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.

The Association between Emergency Department Length of Stay and In-Hospital Mortality in Older Patients Using Machine Learning: An Observational Cohort Study.

The association between emergency department (ED) length of stay (EDLOS) with in-hospital mortality (IHM) in older patients remains unclear. This retrospective study aims to delineate the relationship between EDLOS and IHM in elderly patients. From the ED patients (n = 383,586) who visited an urban academic tertiary care medical center from January 2010 to December 2016, 78,478 older patients (age ≥60 years) were identified and stratified into three age subgroups: 60-74 (early elderly), 75-89 (late elderly), and ≥90 years (longevous elderly). We applied multiple machine learning approaches to identify the risk correlation trends between EDLOS and IHM, as well as boarding time (BT) and IHM. The incidence of IHM increased with age: 60-74 (2.7%), 75-89 (4.5%), and ≥90 years (6.3%). The best area under the receiver operating characteristic curve was obtained by Light Gradient Boosting Machine model for age groups 60-74, 75-89, and ≥90 years, which were 0.892 (95% CI, 0.870-0.916), 0.886 (95% CI, 0.861-0.911), and 0.838 (95% CI, 0.782-0.887), respectively. Our study showed that EDLOS and BT were statistically correlated with IHM (p < 0.001), and a significantly higher risk of IHM was found in low EDLOS and high BT. The flagged rate of quality assurance issues was higher in lower EDLOS ≤1 h (9.96%) vs. higher EDLOS 7 h

Simple Aspiration versus Drainage for Complete Pneumothorax: A Randomized Noninferiority Trial.

Rationale: Management of first episodes of primary spontaneous pneumothorax remains the subject of debate. Objectives: To determine whether first-line simple aspiration is noninferior to first-line chest tube drainage for lung expansion in patients with complete primary spontaneous pneumothorax. Methods: We conducted a prospective, open-label, randomized noninferiority trial. Adults aged 18-50 years with complete primary spontaneous pneumothorax (total separation of the lung from the chest wall), recruited at 31 French hospitals from 2009 to 2015, received simple aspiration (n = 200) or chest tube drainage (n = 202) as first-line treatment. The primary outcome was pulmonary expansion 24 hours after the procedure. Secondary outcomes were tolerance of treatment, occurrence of adverse events, and recurrence of pneumothorax within 1 year. Substantial discordance in the numerical inputs used for trial planning and the actual trial rates of the primary outcome resulted in a reevaluation of the trial analysis plan. Measurement and Main Results: Treatment failure occurred in 29% in the aspiration group and 18% in the chest tube drainage group (difference in failure rate, 0.113; 95% confidence interval [CI], 0.026-0.200). The aspiration group experienced less pain overall (mean difference, -1.4; 95% CI, -1.89, -0.91), less pain limiting breathing (frequency difference, -0.18; 95% CI, -0.27, -0.09), and less kinking of the device (frequency difference, -0.05; 95% CI, -0.09, -0.01). Recurrence of pneumothorax was 20% in this group versus 27% in the drainage group (frequency difference, -0.07; 95% CI, -0.16, +0.02). Conclusions: First-line management of complete primary spontaneous pneumothorax with simple aspiration had a higher failure rate than chest tube drainage but was better tolerated with fewer adverse events. Clinical trial registered with www.clinicaltrials.gov (NCT01008228).

Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis.

The effect of emergency department (ED) length of stay (EDLOS) on in-hospital mortality (IHM) remains unclear. The aim of this systematic review and meta-analysis was to determine the association between EDLOS and IHM. We searched the PubMed, Medline, Embase, Web of Science, Cochrane Controlled Register of Trials, CINAHL, PsycInfo, and Scopus databases from their inception until 14−15 January 2022. We included studies reporting the association between EDLOS and IHM. A total of 11,337 references were identified, and 52 studies (total of 1,718,518 ED patients) were included in the systematic review and 33 in the meta-analysis. A statistically significant association between EDLOS and IHM was observed for EDLOS over 24 h in patients admitted to an intensive care unit (ICU) (OR = 1.396, 95% confidence interval [CI]: 1.147 to 1.701; p < 0.001, I2 = 0%) and for low EDLOS in non-ICU-admitted patients (OR = 0.583, 95% CI: 0.453 to 0.745; p < 0.001, I2 = 0%). No associations were detected for the other cut-offs. Our findings suggest that there is an association between IHM low EDLOS and EDLOS exceeding 24 h and IHM. Long stays in the ED should not be allowed and special attention should be given to patients admitted after a short stay in the ED.

