Search

In pediatric emergency departments (PEDs), seasonal viral outbreaks are believed to be associated with an increase of workload, but no quantification of this impact has been published. A retrospective cross-sectional study aimed to measure this impact on crowding and health care quality in PED. The study was performed in 1 PED for 3 years. Visits related to bronchiolitis, influenza, and gastroenteritis were defined using discharge diagnoses. The daily epidemic load (DEL) was the proportion of visits related to one of these diagnoses. The daily mean of 8 crowding indicators (selected in a published Delphi study) was used. A total of 93,976 children were admitted (bronchiolitis, 2253; influenza, 1277; gastroenteritis, 7678). The mean DEL was 10.4% (maximum, 33.6%). The correlation between the DEL and each indicator was significant. The correlation was stronger for bronchiolitis (Pearson R from 0.171 for number of hospitalization to 0.358 for length of stay). Between the first and fourth quartiles of the DEL, a significant increase, between 50% (patients left without being seen) and 8% (patient physician ratio), of all the indicators was observed. In conclusion, seasonal viral outbreaks have a strong impact on crowding and quality of care. The evolution of "patients left without being seen" between the first and fourth quartiles of DEL could be used as an indicator reflecting the capacity of adaptation of an emergency department to outbreaks.

Despite multiple recommendations, intramuscular epinephrine is poorly prescribed in emergency department receiving pediatric anaphylaxis. To evaluate the role of severity symptoms on this use, we included all admissions for a diagnosis linked to possible allergy in the two pediatric emergency departments of our institution between January 2010 and December 2015. Selection and analysis were restricted to children under 18 years fulfilling Sampson's criteria for anaphylaxis. We retrospectively ranked these admissions with the Ring and Messmer anaphylaxis severity score and compared the use of epinephrine according to this classification. Among 422,483 admissions, 204 (0.05%) fulfilled the anaphylaxis criteria (170 (83.3%) grade II anaphylaxis, and 34 (16.7%) grade III; mean age 7.9 years). Previous allergy, anaphylaxis, and asthma were found in respectively 60.8%, 36.8%, and 35.1%. Food allergy was the main suspected causal trigger. Epinephrine was used in 32.7% (n = 65/199), before admission (11.4% (n = 23/201)) or in the emergency department (22.2% (n = 45/202)). Epinephrine was more frequently prescribed in grade III than in grade II anaphylaxis (84.8% vs 22.3%, p 0.001; OR = 19.05 [7.05-54.10]). Upon discharge, epinephrine auto-injectors prescription and allergy referral were rare (31.7% and 44.2%).Conclusion: Pediatricians intuitively adapt their epinephrine use to the severity of the anaphylaxis and contribute to epinephrine underuse in pediatric anaphylaxis. What is known: • Intramuscular epinephrine is the recommended treatment for pediatric anaphylaxis. However, most of the European and North-American studies show a low prescription rate of epinephrine in both prehospital and pediatric emergency department management. • Reasons for such a low prescription rate are unknown. What is new: • This study confirms that intramuscular epinephrine is poorly prescribed in pediatric anaphylaxis (about one case among 10 before admission and one among 5 in pediatric emergency departments). • Despite recommendations, pediatricians intuitively adapt their prescription to the clinical severity of anaphylaxis, with a fourfold increase prescription in grade III compared to grade II anaphylaxis. This medical behavior ascertainment may be in part explained by the delay between the ED admission/management and the anaphylactic episode onset.

