Medical students' perception of simulation-based assessment in emergency and paediatric medicine: a focus group study.

BACKGROUND: Although simulation-based assessment (SBA) is being implemented in numerous medical education systems, it is still rarely used for undergraduate medical students in France. Objective structured clinical examinations (OSCEs) will be integrated into the national medical curriculum in 2021. In 2016 and 2017, we created a mannequin SBA to validate medical students' technical and psychometric skills during their emergency medicine and paediatric placements. The aim of our study was to determine medical students' perceptions of SBA. METHODS: We followed the grounded theory framework to conduct a qualitative study. A total of 215 students participated in either a paediatric or an emergency medicine simulation-based course with a final assessment. Among the 215 participants, we randomly selected forty students to constitute the focus groups. In the end, 30 students were interviewed. Data were coded and analysed by two independent investigators within the activity theory framework. RESULTS: The analyses found four consensual themes. First, the students perceived that success in the SBA provided them with self-confidence and willingness to participate in their hospital placements (1). They considered SBA to have high face validity (2), and they reported changes in their practice after its implementation (3). Nevertheless, they found that SBA did not help with their final high-stakes assessments (4). They discussed three other themes without reaching consensus: stress, equity, and the structure of SBA. After an analysis with activity theory, we found that students' perceptions of SBA underlined the contradictions between two systems of training: hospital and medical. We hypothesise that a specific role and place for SBA should be defined between these two activity systems. CONCLUSION: The students perceived that SBA would increase self-confidence in their hospital placements and emphasise the general skills required in their future professional environment. However, they also reported that the assessment method might be biased and stressful. Our results concerning a preimplementation mannequin SBA and OSCE could provide valuable insight for new programme design and aid in improving existing programmes. Indeed, SBA seems to have a role and place between hospital placements and medical schools.

Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial.

Importance: Uncontrolled studies suggest that pulmonary embolism (PE) can be safely ruled out using the YEARS rule, a diagnostic strategy that uses varying D-dimer thresholds. Objective: To prospectively validate the safety of a strategy that combines the YEARS rule with the pulmonary embolism rule-out criteria (PERC) rule and an age-adjusted D-dimer threshold. Design, Settings, and Participants: A cluster-randomized, crossover, noninferiority trial in 18 emergency departments (EDs) in France and Spain. Patients (N = 1414) who had a low clinical risk of PE not excluded by the PERC rule or a subjective clinical intermediate risk of PE were included from October 2019 to June 2020, and followed up until October 2020. Interventions: Each center was randomized for the sequence of intervention periods. In the intervention period (726 patients), PE was excluded without chest imaging in patients with no YEARS criteria and a D-dimer level less than 1000 ng/mL and in patients with 1 or more YEARS criteria and a D-dimer level less than the age-adjusted threshold (500 ng/mL if age <50 years or age in years × 10 in patients ≥50 years). In the control period (688 patients), PE was excluded without chest imaging if the D-dimer level was less than the age-adjusted threshold. Main Outcomes and Measures: The primary end point was venous thromboembolism (VTE) at 3 months. The noninferiority margin was set at 1.35%. There were 8 secondary end points, including chest imaging, ED length of stay, hospital admission, nonindicated anticoagulation treatment, all-cause death, and all-cause readmission at 3 months. Results: Of the 1414 included patients (mean age, 55 years; 58% female), 1217 (86%) were analyzed in the per-protocol analysis. PE was diagnosed in the ED in 100 patients (7.1%). At 3 months, VTE was diagnosed in 1 patient in the intervention group (0.15% [95% CI, 0.0% to 0.86%]) vs 5 patients in the control group (0.80% [95% CI, 0.26% to 1.86%]) (adjusted difference, -0.64% [1-sided 97.5% CI, -∞ to 0.21%], within the noninferiority margin). Of the 6 analyzed secondary end points, only 2 showed a statistically significant difference in the intervention group compared with the control group: chest imaging (30.4% vs 40.0%; adjusted difference, -8.7% [95% CI, -13.8% to -3.5%]) and ED median length of stay (6 hours [IQR, 4 to 8 hours] vs 6 hours [IQR, 5 to 9 hours]; adjusted difference, -1.6 hours [95% CI, -2.3 to -0.9]). Conclusions and Relevance: Among ED patients with suspected PE, the use of the YEARS rule combined with the age-adjusted D-dimer threshold in PERC-positive patients, compared with a conventional diagnostic strategy, did not result in an inferior rate of thromboembolic events. Trial Registration: ClinicalTrials.gov Identifier: NCT04032769.