Impact of Teamwork and Communication Training Interventions on Safety Culture and Patient Safety in Emergency Departments: A Systematic Review.

OBJECTIVES: This study aimed to narratively summarize the literature reporting on the effect of teamwork and communication training interventions on culture and patient safety in emergency department (ED) settings. METHODS: We searched PubMed, EMBASE, Psych Info CINAHL, Cochrane, Science Citation Inc, the Web of Science, and Educational Resources Information Centre for peer-reviewed journal articles published from January 1, 1988, to June 8, 2018, that assessed teamwork and communication interventions focusing on how they influence patient safety in the ED. One additional search update was performed in July 2019. RESULTS: Sixteen studies were included from 8700 screened publications. The studies' design, interventions, and evaluation methods varied widely. The most impactful ED training interventions were End-of-Course Critique, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), and crisis resource management (CRM)-based training. Crisis resource management and TeamSTEPPS CRM-based training curriculum were used in most of the studies. Multiple tools, including the Kirkpatrick evaluation model, the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture, the TeamSTEPPS Teamwork Attitudes Questionnaire, the Safety Attitudes Questionnaire, and the Communication and Teamwork Skills Assessment, were used to assess the impact of such interventions. Improvements in one of the domains of safety culture and related domains were found in all studies. Four empirical studies established improvements in patient health outcomes that occurred after simulation CRM training (Kirkpatrick 4), but there was no effect on mortality. CONCLUSIONS: Overall, teamwork and communication training interventions improve the safety culture in ED settings and may positively affect patient outcome. The implementation of safety culture programs may be considered to reduce incidence of medical errors and adverse events.

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.

Factors Associated with Potentially Inappropriate Transfer to the Emergency Department among Nursing Home Residents.

OBJECTIVES: To determine the factors associated with the potentially inappropriate transfer of nursing home (NH) residents to emergency departments (EDs) and to compare hospitalization costs before and after transfer of individuals addressed inappropriately vs those addressed appropriately. DESIGN: Multicenter, observational, case-control study. SETTING AND PARTICIPANTS: 17 hospitals in France, 1037 NH residents. MEASURES: All NH residents transferred to the 17 public hospitals' EDs in southern France were systematically included for 1 week per season. An expert panel composed of family physicians, emergency physicians, geriatricians, and pharmacists defined whether the transfer was potentially inappropriate or appropriate. Residents' and NHs' characteristics and contextual factors were entered into a mixed logistic regression to determine factors associated independently with potentially inappropriate transfers. Hospital costs were collected in the national health insurance claims database for the 6 months before and after the transfer. RESULTS: A total of 1037 NH residents (mean age 87.2 ± 7.1, 68% female) were transferred to the ED; 220 (21%) transfers were considered potentially inappropriate. After adjustment, anorexia [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.57-3.71], high level of disability (OR 0.90, 95% CI 0.81-0.99), and inability to receive prompt medical advice (OR 1.67, 95% CI 1.20-2.32) were significantly associated with increased likelihood of potentially inappropriate transfers. The existence of an Alzheimer's disease special care unit in the NH (OR 0.66, 95% CI 0.48-0.92), NH staff trained on advance directives (OR 0.61, 95% CI 0.41-0.89), and calling the SAMU (mobile emergency medical unit) (OR 0.47, 95% CI 0.34-0.66) were significantly associated with a lower probability of potentially inappropriate transfer. Although the 6-month hospitalization costs prior to transfer were higher among potentially inappropriate transfers compared with appropriate transfers (€6694 and €4894, respectively), transfer appropriateness was not significantly associated with hospital costs. CONCLUSIONS AND IMPLICATIONS: Transfers from NHs to hospital EDs were frequently appropriate. Transfer appropriateness was conditioned by NH staff training, access to specialists' medical advice, and calling the SAMU before making transfer decisions. TRIAL REGISTRATION: clinicaltrials.gov, NCT02677272.