Background Emergency department (ED) crowding is a serious international public health issue with a negative impact on quality of care. Despite two decades of research, there is no consensus on the indicators used to quantify crowding. The aim of our study was to select the most valid ED crowding indicators. Materials and methods The Delphi method was used. Selected indicators originated from a literature review and propositions from FEDORU (National Emergency Department Observatory Network) workgroup. Selected national experts were emergency physicians with a special interest in ED crowding. They had to assess each indicator in terms of validity out of a Likert scale from 1 to 9. Indicators withdrawal criteria after each round (consensus) were over 70% of answers of at least 7 with interquartile range less than 3 (positive consensus) or over 70% of answers of at least 4 and interquartile range less than 3 (negative consensus). The decision to stop the delphi procedure was based on the stability of answers between the rounds. Results 41 (89.13%) experts answered the first round and 37 (80.43%) answered the second round. Among the 57 indicators included, 15 reached consensus: four input indicators, six throughput and five output ones. For those three categories of at least 7 answers rates were, respectively, 80.9, 76.9 and 75.0%. Five indicators were deducible from the mandatory Emergency Department Discharge Summary. They obtained 80.2% of at least 7 answers. Conclusion Our study results enable the construction and validation of a crowding measuring tool from indicators approved by experts. It is necessary to further reflect about ED crowding as a concept and what is expected from a complex score.

International audience; Children's asthma is multifactorial. Environmental factors like air pollution exposure, meteorological conditions, allergens, and viral infections are strongly implicated. However, place of residence has rarely been investigated in connection with these factors. The primary aim of our study was to measure the impact of particulate matter (PM), assessed close to the children's homes, on asthma-related pediatric emergency hospital visits within the Bouches-du-Rhône area in 2013. In a nested case-control study on 3- to 18-year-old children, each control was randomly matched on the emergency room visit day, regardless of hospital. Each asthmatic child was compared to 15 controls. PM10 and PM2.5, meteorological conditions, pollens, and viral data were linked to ZIP code and analyzed by purpose of emergency visit. A total of 68,897 visits were recorded in children, 1182 concerning asthma. Short-term exposure to PM10 measured near children's homes was associated with excess risk of asthma emergency visits (adjusted odds ratio 1.02 (95% CI 1.01-1.04; p = 0.02)). Male gender, young age, and temperature were other risk factors. Conversely, wind speed was a protective factor.CONCLUSION:PM10 and certain meteorological conditions near children's homes increased the risk of emergency asthma-related hospital visits in 3- to 18-year-old children in Bouches-du-Rhône. What is Known: • A relationship between short-term exposure to air pollution and increase in emergency room visits or hospital admissions as a result of increased pollution levels has already been demonstrated. What is New: • This study confirms these results but took into account confounding factors (viral data, pollens, and meteorological conditions) and is based on estimated pollution levels assessed close to the children's homes, rather than those recorded at the hospital. • The study area, the Mediterranean, is favorable to creation of secondary pollutants in these sunny and dry seasons.