Testing the validity of three acute care assessment tools for assessing residents' performance during in situ simulation: the ACAT-SimSit study.

BACKGROUND: The assessment of technical and nontechnical skills in emergency medicine requires reliable and usable tools. Three Acute Care Assessment Tools (ACATs) have been developed to assess medical learners in their management of cardiac arrest (ACAT-CA), coma (ACAT-coma) and acute respiratory failure (ACAT-ARF). OBJECTIVE: This study aims to analyze the reliability and usability of the three ACATs when used for in situ (bedside) simulation. METHODS: This prospective multicenter validation study tested ACATs using interprofessional in situ simulations in seven emergency departments and invited training residents to participate in them. Each session was rated by two independent raters using ACAT. Intraclass correlation coefficients (ICC) were used to assess interrater reliability, and Cronbach's alpha coefficient was used to assess internal consistency for each ACAT. The correlation between ACATs' scores and the learners' level of performance was also assessed. Finally, a questionnaire and two focus groups were used to assess the usability of the ACATs. RESULTS: A total of 104 in situ simulation sessions, including 85 residents, were evaluated by 37 raters. The ICC for ACAT-CA, ACAT-coma and ACAT-ARF were 0.95 [95% confidence interval (CI), 0.93-0.98], 0.89 (95% CI, 0.77-0.95) and 0.92 (95%CI 0.83-0.96), respectively. The Cronbach's alphas were 0.79, 0.80 and 0.73, respectively. The ACAT-CA and ARF showed good construct validity, as third-year residents obtained significantly higher scores than first-year residents ( P  < 0.001; P  < 0.019). The raters supported the usability of the tools, even though they expressed concerns regarding the use of simulations in a summative way. CONCLUSION: This study reported that the three ACATs showed good external validity and usability.

Effect of a specific training intervention with task interruptions on the quality of simulated advance life support: A randomized multi centered controlled simulation study.

PURPOSE: Task interruptions (TI) are frequent disturbances for emergency professionals performing advanced life support (ALS). The aim of our study was to evaluate a specific training intervention with TI on the quality of simulated ALS. METHODS: During this multi centered randomized controlled trial, each team included one resident, one nurse and one emergency physician. The teams were randomized for the nature of their training session: control (without interruption) or intervention (with TI). The primary outcome was non-technical skills assessed with the TEAM score. We also measured the no flow time, the Cardiff score and chest compression depth and rate. RESULTS: On a total of 21 included teams, 11 were randomized to a control training session and 10 to the specific TI training. During training, teams' characteristics and skills were similar between the two groups. During the evaluation session, the TEAM score was not different between groups: median score for control group 33,5 vs 31,5 for intervention group. We also report similar no flow time and Cardiff score. CONCLUSION: In this simulated ALS study, a specific training intervention with TI did not improve technical and non-technical skills. Further research is required to limit the impact of TI in emergency settings.

Pulmonary embolism rule-out decision-making tools for patients aged 35 years or younger in hospital emergency departments: a post-hoc analysis of performance in 3 prospective cohorts. / Capacidad de diferentes reglas de decisión clínica para descartar tromboembolismo pulmonar en pacientes de 35 o menos años atendidos en servicios de urgencias: análisis post-hoc de tres cohortes prospectivas.

OBJECTIVES: To assess the performance of the Pulmonary Embolism Rule-out Criteria (PERC) and the age-modified PERC-35 tool in hospital emergency departments (EDs) for evaluating patients aged 35 years or younger. A secondary aim was to assess other decision-making criteria. MATERIAL AND METHODS: Post-hoc analysis of 3 European cohort studies. We included data for patients aged 35 years or younger suspected of PE who were followed for 3 months. The safety and efficacy of applying the PERC and PERC-35 were assessed with the diagnostic error rate (failure to detect PE) and the proportion of patients in whom a diagnosis of PE was ruled out. We also assessed the safety and efficacy of applying the YEARS and PEGeD criteria. RESULTS: Data for 1235 patients aged 35 years or younger were analyzed. Twenty-two (1.8%; 95% CI, 1.2%-2.7%) PE cases were diagnosed at 3 months. Six (1.0%; 95% CI, 0.5%-2.2%) and 5 (0.9%; 95% CI, 0.4%-2.1%) PE cases were not diagnosed by the PERC and PERC-35 tools, respectively. These tools allowed PE to be ruled out in 591 (48.2%; 95% CI, 45.4%-51.0%) and 554 (46.2%; 95% CI, 43.4%-49.0%) cases, respectively. The error rates of the YEARS and PEGeD criteria, respectively, were 0.4% (95% CI, 0.1%-1.1%) and 0.5% (95% CI, 0.2%-1.2%); their efficacy was similar. CONCLUSION: The safety and efficacy profiles of the PERC and PERC-35 algorithms were similar in patients aged 35 years or younger. However, the large confidence intervals we report do not allow us to confirm the safety of using the tools in patients in this age group.

