality were: aged over 75 years (OR [95% CI] = 4.3 [3.8-4.9]), Charlson Comorbidity Index score > 1 (OR [95% CI] = 1.3 [1.1-1.5], and 2.2 [1.9-2.5] for scores 2 and ≥ 3 respectively), high acuity at triage (OR [95% CI] = 3.9 [3.5-4.4]), ED visit at Hospital 1 (OR [95% CI] = 1.6 [1.4-1.7]), and illness diagnosis compared to trauma (OR [95% CI] = 2.1 [1.7-2.6]). Night-time arrival was associated with decreased in-hospital mortality (OR [95% CI] = 0.852 [0.767-0.947]). CONCLUSION: In this retrospective cohort study, there was no independent association between ED-LOS before admission to general non-ICU wards and in-patient mortality.

Performance of high-sensitivity cardiac troponin T in predicting major cardiovascular events in patients admitted to the emergency department for syncope with normal ECG: An observational prospective study.

INTRODUCTION: History of syncope, clinical examination and electrocardiographic (ECG) findings are fundamental to assess the risk of major cardiovascular events (MACE) in patients attending the emergency department (ED) for syncope. However, in the absence of abnormal clinical examination findings or an abnormal ECG in the ED, transient rhythm or conduction disorders may not be safely excluded, hence predicting MACE remains challenging. High-sensitivity cardiac troponin T (hs-cTnT) may be a useful tool in this context. AIM: The primary objective was to evaluate the performance of hs-cTnT in the diagnosis of MACE at 30 days in patients attending the ED for syncope with a normal initial ECG. METHODS: This was a prospective observational cohort study that took place in the ED of a French university hospital between June 2018 and June 2019. Patients≥18 years admitted to the ED for syncope with a normal ECG were eligible. After receiving verbal consent from patients, the ED physician collected clinical and ECG data and all patients had a blood sample taken that included hs-cTnT measurement. The primary outcome was MACE within 30 days after the ED visit. MACE were evaluated by consulting the patient's medical records and telephoning patients or their general practitioners. Sensitivity, specificity, positive and negative predictive values were calculated with their 95% confidence intervals (CI) for different hs-cTnT thresholds. RESULTS: Data from 246 patients were analysed, including 21 (9%) with MACE. Hs-cTnT had an area under the curve of 0.917 (CI: 0.872-0.962). Hs-cTnT with a threshold of 19ng/L had a sensitivity of 86% (CI: 64-97) and a specificity of 86% (CI: 81-90) for predicting MACE. CONCLUSION: Hs-cTnT may be a relevant tool for assessing MACE risk in patients with syncope and normal ECG results.

Predictive factors for early requirement of respiratory support through phone call to Emergency Medical Call Centre for dyspnoea: a retrospective cohort study.

BACKGROUND: Acute dyspnoea is a common symptom in Emergency Medicine, and severity assessment is difficult during the first time the patient calls the Emergency Medical Call Centre. OBJECTIVE: To identify predictive factors regarding the need for early respiratory support in patients who call the Emergency Medical Call Centre for dyspnoea. DESIGN, SETTINGS AND PARTICIPANTS: This retrospective cohort study carried out in the Emergency Medical Call Centre of the University Hospital of Toulouse from 1 July to 31 December 2019. Patients over the age of 15 who call the Emergency Medical Call Centre regarding dyspnoea and who were registered at the University Hospital or died before admission were included in our study. OUTCOME MEASURE AND ANALYSIS: The primary end-point was early requirement of respiratory support [including high-flow oxygen, non-invasive ventilation (NIV) or mechanical ventilation after intubation] that was initiated by the physicians staffed ambulance before admission to the hospital or within 3 h after being admitted. Associations with patients' characteristics identified during Emergency Medical Call Centre calls were assessed with a backward stepwise logistic regression after multiple imputations for missing values. MAIN RESULTS: During the 6-month inclusion period, 1425 patients called the Emergency Medical Call Centre for respiratory issues. After excluding 38 calls, 1387 were analyzed, including 208 (15%) patients requiring respiratory support. The most frequent respiratory support used was NIV (75%). Six independent predictive factors of requirement of respiratory support were identified: chronic ß2-mimetics medication [odds ratio (OR) = 2.35, 95% confidence interval (CI) 1.61-3.44], polypnea (OR = 5.78, 95% CI 2.74-12.22), altered ability to speak (OR = 2.35, 95% CI 1.55-3.55), cyanosis (OR = 2.79, 95% CI 1.81-4.32), sweats (OR = 1.93, 95% CI 1.25-3) and altered consciousness (OR = 1.8, 95% CI 1.1-3.08). CONCLUSION: During first calls for dyspnoea, six predictive factors are independently associated with the risk of early requirement of respiratory support.