Objecive The study aims to evaluate the potential impact of the revision of the thesaurus used by ED physicians to code medical diagnoses, on the syndromic indicators used daily to achieve the detection objective of the French syndromic surveillance system. Introduction As part of the French syndromic surveillance system SurSaUD®, the French Public Health Agency (Sante publique France) collects daily data from the emergency department (ED) network OSCOUR® [1]. The system aims to timely identify, follow and assess the health impact of unusual or seasonal events on emergency medical activity. Individual ED data contain demographic (age, gender, residence zip code), administrative (dates of attendances and discharge, ED, etc.) and medical information (chief complaint, main and associated medical diagnoses, severity). Medical diagnoses are encoded using the ICD10 classification. Then syndromic groups are built based on these ICD10 codes for ensuring syndromic surveillance in routine. Even if ICD10 is recommended on the national guidelines for coding ED attendances, this thesaurus offers a too large variety of codes. Particularly, it includes lots of diseases that may never be observed or confirmed in ED. This variety let selection of the appropriate codes difficult for physicians in a reactive use and could discourage them to code diagnoses. In order to encourage appropriate and reactive coding practice, we decided in 2017 to produce a new diagnoses thesaurus with a limited list of ICD10 codes. Then a committee of medical and epidemiological experts was created by the Federation of regional emergency observatories (FedORU), to propose an operational thesaurus that includes relevant codes for both ED in a daily routine practice and syndromic surveillance. Methods The committee has met 10 times since 2017. Since it would have been hard to work on the complete ICD10 list, the work was based on a more limited thesaurus already used by part of French ED. Only codes, which were pertinent regarding ED activity and interest for public health alert, have been considered. The main principles that have guided the selection were to 1) keep codes related to diagnoses that physicians are able to diagnose on a clinical basis or with rapid diagnostic tests, 2) remove diagnoses providing redundant information regarding other variables (such as circumstantial information) and 3) ensure that a substitution code was kept when a removed code was frequently used or was of interest for syndromic surveillance. Among the 86 syndromic groups defined on the basis of a list of ICD10 codes selected in the complete thesaurus, 34 are daily analyzed by Sante publique France for outbreak detection and early assessment of public health events. Those 34 syndromic groups have been recalculated by considering the revised thesaurus on a three-year period (from 2015 to 2017) at national level. In order to measure the potential impact of the revised thesaurus on the syndromic groups, we have considered three evaluation measures: 1. the proportion of ICD10 codes deleted (removal rate) from the initial definition of each syndromic group, due to the limitation of the thesaurus (calculated for the 86 syndromic groups); 2. the mean difference in the daily number of attendances between the initial and the new versions of each syndromic group (calculated for the 34 syndromic groups); 3. the linear correlation coefficient between the daily numbers of attendances of the initial and the new version of each syndromic group, in order to assess if the daily fluctuations of the new syndromic group are similar to those of the initial syndromic group (calculated for the 34 syndromic groups). Results Among the 86 syndromic groups, 75 (85%) have been impacted by the revised thesaurus, which implied codes removal. Among those 75 syndromic groups, the number of ICD10 codes included in their definition has been reduced by 71% on average. This removal rate varied between 17% and 100%. Syndromic groups including initially more than 100 codes have been the most concerned by a limitation of the number of ICD10 codes. Among the 34 syndromic groups daily analyzed for outbreak detection, 32 have been impacted by code removal with a mean removal rate of 68% (0%-97%). On average, 77% of daily attendances have been retained by the new version of syndromic groups, varying from 15% to 100%. Only 3 syndromic groups have kept less than 60% of attendances: Decrease of well-being (36%), Conjunctivitis (32%) and Hypothermia (15%). On average, the correlation coefficient has been of 0.96, varying from 0.57 to 1. The lowest values have been observed for the same three syndromic groups listed above: Decrease of well-being (0.57), Conjunctivitis (0.91) and Hypothermia (0.59). 18 among the 34 syndromic groups had a correlation coefficient higher than 0.99. Conclusions The study showed that most of the syndromic groups were impacted by the revised thesaurus, which resulted in a removal of about two thirds of the ICD10 codes usually considered in daily surveillance. However, more than three quarters of attendances were still retained in the new syndromic groups. This new thesaurus was conceived to rationalize the number of diagnoses codes but a substitution code was systematically proposed to replace removed codes. Those results highlighted that a large number of codes included in the complete ICD10 thesaurus were rarely used and that the most frequent codes were kept in the revised thesaurus version. However, this study showed that a few syndromic groups were strongly impacted by the revised thesaurus and can suffer of reduced performances to detect unusual variations. Based on those results, a second round of exploration of specific parts of the complete ICD10 thesaurus will be necessary to adapt either syndromic groups or the revised thesaurus. Even if the number of attendances may be reduced due to the removal of ICD10 codes, temporal variations remain similar for the majority of syndromic groups. Syndromic surveillance system does not aim to provide exhaustive quantification of attendances for a pathology, but aims to be able to detect expected or unusual public health variations. These evaluation results correspond to the worst-case scenario assuming that ED physicians will not modify their encoding habits by using the substitution codes but keep using their current thesaurus. However, we expect that this new and simplified version will facilitate diagnosis encoding task and lead toward a better diagnosis encoding rate. Once this new thesaurus will be widely used, we can expect a substantial improvement of the quality of ED medical data and then of syndromic surveillance results. Finally, this study enhances the importance that both data providers and epidemiologists in charge of syndromic surveillance work closely, in order to improve system in shared objectives. References [1] Fouillet A, Bousquet V, Pontais I, Gallay A, Caserio-Schonemann C. The French emergency department OSCOUR network: evaluation after a 10-year existence. Online J Public Health Inform. 2015; 7(1): e74.