OBJETIVO: Evaluar la capacidad de la regla PERC (Pulmonary Embolism Rule-out Criteria) y la regla modificada por edad (PERC-35) para descartar tromboembolia pulmonar (TEP) en servicios de urgencias hospitalarios (SUH) en pacientes 35 años. El objetivo secundario fue analizar otras reglas de decisión clínica. METODO: Análisis post-hoc de 3 estudios de cohorte europeos (PROPER, PERCEPIC y MODIGLIANI). Se incluyeron pacientes 35 años con sospecha de TEP en SUH y con seguimiento a 3 meses. La seguridad y eficacia de PERC y PERC-35 se evaluaron con su tasa de error -no detectar TEP- y la proporción de pacientes con diagnóstico de TEP descartado. Se evaluó la seguridad y eficacia de las reglas YEARS y PEGeD. RESULTADOS: Se analizaron 1.235 pacientes 35 años. Hubo 22 (1,8%, IC 95%: 1,2-2,7) TEP diagnosticados a los 3 meses. Hubo 6 (1,0%, IC 95%: 0,5-2,2) y 5 (0,9%, IC 95%: 0,4-2,1) TEP no diagnosticados con las reglas PERC y PERC-35 respectivamente. Estas reglas permitieron descartar TEP en 591 (48,2%, IC 95%: 45,4- 51,0) y 554 (46,2%, IC 95%: 43,4- 49,0) respectivamente. La tasa de error de YEARS y PEGeD fue del 0,4% (IC 95%: 0,1- 1,1) y 0,5% (IC 95%: 0,2-1,2), con una eficacia similar. CONCLUSIONES: En pacientes 35 años, las reglas PERC y PERC-35 mostraron perfiles de seguridad y eficacia similares. Sin embargo, el amplio intervalo de confianza comunicado en este estudio no permite confirmar su seguridad.

Innovating for a Safe Simulation Challenge During a Pandemic: An Avatar Simulation Concept.

SUMMARY STATEMENT: We present a new simulation-based challenge (Sim'Cup) concept, created in response to the COVID-19 pandemic. It took place in 2020, during the European Society of Emergency Medicine and the Societé Française de Médecine d'Urgence (SFMU) conferences. Usually, during the conferences, a Sim'Cup is held with onsite participants who are involved in a consecutive series of face-to-face simulations organized in 2 qualifying rounds, followed by a final round. When congresses were transformed into online events, the Sim'Cup had to evolve into a virtual format as well. We developed the e-Sim'Cup concept as follows: participants staying safely at home, piloting the trainers, as if they were their own avatar, in a simulation room with a full-scale high-fidelity manikin (Gaumard, Laerdal) using real-time scenarios. Participants gave instructions to the avatars through a smartphone and via a website. Each team participated in 2 scenarios. At the end of each scenario, teams had to undergo a self-debriefing, followed by a short debriefing with the organizers. Twenty-seven participants divided into 9 teams participated in 1 of the 2 e-Sim'Cup events.We evaluated the impact of this approach using the Educational Practices Questionnaire, and we also analyzed the participants' perception of their satisfaction and their feelings of improvement with this virtual format. Moreover, we conducted qualitative analyses of the self-debriefings. Thirteen participants filled out the questionnaire, giving a combined high Educational Practices Questionnaire score [72 (66.5-77) of 80], which reflects the presence of educational best practices during the e-Sim'Cups. They appreciated the adjusted Sim'Cup format and believed that they were able to improve their communication, clinical skills, and self-confidence. The qualitative analysis suggested that the approach was perceived as immersive by the 27 participants, with some challenges due to technical problems but an overall feeling of improvement regarding their crisis resource management skills. The hybrid remote simulation concept satisfied the participants who believed that it improved important skills in emergency medicine. The increasing number of remote activities and conferences lead us to believe that our e-Sim'Cup concept can be easily reproducible in any simulation center, as it requires only the application of the educational concept and either the use of the website or the use of some widely available technical devices.