Management of patients suffering from mild traumatic brain injury 2023.

OBJECTIVE: To develop a multidisciplinary French reference that addresses initial pre- and in-hospital management of a mild traumatic brain injury patient. DESIGN: A panel of 22 experts was formed on request from the French Society of Emergency Medicine (SFMU) and the French Society of Anaesthesiology and Critical Care Medicine (SFAR). A policy of declaration and monitoring of links of interest was applied and respected throughout the process of producing the guidelines. Similarly, no funding was received from any company marketing a health product (drug or medical device). The expert panel had to respect and follow the Grade® (Grading of Recommendations Assessment, Development and Evaluation) methodology to evaluate the quality of the evidence on which the recommendations were based. Given the impossibility of obtaining a high level of evidence for most of the recommendations, it was decided to adopt a "Recommendations for Professional Practice" (RPP) format, rather than a Formalized Expert Recommendation (FER) format, and to formulate the recommendations using the terminology of the SFMU and SFAR Guidelines. METHODS: Three fields were defined: 1) pre-hospital assessment, 2) emergency room management, and 3) emergency room discharge modalities. The group assessed 11 questions related to mild traumatic brain injury. Each question was formulated using a PICO (Patients Intervention Comparison Outcome) format. RESULTS: The experts' synthesis work and the application of the GRADE® method resulted in the formulation of 14 recommendations. After two rounds of rating, strong agreement was obtained for all recommendations. For one question, no recommendation could be made. CONCLUSION: There was strong agreement among the experts on important, transdisciplinary recommendations, the purpose of which is to improve management practices for patients with mild head injury.

Emergency management of patients with Glanzmann thrombasthenia: consensus recommendations from the French reference center for inherited platelet disorders.

Glanzmann thrombasthenia (GT) is a genetic bleeding disorder characterised by severely reduced/absent platelet aggregation in response to multiple physiological agonists. The severity of bleeding in GT varies markedly, as does the emergency situations and complications encountered in patients. A number of emergency situations may occur in the context of GT, including spontaneous or provoked bleeding, such as surgery or childbirth. While general management principles apply in each of these settings, specific considerations are essential for the management of GT to avoid escalating minor bleeding events. These recommendations have been developed from a literature review and consensus from experts of the French Network for Inherited Platelet Disorders, the French Society of Emergency Medicine, representatives of patients' associations, and Orphanet to aid decision making and optimise clinical care by non-GT expert health professionals who encounter emergency situations in patients with GT.

Effect of age on the association between the Glasgow Coma Scale and the anatomical brain lesion severity: a retrospective multicentre study.

Background and importance Older adults are at higher risk of undertriage and mortality following a traumatic brain injury (TBI). Early identification and accurate triage of severe cases is therefore critical. However, the Glasgow Coma Scale (GCS) might lack sensitivity in older patients. Objective This study investigated the effect of age on the association between the GCS and TBI severity. Design, settings, and participants This multicentre retrospective cohort study (2003-2017) included TBI patients aged ≥16 years with an Abbreviated Injury Scale (AIS of 3, 4 or 5). Older adults were defined as aged 65 and over. Outcomes measure and analysis Median GCS score were compared between older and younger adults, within subgroups of similar AIS. Multivariable logistic regressions were computed to assess the association between age and mortality. The primary analysis comprised patients with isolated TBI, and secondary analysis included patients with multiple trauma. Main results A total of 12 562 patients were included, of which 9485 (76%) were isolated TBIs. Among those, older adults represented 52% ( n  = 4931). There were 22, 27 and 51% of older patients with an AIS-head of 3, 4 and 5 respectively compared to 32, 25 and 43% among younger adults. Within the different subgroups of patients, median GCS scores were higher in older adults: 15 (14-15) vs. 15 (13-15), 15 (14-15) vs. 14 (13-15), 15 (14-15) vs. 14 (8-15), for AIS-head 3, 4 and 5 respectively (all P  < 0.0001). Older adults had increased odds of mortality compared to their younger counterparts at all AIS-head levels: AIS-head = 3 [odds ratio (OR) = 2.9, 95% confidence interval (CI) 1.6-5.5], AIS-head = 4, (OR = 2.7, 95% CI 1.6-4.7) and AIS-head = 5 (OR = 2.6, 95% CI 1.9-3.6) TBI (all P  < 0.001). Similar results were found among patients with multiple trauma. Conclusions In this study, among TBI patients with similar AIS-head score, there was a significant higher median GCS in older patients compared to younger patients.