Derivation of a clinical predicting rule for obstructive urolithiasis and alternative diagnosis requiring urgent intervention: the CLAD score.

Most patients with renal colic are discharged from the emergency department (ED) after evaluation and pain alleviation. These patients may not require urgent imaging by computed tomography. We derived a clinical prediction score in patients with renal colic to identify those at very low risk for complications and alternative diagnoses requiring urgent intervention. This retrospective chart review was carried out in 2 ED at an urban university hospital from January to December 2015. All patients with a diagnosis of renal colic were included. The primary outcome was an intervention required for renal colic or alternative diagnoses within 7 days of ED presentation. A stepwise logistic regression was used to assess factors associated with the outcome. A score was derived as a weighted sum of these predictors and its performance was calculated. The database was submitted to the French National Commission for Data Protection and Liberties (CNIL): declaration n°2164898v0 (03/22/2018). 871 with complete data were analyzed. In 94 (11%) patients, an intervention was performed for obstructive urolithiasis or alternative diagnosis. Five factors were most predictive of intervention: age > 45 years (1 point), a history of urologic surgery (1 point), pulse > 100 bpm (1 point), temperature > 37.8 °C (2 point), and urine dipstick negative for blood (1 point), yielding a score of 0-6 points (the Complicated uroLithiasis and Alternative Diagnosis (CLAD) score). The area under the curve of the receiver operating characteristic curve was 0.82 (95% CI 0.77-0.87). We derived a clinical score for renal colic that predicted the presence of obstructive urolithiasis and acute alternative diagnoses requiring intervention.

Diagnostic performances of lung ultrasound associated with inferior vena cava assessment for the diagnosis of acute heart failure in elderly emergency patients: a diagnostic study.

BACKGROUND AND IMPORTANCE: Few studies are looking at the usefulness of lung ultrasound combined with inferior vena cava (ultrasound strategy) in the particularly challenging diagnosis of acute heart failure (AHF) in elderly dyspneic patients attending the emergency department (ED). OBJECTIVE, DESIGN, SETTINGS, AND PARTICIPANTS: This was a prospective diagnostic study conducted in two French EDs from December 2015 to March 2019, aimed to determine the accuracy of an ultrasound strategy for the diagnosis of AHF in the elderly. Patients aged 65 and older referred to the ED for dyspnea were screened for inclusion. INTERVENTION: An emergency physician, blinded to the first findings, performed chest ultrasound, and assessment of inferior vena cava (ultrasound strategy). OUTCOME MEASURE AND ANALYSIS: The primary endpoint was a final diagnosis of AHF, adjudicated by two independent experts after reviewing the entire medical record. The sensitivity and specificity of ultrasound and standard strategies were calculated. MAIN RESULTS: A total of 116 patients were included, mean age 84 years (SD 9). Among them, there were 76 (66%) cases of AHF and 51 (44%) cases of pneumonia. The ultrasound work up had a sensitivity of 82% [95% confidence interval (CI), 71-90] and a specificity of 68% (95% CI, 51-90] for AHF. The standard strategy had a sensitivity of 92% (95% CI, 84-97) and a specificity of 53% (95% CI, (36-68). CONCLUSIONS: In this prospective study, there was no statistically significant difference between point-of-care ultrasound and a combination of clinical, radiographic, and biological findings for the diagnosis of acute heart failure.

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.

Association between boarding in the emergency department and in-hospital mortality: A systematic review.