Simulation-based summative assessment in healthcare: an overview of key principles for practice.

BACKGROUND: Healthcare curricula need summative assessments relevant to and representative of clinical situations to best select and train learners. Simulation provides multiple benefits with a growing literature base proving its utility for training in a formative context. Advancing to the next step, "the use of simulation for summative assessment" requires rigorous and evidence-based development because any summative assessment is high stakes for participants, trainers, and programs. The first step of this process is to identify the baseline from which we can start. METHODS: First, using a modified nominal group technique, a task force of 34 panelists defined topics to clarify the why, how, what, when, and who for using simulation-based summative assessment (SBSA). Second, each topic was explored by a group of panelists based on state-of-the-art literature reviews technique with a snowball method to identify further references. Our goal was to identify current knowledge and potential recommendations for future directions. Results were cross-checked among groups and reviewed by an independent expert committee. RESULTS: Seven topics were selected by the task force: "What can be assessed in simulation?", "Assessment tools for SBSA", "Consequences of undergoing the SBSA process", "Scenarios for SBSA", "Debriefing, video, and research for SBSA", "Trainers for SBSA", and "Implementation of SBSA in healthcare". Together, these seven explorations provide an overview of what is known and can be done with relative certainty, and what is unknown and probably needs further investigation. Based on this work, we highlighted the trustworthiness of different summative assessment-related conclusions, the remaining important problems and questions, and their consequences for participants and institutions of how SBSA is conducted. CONCLUSION: Our results identified among the seven topics one area with robust evidence in the literature ("What can be assessed in simulation?"), three areas with evidence that require guidance by expert opinion ("Assessment tools for SBSA", "Scenarios for SBSA", "Implementation of SBSA in healthcare"), and three areas with weak or emerging evidence ("Consequences of undergoing the SBSA process", "Debriefing for SBSA", "Trainers for SBSA"). Using SBSA holds much promise, with increasing demand for this application. Due to the important stakes involved, it must be rigorously conducted and supervised. Guidelines for good practice should be formalized to help with conduct and implementation. We believe this baseline can direct future investigation and the development of guidelines.

Usability and reproducibility of three tools to assess medical students and residents in emergency medicine.

OBJECTIVES: It is critical to assess competency of medical students and residents in emergency medicine (EM) during undergraduate and graduate medical education. However, very few valid tools exist to assess both technical and nontechnical skills in the specific context of EM. Three Acute Care Assessment Tools (ACAT 1, 2, and 3) have been previously developed for three acute care conditions: cardiac arrest (1), coma (2), and acute respiratory failure (3). This study aimed to evaluate the reproducibility of the tools. METHODS: The tool was tested using recorded videos of simulation sessions of fourth year medical students and first year residents in EM. Raters independently reviewed the videos two times in a 3-month interval, and interrater and intrarater reliability using intraclass correlation (ICC) was calculated. Secondary endpoints included the completeness rate and relevance of the ACAT. RESULTS: Sixty-two sessions were recorded and 48 videos analyzed (18 for CA and 15 for both respiratory failure and coma. The learners were residents in 32 (66%) of videos. Interrater reliability was excellent (ICC >0.9 for all three contexts) and so was the intrarater reliability (>0.88), both upon first review (month 0, M0) and at 3 months (M3). The usability of the ACAT was good, with a completeness of the items that ranged from 96% to 100%. Only one item of the ACAT 1 had a relevance of 27%, as it could not be completed in 13 scenarios out of 18. CONCLUSIONS: The results demonstrate educators can evaluate students similarly utilizing video recordings of simulated medical scenario. The excellent completeness of the rated items advocated for good usability. The three ACATs can be utilized to assess for completeness of predefined tasks in three acute care broad scenario in a competency-based medical education framework.

MOdified DIagnostic strateGy to safely ruLe-out pulmonary embolism In the emergency depArtment: study protocol for the Non-Inferiority MODIGLIANI cluster cross-over randomized trial.