Objective The study describes the characteristics of attendances for low back pain (LBP) in the French emergency departments (ED) network Oscour®, in order to give an overview of this disease before launching a prevention campaign. Introduction LBP is one of the leading contributors to disease burden worldwide [1]. In France, LBP is a frequent reason of general practice consultations. According to a study published in 2017 and based on 2014 data issued of the National Health Insurance Cross-Schemes Information System (Sniiram) [2], this pathology stands for 30% of thickness leave and 4 of 5 people will suffer of low back pain during their own life. Most often, LBP is a chronic pathology with acute episodes which most often require emergency care. In order to prevent chronicity, French health care insurance launched into a mainstream national prevention campaign during spring 2018. This campaign was also targeted for health professional to inform them of the best recommendations to provide to their patients. Then the French society of emergency medicine (SFMU) has been asked to relay this campaign to emergency departments (ED) where LBP is a frequent reason of attendance. Since 2004, the French syndromic surveillance system SurSaUD® [3] coordinated by the French Public Health Agency (Sante publique France) daily collects morbidity data from the emergency departments (ED) network Oscour®. Almost 92% of the French ED attendances were recorded by the system in 2017. The availability of this large ED dataset on the whole territory since several years gives the opportunity to describe LBP attendances before the potential fallout of the national prevention campaign. Methods For each ED attendance, the SurSaUD® system daily collects individual data containing demographic (age, gender, zip code), administrative (ED unit, date of attendance, transport…) and medical information (medical diagnosis (ICD10), chief complaint, severity, hospit.). These data are routinely analyzed to detect and follow-up various expected or unusual public health events all over the territory [3] and also constitute a large database to perform in-depth studies on specific public health issues. ED attendances with a medical diagnosis of LBP have been identified using at least one of the following ICD10 codes “M545”, “M5450”, “M5456”, “M5457”, “M5458”, “M5459”. Those data have been analyzed from 01/01/2014 to 31/12/2017 (504 ED) for the following age groups; less than 18 years old (yo), 18 to 34 yo, 35 to 49 yo, 50 to 64 yo, 65 to 84 yo and 85 yo and over, at national and regional levels. ED attendances have been also described by month, day of week and hour of day. Hospitalizations after discharge, stay duration in ED services, transport and associated diagnoses were also analyzed. Results From 2014 to 2017, 481,291 ED attendances for LBP were recorded corresponding to 1.12% of the total number of ED attendances with a coded diagnosis. 60% of annual ED attendances for LBP concern 18 to 50 years old adults. The proportion of LBP attendances among the all-cause activity remains stable between 2014 and 2017. At the regional level, LBP proportion among the all-cause activity is similar to the national value in metropolitan regions (0.8% in Brittany to 1.6% in Corsica) and is lower than the national value in overseas regions (0.4% in Mayotte to 0.8% in Guyane) except for Saint-Barthelemy (1.8%). At the national level, almost 10% of ED attendances for LBP are hospitalized after discharge. This proportion increases with age to reach 43% for the 85 years old and more. Proportion of hospitalization ranges between 5.6% (in Paris area) and 17.1% (in Brittany) in metropolitan regions and between 2.8% (Guyane) and 9.3% (Reunion island) in overseas regions. From 2014 to 2017, ED attendances for LBP remain stable by month. However, we observed a slight decrease along the week with more attendances on Monday (17.8% of LBP attendances) than the other days. The attendances are more frequent in the morning (between 6 and 12 AM). At the national level, mean stay duration for LBP attendances in ED is almost 5 hours whereas median stay duration is 2 hours and 45 minutes. Stay duration is longer for patient arrived during night hours (from midnight to 6 AM) and for those hospitalized after discharge. Stay duration is also increasing with age. At the regional level, mean stay duration varies from 3 to more than 6 hours. Conclusions The broad coverage of the French ED network on the whole territory since several years enables to give an overview of ED attendances for acute LBP and their characteristics. One strength of the system is its strong partnership between epidemiologists and the ED physicians. It enables to verify that the results of the study are consistent with their perception on the field. The results of this study will be used as reference to evaluate potential benefits of this campaign. Finally, this study is a good illustration of how the syndromic surveillance system in collaboration with ED physicians, can quickly provide valuable data to support political strategies. References [1] Maher et al, Non-specific low back pain Lancet 2017; 389: 736–47 Published Online October 10, 2016, http://dx.doi.org/10.1016/ S0140-6736(16)30970-9 [2] Assurance Maladie, Le patient adulte atteint de lombalgie commune; Livret d’information Octobre 2017 donnees SNIRAAM 2014, https://www.ameli.fr/sites/default/files/Documents/346618/document/lombalgie-professionnels-de-sante_assurance-maladie.pdf [3] Caserio-Schonemann C, Bousquet V, Fouillet A, Henry V, pour l’equipe projet SurSaUD®. Le systeme de surveillance syndromique SurSaUD®. Bull Epidemiol Hebd. 2014;(3-4):38-44.