IMPORTANCE: Boarding in the emergency department (ED) is a critical indicator of quality of care for hospitals. It is defined as the time between the admission decision and departure from the ED. As a result of boarding, patients stay in the ED until inpatient beds are available; moreover, boarding is associated with various adverse events. STUDY OBJECTIVE: The objective of our systematic review was to determine whether ED boarding (EDB) time is associated with in-hospital mortality (IHM). METHODS: A systematic search was conducted in academic databases to identify relevant studies. Medline, PubMed, Scopus, Embase, Cochrane, Web of Science, Cochrane, CINAHL and PsychInfo were searched. We included all peer-reviewed published studies from all previous years until November 2018. Studies performed in the ED and focused on the association between EDB and IHM as the primary objective were included. Extracted data included study characteristics, prognostic factors, outcomes, and IHM. A search update in PubMed was performed in May 2019 to ensure the inclusion of recent studies before publishing. RESULTS: From the initial 4,321 references found through the systematic search, the manual screening of reference lists and the updated search in PubMed, a total of 12 studies were identified as eligible for a descriptive analysis. Overall, six studies found an association between EDB and IHM, while five studies showed no association. The last remaining study included both ICU and non-ICU subgroups and showed conflicting results, with a positive association for non-ICU patients but no association for ICU patients. Overall, a tendency toward an association between EDB and IHM using the pool random effect was observed. CONCLUSION: Our systematic review did not find a strong evidence for the association between ED boarding and IHM but there is a tendency toward this association. Further well-controlled, international multicenter studies are needed to demonstrate whether this association exists and whether there is a specific EDB time cut-off that results in increased IHM.

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.

Development and Evaluation of a Virtual Research Environment to Improve Quality of Care in Overcrowded Emergency Departments: Observational Study.

BACKGROUND: Despite a wide range of literature on emergency department (ED) overcrowding, scientific knowledge on emergency physicians' cognitive processes coping with overcrowding is limited. OBJECTIVE: This study aimed to develop and evaluate a virtual research environment that will allow us to study the effect of physicians' strategies and behaviors on quality of care in the context of ED overcrowding. METHODS: A simulation-based observational study was conducted over two stages: the development of a simulation model and its evaluation. A research environment in emergency medicine combining virtual reality and simulated patients was designed and developed. Afterwards, 12 emergency physicians took part in simulation scenarios and had to manage 13 patients during a 2-hour period. The study outcome was the authenticity of the environment through realism, consistency, and mastering. The realism was the resemblance perceived by the participants between virtual and real ED. The consistency of the scenario and the participants' mastering of the environment was expected for 90% (12/13) of the participants. RESULTS: The virtual ED was considered realistic with no significant difference from the real world with respect to facilities and resources, except for the length of time of procedures that was perceived to be shorter. A total of 100% (13/13) of participants deemed that patient information, decision making, and managing patient flow were similar to real clinical practice. The virtual environment was well-mastered by all participants over the course of the scenarios. CONCLUSIONS: The new simulation tool, Virtual Research Environment in Emergency Medicine, has been successfully designed and developed. It has been assessed as perfectly authentic by emergency physicians compared with real EDs and thus offers another way to study human factors, quality of care, and patient safety in the context of ED overcrowding.

Memory impairment following intentional self-poisoning with benzodiazepines: Should we pay more attention to attention?

STUDY HYPOTHESIS: In cases where patients attempt suicide through intentional self-poisoning, they often ingest drugs such as benzodiazepines that alter the central nervous system and memory. This is problematic, given that experts recommend the recovery of a patient's cognitive capacity before any psychiatric assessment is conducted. A previous pilot study by our group showed that cognitive tests focusing on attention are the most valuable when it comes to determining whether sufficient cognitive recovery has occurred to ensure that patients will remember the assessment after intentional self-poisoning with benzodiazepines. The main aim of our study was to determine cognitive predictors of the recall of the psychiatric assessment after a suicide attempt. The second aim was to determine the threshold for episodic memory. METHODS: We recruited 97 patients admitted for intentional self-poisoning. At the time of the psychiatric assessments, we quantified plasma benzodiazepine levels and performed a cognitive assessment. We then used a linear regression model to identify the associations in a control and a benzodiazepine group between cognitive functions and episodic memory scores obtained 24 hours after psychiatric assessment. RESULTS: Our model accounted for 28% and 37%, respectively, of the variance in memory in the control and benzodiazepine groups. The most significant correlations were found for the Wechsler Adult Intelligence Scale coding test in both groups. In the control group, tests such as visual and verbal memory were also associated with recall. CONCLUSIONS: Benzodiazepines particularly affect memory by impairing what is remembered of attentional tests. These are, however, the most suitable cognitive tests for predicting recall of the memory assessment.