INTRODUCTION: In the work-up strategy for pulmonary embolism (PE) in the ED, the recently introduced YEARS rule allows the raising of the D-dimer threshold to 1000 ng/ml in patients with no signs of deep venous thrombosis and no hemoptysis and in whom PE is not the most likely diagnosis. However, this decision rule has never been prospectively compared to the usual strategy. Furthermore, it is unclear if the YEARS rule can be used on top of the Pulmonary Embolism Rule-out Criteria (PERC). We aim to assess the non-inferiority of YEARS compared to current guidelines to rule out PE among PERC-positive ED patients with suspicion of PE. METHODS/DESIGN: The MODIGLIANI study is a multicenter, European, non-inferiority, cluster-randomized, two periods cross-over, controlled trial. Each center will be randomized for the sequence of two 4-month periods: intervention (MOdified Diagnostic Strategy: MODS) followed by control (usual care), or control followed by intervention with 1 month of "wash-out" between the two periods. In the control period, the threshold will be as usual (500 ng/ml for patients aged 50 years or younger and age × 10 for older patients). In the MODS period, the threshold of D-dimers to rule out PE will be raised to 1000 ng/ml if no item of the YEARS score is present or will remain unchanged otherwise. Patients will be included if they have a suspicion of PE, defined as chest pain, dyspnea, or syncope. Non-inclusion criteria comprise a high clinical probability of PE or PERC-negative patients with low clinical probability. ETHICS AND DISSEMINATION: The study has received the following approvals: Comité de protection des personnes Ile de France XI (France) and Comité de Ética de la Investigación con medicamentos del Hospital Clínic de Barcelona (Spain). Results will be made available to all included participants and other researchers. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04032769. Registered on 24 July 2019.

End tidal carbon dioxide monitoring in acute asthma: a prospective pilot study in emergency department patients.

The peak expiratory flow rate (PEFR) is the gold standard for monitoring asthmatic patients. However, its measurement requires understanding and active participation. End tidal carbon dioxide (EtCO2) may be considered an accurate surrogate for PaCO2, a severity marker in acute asthma. We studied the use of EtCO2 as a monitoring tool in acute asthma. PATIENTS AND METHODS: This was a prospective study that included consecutive patients admitted to our emergency department for acute asthma exacerbation. Data were collected at first medical contact (T0) and after 1 h of treatment (T60). The primary endpoint was the change in EtCO2; the secondary endpoints included changes in the EtCO2 Q angle value, plateau T time, and change in EtCO2 values for the patients with a PEFR ratio less than 50% after treatment. RESULTS: Fifty-five patients were included and 36 waveforms were analysed. The mean age was 37 years and 26 (47%) were women. The median initial PEFR was 200 [interquartile range (IQR): 150-240]; the median EtCO2 at T0 and T60 was 35 (IQR: 30-38) and 34 (IQR: 29-37). There was no significant change in EtCO2 after treatment. There was no significant change in the Q angle and the T time after treatment. At T60, 20 (36%) patients had a PEFR ratio less than 50%. Change in EtCO2 from T60 to T0 was associated with a PEFR ratio less than 50%. CONCLUSION: After 1 h of treatment, there was no significant change in EtCO2. A decrease in EtCO2 seems to be associated with a higher risk of PEFR ratio less than 50% after treatment.

Prevalence of pulmonary embolism in emergency department patients with isolated syncope: a prospective cohort study.

BACKGROUNDS: Paramount to guide the diagnostic strategy, the prevalence of pulmonary embolism in patients with syncope and no other symptoms is uncertain. We aimed to assess the pulmonary embolism prevalence in patients that present to the emergency department (ED) with syncope and no chest pain nor dyspnea. METHODS: Multicenter prospective cohort study in seven EDs in France. Adult patients who presented to the ED with syncope (transient loss of consciousness) were included. Patients with chest pain or dyspnea were excluded. Included patients underwent formal work-up for pulmonary embolism, including D-dimer testing and further imaging if positive. Cases of pulmonary embolism were adjudicated by two independent expert radiologists with the review of imaging studies. Secondary objectives included the pulmonary embolism prevalence in the subgroup of patients with cancer, in patients with negative Pulmonary Embolism Rule Out criteria (PERC) score, and according to the clinical probability assessed either by Wells or revised Geneva score. RESULTS: We analyzed 411 patients, in whom 128 (31%) underwent a computed tomographic pulmonary angiogram and 9 (2%) a ventilation-perfusion scan. A pulmonary embolism was confirmed in nine patients (prevalence of 2.2%, 95% confidence interval, 1.1-4.3%), including one subsegmental pulmonary embolism. This prevalence was of 18% (3-52%) in patients with cancer and 0.7% (0.1-4%) in PERC negative patients. CONCLUSION: In our sample of patients with isolated syncope, the prevalence of pulmonary embolism was 2.2%. This value is not sufficiently low to negate the requirement for a formal work up in the ED, even in the absence of chest pain or dyspnea. However, the large confidence interval precludes any strong conclusion.