International audience

Objective To evaluate whether SAMU data could be relevant for health surveillance and proposed to be integrated into the French national syndromic surveillance SurSaUD® system. Introduction The syndromic surveillance SurSaUD® system developed by Sante publique France, the French National Public Health Agency collects daily data from 4 data sources: emergency departments (OSCOUR® ED network) [1], emergency general practioners (SOS Medecins network), crude mortality (civil status data) and electronic death certification including causes of death [2]. The system aims to timely identify, follow and assess the health impact of unusual or seasonal events on emergency medical activity and mortality. However some information could be missed by the system especially for non-severe (absence of ED consultation) or, in contrast, highly severe purposes (direct access to intensive care units). The French pre-hospital emergency medical service (SAMU) [3] represents a potential valuable data source to complete the SurSaUD® surveillance system, thanks to reactive pre-hospital data collection and a large geographical coverage on the whole territory. Data are still not completely standardized and computerized but a governmental project to develop a national common IT system involving all French SAMU is in progress and will be experimented in the following years. Methods A pilot study was performed in the South of France PACA region, where data from the six local SAMU structures are centralized into an interconnected database. A minimal set of variables required for health monitoring (administrative and medical items) and modalities for data extraction and transmission to Sante publique France were defined. SAMU data were transmitted daily to Sante Publique France and the PACA regional team developed a Microsoft Access® application to import decrypted data, request database and analyze indicators. Retrospective part of the study was performed over a 2-year period (2013-2014) and the prospective part during 2015 was based on daily data collection. Completeness and quality of variables were analyzed. SAMU indicators including several level of specificity were built and compared to existing SurSaUD® indicators in different situations (for detection, seasonal follow-up and health impact assessment) using Spearman coefficient correlation. Results During the pilot study, data from five of the six SAMU structures of PACA region were structured enough to be analyzed. On the study period, almost 2,400,000 files were recorded and 89% contain medical information. Data completeness was high (87%) and stable during the whole period. The annual rate of SAMU solicitation was 16 for 100 inhabitants at the regional scale. 15% of the records were opened only for medical advice. In contrast, patients were evacuated directly in intensive care unit in 9.5% of cases without ED admission. Coding quality depended on the existence and the use of official thesauri and varied widely among SAMU structures. Despite coding variations, SAMU indicators for winter epidemics were significantly correlated with ED and SOS Medecins indicators. Respectively with ED flu, bronchiolitis and gastroenteritis indicators, the strongest correlations were found for SAMU lower respiratory infection (0.74), SAMU bronchiolitis (0.72) and SAMU gastroenteritis / diarrhea / vomiting (0.81). Conclusions This pilot study demonstrated the feasibility to collect daily SAMU activity data. The key strengths of SAMU data were a large geographic coverage, the subsidiarity with SurSaUD® system data sources, the follow-up of prehospital activity and for patients directly admitted into an intensive care unit. Some limitations were highlighted related to differences in coding practices especially for medical diagnosis. The generalization of this study will require the standardization of coding practices and homogenization of thesaurus. The implementation of the national SAMU information system should allow in a very next future to widely progressing on these topics. References [1] Fouillet A, Bousquet V, Pontais I, Gallay A and Caserio-Schonemann C. The French Emergency Department OSCOUR Network:Evaluation After a 10-year Existence. Online Journal of Public Health Informatics ISSN 1947-2579-7(1):e74, 2015 [2] Caserio-Schonemann C, Bousquet V, Fouillet A, Henry V. Le systeme de surveillance syndromique SurSaUD (R). Bull Epidemiol Hebd 2014;3-4:38-44. [3] Baker, D.J.. The French prehospital emergency medicine system (SAMU): An introduction (2005) CPD Anaesthesia, 7 (1), pp. 20-25.