Levocetirizine and Prednisone Are Not Superior to Levocetirizine Alone for the Treatment of Acute Urticaria: A Randomized Double-Blind Clinical Trial.

STUDY OBJECTIVE: We evaluate the efficacy of a 4-day course of prednisone added to antihistamine for the management of acute urticaria in an emergency department (ED). METHODS: In this double-blind randomized clinical trial, patients were eligible for inclusion if aged 18 years or older and with acute urticaria of no more than 24 hours' duration. Patients with anaphylaxis or who had received antihistamines or glucocorticoids during the previous 5 days were not included. In addition to levocetirizine (5 mg orally for 5 days), patients were assigned to receive prednisone (40 mg orally for 4 days) or placebo. The primary endpoint of the study was itching relief 2 days after the ED visit, rated on a numeric scale of 0 to 10. Secondary endpoints were rash resolution, relapses, and adverse events. RESULTS: A total of 100 patients were included, 50 in each group. Seven patients in the prednisone group and 8 in the placebo group discontinued treatment. At 2-day follow-up, 62% of patients in the prednisone group had an itch score of 0 versus 76% of those in the placebo group (Δ 14%; 95% confidence interval -31% to 4%). Thirty percent of patients in the prednisone group and 24% in the placebo group reported relapses (Δ 6%; 95% confidence interval -23% to 11%). Mild adverse events were reported by 12% of patients in the prednisone group and 14% in the placebo group. CONCLUSION: The addition of a prednisone burst did not improve the symptomatic and clinical response of acute urticaria to levocetirizine. This study does not support the addition of corticosteroid to H1 antihistamine as first-line treatment of acute urticaria without angioedema.

Factors predisposing nursing home resident to inappropriate transfer to emergency department. The FINE study protocol.

BACKGROUND: Each year, around one out of two nursing home (NH) residents are hospitalized in France, and about half to the emergency department (ED). These transfers are frequently inappropriate. This paper describes the protocol of the FINE study. The first aim of this study is to identify the factors associated with inappropriate transfers to ED. METHODS/DESIGN: FINE is a case-control observational study. Sixteen hospitals participate. Inclusion period lasts 7 days per season in each center for a total period of inclusion of one year. All the NH residents admitted in ED during these periods are included. Data are collected in 4 times: before transfer in the NH, at the ED, in hospital wards in case of patient's hospitalization and at the patient's return to NH. The appropriateness of ED transfers (i.e. case versus control NH residents) is determined by a multidisciplinary team of experts. RESULTS: Our primary objective is to determine the factors predisposing NH residents to inappropriate transfer to ED. Our secondary objectives are to assess the cost of the transfers to ED; study the evolution of NH residents' functional status and the psychotropic and inappropriate drugs prescription between before and after the transfer; calculate the prevalence of potentially avoidable transfers to ED; and identify the factors predisposing NH residents to potentially avoidable transfer to ED. DISCUSSION: A better understanding of the determinant factors of inappropriate transfers to ED of NH residents may lead to proposals of recommendations of better practice in NH and would allow implementing quality improvement programs in the health organization.

Treatment of Acute Renal Colic in US and French EDs: Simulated Cases and Real Cases in Acute Pain Management.

OBJECTIVES: To assess the prescribing patterns in acute renal colic in emergency departments in US and France, by comparing physicians' intended prescription practices with actual prescription data in a sample of emergency practitioners. METHODS: Pharmaco-epidemiological international study in two phases. First, we surveyed emergency physicians in US and France as to what analgesics they would use for simulated cases of renal colic. We then conducted a retrospective review of actual cases of emergency department patients with pain scores ≥6/10 with acute renal colic during a period of 6 months before the survey. We compared nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids used for pain treatment in the two groups, and the differences between the two countries. RESULTS: One hundred six prescribers and 100 patients were included in the study. Comparison between simulated and real cases showed that NSAIDs and opioids were less frequently prescribed in real life (78% vs 99% and 51% vs 100% respectively). Morphine was the most prescribed opioid (96% of simulated cases and 34% of real ones). Acetaminophen use was increased in real life cases (58% vs 0%). Concerning the differences between countries, US physicians are more likely to administer morphine (64% vs 38%) and French physicians NSAIDs (88% vs 68%). The NSAIDs used are ketorolac in the United States (94% of simulated cases vs 64%) and ketoprofen in France (94% and 88% respectively). DISCUSSION: We showed clear differences between intended and real analgesic prescription practices for patients suffering from renal colic. Some differences exist for pain perceptions and treatments between US and France.