Safety of the Combination of PERC and YEARS Rules in Patients With Low Clinical Probability of Pulmonary Embolism: A Retrospective Analysis of Two Large European Cohorts.

BACKGROUND: This study aimed to determine the failure rate of a combination of the PERC and the YEARS rules for the diagnosis of pulmonary embolism (PE) in the emergency department (ED). METHODS: We performed a retrospective analysis of two European cohorts of emergency patients with low gestalt clinical probability of PE (PROPER and PERCEPIC). All patients we included were managed using a conventional strategy (D-dimer test, followed, if positive, by computed tomographic pulmonary angiogram (CTPA). We tested a diagnostic strategy that combined PERC and YEARS to rule out PE. The primary endpoint was a thromboembolic event diagnosed in the ED or at 3-months follow-up. Secondary endpoints included a thromboembolic event at baseline in the ED and a CTPA in the ED. Ninety-five percent confidence intervals (CIs) of proportions were calculated with the use of Wilson's continuity correction. RESULTS: We analyzed 1,951 patients (mean ± SD age = 47 ± 18 years, 56% women) with an overall proportion of patients with PE of 3.5%. Both PERC and YEARS strategies were associated with 11 missed PE in the ED: failure rate 0.57 (95% CI = 0.32-1.02). At 3-month follow-up, the overall failure rate was 0.83% (95% CI = 0.51-1.35). Among the 503 patients who underwent a CTPA (26%), the use of the PERC-YEARS combination would have ruled out PE without CTPA in 249 patients (50% [95%CI = 45%-54%], absolute reduction 13% (95% CI = 11%-14%]). CONCLUSION: The combination of PERC then YEARS was associated with a low risk of PE diagnostic failure and would have resulted in a relative reduction of almost half of CTPA.

Agreement between arterial and venous lactate in emergency department patients: a prospective study of 157 consecutive patients.

INTRODUCTION: In the emergency department (ED), lactate is routinely used for risk stratification. Whether venous or arterial lactate measured on blood gas is interchangeable is not known. We hypothesized that venous lactate can be used instead of arterial lactate for the evaluation of acute patients in the ED. PATIENTS AND METHODS: This was a prospective single-center study. All patients requiring a lactate measurement were enrolled and we simultaneously drew arterial and venous blood. We followed up all patients to hospital discharge. Our primary aim was to evaluate agreements between the two measurements using Bland and Altman plots with the report of bias (mean difference) and limits of agreements. We also aimed to determine the rate of misclassification (defined as one measurement<1.8 mmol/l and the other>2.2). Our secondary aim was to evaluate their respective prognostic value to predict in-hospital death or admission in the ICU longer than 72 h. RESULTS: The mean age of the 132 analyzed patients was 62 years (SD: 18 years), and 59% were men. The mean difference (bias) between arterial and venous lactate was -0.6 mmol/l (limits of agreement: -1.7 to 0.6 mmol/l). The rate of misclassification was 8% (95% confidence interval: 3-2%). Both methods present similar performances for the prediction of poor outcomes, with an area under the receiving operator characteristic curves of 0.67 for both. Results were similar when focused only on septic patients. CONCLUSION: Venous and arterial lactates do not agree well, and there is a high misclassification rate. Venous lactate does not appear to be interchangeable with arterial sampling.

Effect of emergency physician burnout on patient waiting times.

Burnout is common in emergency physicians. This syndrome may negatively affect patient care and alter work productivity. We seek to assess whether burnout of emergency physicians impacts waiting times in the emergency department. Prospective study in an academic ED. All patients who visited the main ED for a 4-month period in 2016 were included. Target waiting times are assigned by triage nurse to patients on arrival depending on their severity. The primary endpoint was an exceeded target waiting time for ED patients. All emergency physicians were surveyed by a psychologist to assess their level of burnout using the Maslach Burnout Inventory. We defined the level of burnout of the day in the ED as the mean burnout level of the physicians working that day (8:30 to the 8:30 the next day). A logistic regression model was performed to assess whether burnout level of the day was independently associated with prolonged waiting times, along with previously reported predictors. Target waiting time was exceeded in 7524 patients (59%). Twenty-six emergency physicians were surveyed. Median burnout score was 35 [Interquartile (24-49)]. A burnout level of the day higher than 35 was independently associated with an exceeded target waiting time (adjusted odds ratio 1.54, 95% confidence interval 1.39-1.70), together with previously reported predictors (i.e., day of the week, time of the day, trauma, age and daily census). Burnout of emergency physicians was independently associated with a prolonged waiting time for patients visiting the ED.