Validation of the cutaneous impact location to predict intracranial lesion among elderly admitted to the Emergency Department after a ground-level fall.

INTRODUCTION: In the Emergency Departments, almost one out of two head CT scans are carried out for traumatic brain injuries among elderly victims of ground level-falls. Recently, a new predictive factor for intracranial lesions in this population has been suggested: presence and location of cutaneous impact. The aim of this study was to establish determinants of intracranial lesion among older patients admitted to EDs due to ground-level falls with traumatic brain injury using the head cutaneous impact location. METHODS: A retrospective, observational and monocentric study of patients admitted to Emergency Department for ground-level falls with traumatic brain injury was carried out between 01 January 2017 and 31 July 2017. The primary outcome was identification of an acute intracranial lesion. A bootstrap procedure was employed to evaluate performance and internal validity of the final model. RESULTS: Among the 1036 patients included, the mean age was 85.6 (SD 7.6) years and 94/1036 (9.1%, 95% CI 7.4-10.9) patients presented with an acute intracranial lesion. Multivariable analysis adjusted by bootstrap shrinkage showed that compared with temporal-parietal or occipital impact, Odds Ratio of intracranial lesions were 0.61 (95% CI 0.39-0.95, p = 0.03) in patients with frontal impact, 0.27 (95% CI 0.12-0.59, p = 0.001) in patients with facial impact and 0.21 (95% CI 0.06-0.77, p = 0.018) in patients without cutaneous impact. Subcutaneous hematoma (OR 1.97, p = 0.007), loss of consciousness (OR 4.66, p<0.001), fall-related amnesia (OR 2.58, p = 2.6), vomiting (OR 2.62, p = 0.002) and altered Glasgow Score (OR 6.79, p<0.001) were as well associated with high risk of intracranial lesion. Taking antiplatelets or anticoagulants were not associated with an increased risk of intracranial lesions. The model discrimination was adequate (C-statistic 0.79; 95% CI 0.73 - 0.85). CONCLUSION: Our results establish specific determinants of intracranial lesions among elderly after ground level-falls. The cutaneous impact location may identify patients with high risk of intracranial lesion. Further researches are needed to propose a specific score based on these determinants so as to better target Head CT scan use.

Is it valid to assess an individual's performance in team training simulation when the supporting team are confederates? A controlled and randomized clinical trial.

BACKGROUND: During simulation training, the confederate is a member of the pedagogical team. Its role is to facilitate the interaction between participants and the environment, and is thought to increase realism and immersion. Its influence on participants' performance in full-scale simulation remains however unknown. The purpose of this study was to observe the effect of the presence of confederates on the participants' performance during full-scale simulation of crisis medical situations. METHODS: This was a prospective, randomized study comparing 2 parallel groups. Participants were emergency medicine residents engaging in a simulation session, with or without confederates. Participants were then evaluated on their Crisis Resource Management performance (CRM). The overall performance score on the Ottawa Global Rating Scale was assessed as primary outcome and the 5 non-technical CRM skills as secondary outcomes. RESULTS: A total of 63 simulation sessions, including 63 residents, were included for statistical analysis (n = 32 for Control group and 31 for Confederate group). The mean Overall Performance score was 3.9 ± 0.8 in the Control group and 4.0 ± 1.1 in the Confederate group, 95% confidence interval of the difference [-0.6; 0.4], p = 0.60. No significant differences between the two groups were observed on each CRM items (leadership, situational awareness, communication, problem solving, resource utilization) CONCLUSION: In this randomized and controlled study, the presence of confederates during full-scale simulated practice of crisis medical situations does not seem to influence the CRM skills performance of Emergency medicine residents. TRIAL REGISTRATION: This study does not need to be registered on Clintrial as it does not report a health care intervention on human participants.

Risk factors for the presence of important fractures in ED patients with shoulder dislocation: a retrospective cohort study.