Blood alcohol concentration in intoxicated patients seen in the emergency department: does it influence discharge decisions?

OBJECTIVE: The purpose of this study was to investigate whether blood alcohol concentration (BAC) measurement was routinely requested in emergency departments and whether the observation period in the emergency department allowed sufficient time for alcohol elimination before the patient was discharged. METHOD: A retrospective review of medical records of all emergency alcohol-related admissions over a 12-month period from January 2012, in patients older than 18 years, was conducted. We estimated BAC at discharge for each patient by using the following formula: [BAC at admission--(length of stay × 15)]. Then, we focused on patients discharged from the emergency department with an estimated BAC greater than 50 mg/100 ml because of the risk of subsequent legal proceedings, because this is the legal limit for driving in France. RESULTS: A total of 907 patients admitted for acute alcohol intoxication (F10.0) were included, of whom 592 were male. Women were more likely to be admitted at night. The mean length of stay was 18.7 hours. BAC was measured in 893 patients. Patients ages 35-49 years had the highest measured BAC. No repeat BAC was taken before the discharge decision. Three hundred thirteen patients were discharged with an estimated BAC above 50 mg/100 ml. CONCLUSIONS: Emergency physicians routinely requested BAC at admission but did not request alcohol kinetics while the patient was under observation. The discharge decision was based on clinical judgment. Doctors who do not advise patients appropriately before discharge may be guilty of negligence in their duty of care.

Predictive value of the heart-type fatty acid-binding protein and the Pulmonary Embolism Severity Index in patients with acute pulmonary embolism in the emergency department.

OBJECTIVES: Heart-type fatty acid-binding protein (h-FABP), sensitive troponins, natriuretic peptides, and clinical scores such as the Pulmonary Embolism Severity Index (PESI) are candidates for risk stratification of patients with acute pulmonary embolism (PE). The aim was to compare their respective prognostic values to predict an adverse outcome at 1 month. METHODS: The authors prospectively included 132 consecutive patients with confirmed acute PE. On admission to the emergency department (ED), plasma concentrations of h-FABP, sensitive cardiac troponin I-Ultra (cTnI-Ultra), and brain natriuretic peptide (BNP) were measured and the PESI calculated in all patients. The combined 30-day outcomes of interest were death, cardiac arrest, mechanical ventilation, use of catecholamines, and recurrence of acute PE. RESULTS: During the first 30 days, 14 (10.6%) patients suffered complications. Among the biomarkers, h-FABP above 6 µg/L was a stronger predictor of an unfavorable outcome (odds ratio [OR] = 17.5, 95% confidence interval [CI] = 4.2 to 73.3) than BNP > 100 pg/mL (OR = 5.7, 95% CI = 1.6 to 20.4) or cTnI-Ultra > 0.05 µg/L (OR = 3.4, 95% CI = 1.1 to 10.9). The PESI classified 83 of 118 patients (70.3%) with favorable outcomes and only one of 14 (7%) with adverse outcomes in low class I or II (OR = 30.8, 95% CI = 3.2 to 299.7). The areas under the receiver operating characteristic (ROC) curves (AUCs) were 0.90 (95% CI = 0.81 to 0.98) for h-FABP, 0.89 (95% CI = 0.82 to 0.96) for PESI, 0.79 (95% CI = 0.67 to 0.90) for BNP, and 0.76 (95% CI = 0.64 to 0.87) for cTnI-Ultra. The combination of h-FABP with PESI was a particularly useful prognostic indicator because none of the 79 patients (59.8%) with h-FABP < 6 ng/mL and PESI class < III had an adverse outcome. CONCLUSIONS: h-FABP and the PESI are superior to BNP and cTnI-Ultra as markers for risk stratification of patients with acute PE. The high sensitivity of their combination identified a large number of low-risk patients in the ED.