Capacidad de diferentes reglas de decisión clínica para descartar tromboembolismo pulmonar en pacientes de 35 o menos años atendidos en servicios de urgencias: análisis post-hoc de tres cohortes prospectivas / Pulmonary embolism rule-out decision-making tools for patients aged 35 years or younger in hospital emergency departments: a post-hoc analysis of performance in 3 prospective cohorts

Objetivos: Evaluar la capacidad de la regla PERC (Pulmonary Embolism Rule-out Criteria) y la regla modificada por edad (PERC-35) para descartar tromboembolia pulmonar (TEP) en servicios de urgencias hospitalarios (SUH) en pacientes # 35 años. El objetivo secundario fue analizar otras reglas de decisión clínica. Método: Análisis post-hoc de 3 estudios de cohorte europeos (PROPER, PERCEPIC y MODIGLIANI). Se incluyeron pacientes # 35 años con sospecha de TEP en SUH y con seguimiento a 3 meses. La seguridad y eficacia de PERC yPERC-35 se evaluaron con su tasa de error -no detectar TEP- y la proporción de pacientes con diagnóstico de TEP descartado. Se evaluó la seguridad y eficacia de las reglas YEARS y PEGeD. Resultados: Se analizaron 1.235 pacientes # 35 años. Hubo 22 (1,8%, IC 95%: 1,2-2,7) TEP diagnosticados a los 3 meses. Hubo 6 (1,0%, IC 95%: 0,5-2,2) y 5 (0,9%, IC 95%: 0,4-2,1) TEP no diagnosticados con las reglas PERC y PERC-35 respectivamente. Estas reglas permitieron descartar TEP en 591 (48,2%, IC 95%: 45,4- 51,0) y 554 (46,2%, IC 95%: 43,4- 49,0) respectivamente. La tasa de error de YEARS y PEGeD fue del 0,4% (IC 95%: 0,1- 1,1) y 0,5% (IC 95%: 0,2-1,2), con una eficacia similar. Conclusiones: En pacientes # 35 años, las reglas PERC y PERC-35 mostraron perfiles de seguridad y eficacia similares. Sin embargo, el amplio intervalo de confianza comunicado en este estudio no permite confirmar su seguridad. (AU)

Objectives: To assess the performance of the Pulmonary Embolism Rule-out Criteria (PERC) and the age-modified PERC-35 tool in hospital emergency departments (EDs) for evaluating patients aged 35 years or younger. A secondary aim was to assess other decision-making criteria. Method: Post-hoc analysis of 3 European cohort studies. We included data for patients aged 35 years or younger suspected of PE who were followed for 3 months. The safety and efficacy of applying the PERC and PERC-35 were assessed with the diagnostic error rate (failure to detect PE) and the proportion of patients in whom a diagnosis of PE was ruled out. We also assessed the safety and efficacy of applying the YEARS and PEGeD criteria. Results: Data for 1235 patients aged 35 years or younger were analyzed. Twenty-two (1.8%; 95% CI, 1.2%-2.7%) PE cases were diagnosed at 3 months. Six (1.0%; 95% CI, 0.5%-2.2%) and 5 (0.9%; 95% CI, 0.4%-2.1%) PE cases were not diagnosed by the PERC and PERC-35 tools, respectively. These tools allowed PE to be ruled out in 591 (48.2%; 95% CI, 45.4%-51.0%) and 554 (46.2%; 95% CI, 43.4%-49.0%) cases, respectively. The error rates of the YEARS and PEGeD criteria, respectively, were 0.4% (95% CI, 0.1%-1.1%) and 0.5% (95% CI, 0.2%-1.2%); their efficacy was similar. Conclusions: The safety and efficacy profiles of the PERC and PERC-35 algorithms were similar in patients aged 35 years or younger. However, the large confidence intervals we report do not allow us to confirm the safety of using the tools in patients in this age group. (AU)

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

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

External validation of a clinical decision rule: we need events in a population in order to rule them out!