BACKGROUND: Prereduction shoulder X-rays are frequently done to rule out an important fracture that might preclude reduction of a shoulder dislocation in the ED. Our objective was to determine the risk factors for an important fracture in patients admitted to the ED with shoulder dislocation. METHODS: This retrospective cohort study was conducted at the Toulouse University Hospital from 1 January 2017 to 31 December 2018. All patients admitted to the ED with clinical presentation of shoulder dislocation were included. The primary end point was the presence of an important fracture (excluding Bankart and Hill-Sachs fractures). Logistic regression was used to determine independent risk factors for the presence of an important fracture. RESULTS: Six hundred and two patients were included in the study and 81 (13%) had an important fracture. Three risk factors were associated with important fracture: age over 40 years (adjusted OR (aOR)=2.7; 95% CI 1.5 to 4.8), first incident (aOR=4.3; 95% CI 1.7 to 10.8) and the circumstances in which the trauma occurred (fall from a height or direct impact, fall of over 1 m, road accident or epilepsy) (aOR=5.5; 95% CI 2.6 to 30). One hundred sixty-six patients (28%) had no risk factors in our cohort. In the absence of these risk factors, the risk of an important fracture was found to be 0.6% (95% CI 0 to 3.3). CONCLUSION: We describe 3 independent clinical risk factors associated with an important fracture in ED patients with shoulder dislocation: age >40 years, first incident and a traumatic circumstance. Prereduction radiography may be safely avoided when these factors are absent.

Factors associated with Emergency Medical Dispatcher request and residents' inappropriate transfers from Nursing Homes to Emergency Department.

PURPOSE: In the last decades, the amount of emergency department (ED) transfers of nursing home (NH) residents has disproportionally increased in western countries. The main role of emergency medical dispatcher (EMD) among this population is to refer residents to EDs in the most appropriate way. The aim of this study was to assess risk factors of inappropriate transfers from NH to ED after EMD request. METHODS: This research was a secondary analysis of a prospective observational multicenter study carried out in 17 EDs entitled FINE aimed to assess potentially inappropriate transfer prevalence among this population. Inappropriate transfers were determined in the FINE study threw a standardized approach by a unique expert team. RESULTS: Overall, 572/1037 (55.2%) of residents were transferred to the ED after an EMD's decision. Among them, 92/572 (16.1%) transfers was defined as inappropriate. The average age was 87.3 years old (SD = 0.3). The main reason for ED transfer were falls (217/572, 37.9%). In multivariate analysis, the presence of a Special Care Unit in NH was significantly associated with a high rate of inappropriate transfer (OR 1.78; 95 CI [1.07-2.93]; p = 0.02) whereas a medical examination by a general practitioner before the transfer (OR 0.55; 95 CI [0.33-0.83]; p = 0.02) and a prompt access to psychiatric advice (OR 0.54; 95 CI [0.33-0.84]; p = 0.007) were associated with a low rate of potentially inappropriate transfer. CONCLUSION: Promoting onsite medical assessment and partnership thanks to available geriatrician's advice may help the emergency medical dispatcher to improve the appropriateness of residents' transfer from Nursing Home to the emergency department.

Cutaneous impact location: a new tool to predict intracranial lesion among the elderly with mild traumatic brain injury?

BACKGROUND: Mild traumatic brain injury is the leading cause of arrivals to emergency department due to trauma in the 65-year-old population and over. Recent studies conducted in ED suggested a low intracranial lesion prevalence. The objectives of this study were to assess the prevalence and risk factors of intracranial lesion in older patients admitted to emergency department for mild traumatic brain injury by reporting in the emergency department the precise anamnesis of injury and clinical findings. METHODS: Patients of 65 years old and over admitted in emergency department were prospectively included in this monocentric study. The primary outcome was the prevalence of intracranial lesion threw neuroimaging. RESULTS: Between January and June 2019, 365 patients were included and 66.8% were women. Mean age was 86.5 years old (SD = 8.5). Ground-level fall was the most common cause of mild traumatic brain injury and occurred in 335 patients (91.8%). Overall, 26 out of 365 (7.2%) patients had an intracranial lesion. Compared with cutaneous frontal impact (medium risk group), the relative risk of intracranial lesion was 2.54 (95% CI 1.20 to 5.42) for patients with temporoparietal or occipital impact (high risk group) and 0.12 (95% CI 0.01 to 0.93) for patients with facial impact or no cutaneous impact (low risk group). There was not statistical increase in risk of intracranial injury with patients receiving antiplatelets (RR = 1.43; 95% CI 0.68 to 2.99) or anticoagulants (RR = 0.98; 95% CI 0.45 to 2.14). CONCLUSION: Among patients of 65 years old and over, the prevalence of intracranial lesion after a mild traumatic brain injury was similar to the younger adult population. The cutaneous impact location on clinical examination at the emergency department may identify older patients with low, medium and high risk for intracranial lesion.