International audience; Introduction: Particulate matter, nitrogen dioxide (NO2) and ozone are recognized as the three pollutants that most significantly affect human health. Asthma is a multifactorial disease. However, the place of residence has rarely been investigated. We compared the impact of air pollution, measured near patients' homes, on emergency department (ED) visits for asthma or trauma (controls) within the Provence-Alpes Cote-d'Azur region. Methods: Variables were selected using classification and regression trees on asthmatic and control population, 3-99 years, visiting ED from January 1 to December 31, 2013. Then in a nested case control study, randomization was based on the day of ED visit and on defined age groups. Pollution, meteorological, pollens and viral data measured that day were linked to the patient's ZIP code. Results: A total of 794,884 visits were reported including 6250 for asthma and 278,192 for trauma. Factors associated with an excess risk of emergency visit for asthma included short-term exposure to NO2, female gender, high viral load and a combination of low temperature and high humidity. Conclusion: Short-term exposures to high NO2 concentrations, as assessed close to the homes of the patients, were significantly associated with asthma-related ED visits in children and adults. (c) 2017 Elsevier Ltd. All rights reserved.

Letters to the editor are presented in response to the article "Emergency Care for Homeless Patients: A French Multicenter Cohort Study" by A.L. Feral-Pierssens, A. Aubrey, J. Truchot, et al. which appears in a 2016 issue of the journal, and it mentions pediatric medical care for homeless children.

We aimed to estimate the influenza epidemic burden on ED attendances and hospitalizations among patients over 65y, during 2010-2015 period. Weekly numbers of visits and hospitalizations for influenza proxy-variables were modeled separately using a negative binomial regression model, including laboratory confirmed influenza identifications. Attendances and hospitalizations for acute bronchitis, pneumonia,COPD, dyspnea, asthma, acute cardiac failure, and dehydration were significantly associated with influenza positivity rate. We showed that the burden of influenza is underestimated among the elderly and should be better estimated using a dedicated diagnostic codes grouping.

Background. A 13-valent pneumococcal conjugate vaccine (PCV13) seems to be associated with a reduction of community-acquired pneumonia (CAP) in children. Methods. To explore the link between PCV13 implementation and children' visits in emergency departments (EDs) for pneumonia, we analyzed mandatory Electronics Emergency Department Abstracts (EEDA), in 7 EDs, located in southern France, from 2009 to 2014. Diagnosis related to visits were coded using International Classification Diseases-10 codes. All codes available for EEDA were used to define bacterial pneumonia (BP), viral pneumonia (VP), and nonspecific pneumonia (NSP). For adjustment, we also used codes related to influenza and bronchiolitis. Comparisons between periods (pre-PCV13, transitional, early post-PCV13, and late post-PCV13) were made by logistic regression. On daily aggregated data, a general linear model was constructed with daily proportion of BP as dependent variable, period as fixed factor, and daily proportion of viral respiratory infections (flu plus bronchiolitis) as covariate. Results. Among 718 758 visits, 7284 were coded as CAP. A significant decline in CAP was noted only for children between 2 and 5 years of age. In contrast, the proportion of BP was dramatically reduced: 2.49 vs 5.17/1000 visits (odds ratio, 0.48; 95% confidence interval, 0.42-0.55), whereas the proportion of VP was similar and NSP increased. After adjustment on influenza plus bronchiolitis, the decrease of BP remained significant. Conclusions. Electronics Emergency Department Abstracts analysis confirms an important reduction in children ED visits for BP after PCV13 implementation. The EEDA also allow a real-time surveillance of pneumonia and an adjustment on confounding factors, such as viral respiratory infections.