We respond to the Lorton et al. article on external validation of the PECARN study. With an event rate of only 0.6%, we believe that their study failed to confirm the safety of this rule. Such a low number of events should call for caution when interpreting the results of diagnostic tests.

Mid-regional pro-adrenomedullin and copeptin to predict short-term prognosis of COPD exacerbations: a multicenter prospective blinded study.

BACKGROUND: Exacerbations of COPD (ECOPD) are a frequent cause of emergency room (ER) visits. Predictors of early outcome could help clinicians in orientation decisions. In the current study, we investigated whether mid-regional pro-adrenomedullin (MR-proADM) and copeptin, in addition to clinical evaluation, could predict short-term outcomes. PATIENTS AND METHODS: This prospective blinded observational study was conducted in 20 French centers. Patients admitted to the ER for an ECOPD were considered for inclusion. A clinical risk score was calculated, and MR-proADM and copeptin levels were determined from a venous blood sample. The composite primary end point comprised 30-day death or transfer to the intensive care unit or a new ER visit. RESULTS: A total of 379 patients were enrolled in the study, of whom 277 were eventually investigated for the primary end point that occurred in 66 (24%) patients. In those patients, the median (interquartile range [IQR]) MR-proADM level was 1.02 nmol/L (0.77-1.48) versus 0.83 nmol/L (0.63-1.07) in patients who did not meet the primary end point (P=0.0009). In contrast, copeptin levels were similar in patients who met or did not meet the primary end point (P=0.23). MR-proADM levels increased with increasing clinical risk score category: 0.74 nmol/L (0.57-0.89), 0.83 nmol/L (0.62-1.12) and 0.95 nmol/L (0.75-1.29) for the low-, intermediate- and high-risk categories, respectively (P<0.001). MR-proADM was independently associated with the primary end point (odds ratio, 1.65; 95% confidence interval [CI], 1.10-2.48; P=0.015). MR-proADM predicted the occurrence of primary end point with a sensitivity of 46% (95% CI, 33%-58%) and a specificity of 79% (95% CI, 74-84). CONCLUSION: MR-proADM but not copeptin was significantly associated with outcomes at 30 days, even after adjustment for clinical risk category. Overall, MR-proADM, alone or combined with the clinical risk score, was a moderate strong predictor of short-term outcomes.

Temporal trends in nitrate utilization for acute heart failure in elderly emergency patients: A single-centre observational study.

BACKGROUND: We previously conducted a pilot study that reported the safety of isosorbide dinitrate boluses for elderly emergency patients with acute heart failure syndrome. AIMS: To assess the temporal trend in the rate of elderly patients treated with isosorbide dinitrate, and to evaluate subsequent outcome differences. METHODS: This was a single-centre study. We compared patients aged>75 years who attended the emergency department with a primary diagnosis of acute pulmonary oedema in the years 2007 and 2014. The primary endpoint was the rate of patients who received isosorbide dinitrate boluses in the emergency department. Secondary endpoints included in-hospital mortality, need for intensive care and length of stay. RESULTS: We analysed 368 charts, 232 from patients included in 2014 (63%) and 136 in 2007 (37%). The mean age was 85±6 years in both groups. There was a significant rise in the rate of patients treated with isosorbide dinitrate between 2007 and 2014: 97 patients (42%) in 2014 vs. 24 patients (18%) in 2007 (P<0.01). Comparing the two periods, we report similar in-hospital mortality rates (8% vs. 11%; P=0.5), rates of admission to the intensive care unit (13% vs. 17%; P=0.3) and lengths of stay (10 days in both groups). CONCLUSION: We observed a significant rise in the rate of elderly patients treated with isosorbide dinitrate boluses for acute heart failure. However, we did not observe any significant improvement in outcomes.

Weaker compressions after night shift? The WeCAN manikin study.

To assess whether the quality of chest compressions (CC) differs before and after a night shift. We carried out a cluster randomized study in three Emergency Departments and three ICUs in Paris, France. Physicians were assessed on a control day and immediately following after a night shift. The primary endpoint was the proportion of CC with a depth greater than 50 mm. We analyzed 67 participants. The proportion of CC with a depth greater than 50 mm was similar on a control day and after a night shift [52% in both groups, mean difference of 0 (95% confidence interval: -17 to 17)]. Other indicators of CC quality were unchanged after a night shift, except for the mean depth of CC (51 vs. 48 mm, P=0.01). We report in our sample that the quality of CC after a night shift is not inferior to a control day.