The use of statins in the elderly is associated with less severe hypoglycemia in patient with diabetes.

Three hundred and eighty-nine older patients with diabetes attending an ambulatory diabetes center were included to determine risk factors of severe hypoglycemia (SH). Thirty-three (8.5%) patients had at least one severe hypoglycemia. In multivariate analyze, statin was associated with lower risk and insulin was associated with higher risk of SH.

The Temporal Trend in the Transfer of Older Adults to the Emergency Department for Traumatic Injuries: A Retrospective Analysis According to Their Place of Residence.

OBJECTIVES: There has been an increase in the number of visits by older individuals to emergency departments (EDs). The primary cause of this is trauma. The objective of this study was to evaluate the temporal changes in the use of EDs by older individuals for traumatic injuries, characterize their trauma, and specify the mode of transport to the ED according to their place of residence (community-dwelling or nursing home resident). DESIGN: A monocentric, retrospective study of patients over 65 years of age, admitted to University Center Hospital ED for trauma between 2013 and 2017. PARTICIPANTS: In total, 20,741 patients were included. RESULTS: The mean age was 81.8 years (standard deviation 9.1 years); 11,879 (57.3%) patients were community-living with family, 5077 (24.5%) were nursing home (NH) residents, and 3785 (18.22%) patients were community-dwelling living alone. Overall, 33.3% of the NH residents were transferred during the weekend compared with 28.04% of the community-dwelling individuals (P < .001). Ten percent (1577 patients) of the community-dwelling individuals compared with 21.8% (1109 patients) of the transfers of NH residents to ED occurred late at night (P < .001). The primary reason for use of the ED was head trauma (32.0%), followed by cutaneo-mucous wounds (28.7 %) and limb fractures (25.9%). In most cases, NH residents were transferred by ambulance (5000 residents; 98.4%), compared with community-dwelling individuals (11,118; 70.1%; P < .001). Overall, 7459 (36.0 %) patients were hospitalized. CONCLUSION AND IMPLICATIONS: In comparison with community-dwelling individuals, ED transfers of NH residents in the context of trauma-related emergency were higher during after-hour periods, lengthes of stay at the ED were longer, and residents were admitted less to the in hospital.

Organizational and environmental factors associated with transfers of nursing home residents to emergency departments.

BACKGROUND/OBJECTIVES: The emergency department transfer (EDT) rate of residents from nursing homes (NHs) to emergency departments is an important public health issue. The purpose of this study was to examine whether organizational and geographical factors were associated with EDT among older adults living in NHs. DESIGN: Retrospective analysis using information from patients' medical charts regarding hospitalization in the last 12 months. Information came from the baseline data of the IQUARE clinical trial. PARTICIPANTS: 5926 residents (86.0 years old, standard deviation, SD = 2.9), from 175 NHs with available data on EDT. OUTCOME MEASURE: The EDT rate was estimated for each NH, from the number of residents who were transferred to an emergency department (one transfer or more) in the previous 12 months. RESULTS: 1119 (18.9%, SD = 11.5) residents were transferred to an emergency department at least once during the past year. In adjusted multiple linear regression, NHs located in rural areas had an EDT rate significantly lower than those in urban areas (confidence interval, 95% CI - 10.15, - 2.16, p = 0.003), with an absolute EDT rate of 16.4% (SD = 9.1) versus 20.4% (SD = 12.5); pharmacy for internal use was significantly associated with a lower EDT rate compared with the NHs with no PUI [11.9% (SD = 9.2); 19.1% (SD = 10.1), 95% CI - 16.33, - 3.09, p = 0.004] and the implementation of a personalized care project in NHs was significantly associated with a lower EDT rate [18.6% (SD = 11.4), 22.4% (SD = 12.4), 95% CI - 11.67, - 0.63, p = 0.03]. CONCLUSION: Our study suggests that a structured plan of care, a strategy to improve medication and being located in rural areas reduce the EDT rate in NH residents. IQUARE STUDY TRIAL REGISTRATION NUMBER: NCT01703689.