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Background: Influenza can be associated with nonrespiratory disease presentation, but these are less well documented due to the lack of routine testing for influenza in the healthcare system, especially if patients do not present with influenza-like illness (ILI). We aimed to measure the proportion of influenza cases seeking care at emergency department (ED) for a nontraumatic cause, to describe their clinical presentation and their ED-discharge diagnosis., Methods: The study was conducted at seven hospitals in France, Spain, Italy and Germany during the 2019-20 influenza season, for a period of 10 weeks. Patients (≥ 18 years) consulting for nontraumatic causes at the ED were invited to participate. Consenting patients provided upper respiratory swab samples for influenza testing by reverse transcription polymerase chain reaction. Clinical and demographic data were collected., Results: There were 8678 patients included, 50.7% were female and the median age was 57 years. Among them, 494 (5.7%) were laboratory-confirmed influenza (LCI) cases. Nonetheless, only 24.3% of LCI cases had an ED-discharge of influenza. Of all cases confirmed as influenza, 47.6% had a nonrespiratory discharge diagnosis, which frequency increased with age. ILI case definition from the European Centre for Disease Prevention and Control was the most frequently met among influenza cases (68.6%). Older patients (≥ 65 years) were less frequently identified based on any ILI signs/symptoms., Conclusion: Our findings indicate that the impact of influenza among patients seeking care at the ED cannot be easily assessed based on clinical presentation and medical records alone. Preventing influenza among adult population may reduce healthcare utilization., (© 2024 The Author(s). Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Assess the changes in post-traumatic stress disorder (PTSD), burnout, anxiety, depression, jobstrain, and isostrain levels over time among healthcare workers in emergency departments (EDs) after successive outbreaks of COVID-19. A prospective, multicenter study was conducted in 3 EDs and an emergency medical service. Healthcare workers who participated in our previous study were invited to participate in a follow-up 16 and 18 months and completed the questionnaires to assess symptoms of PTSD, burnout, anxiety, depression, jobstrain, and isostrain. Among the 485 healthcare workers asked to participate, 211 (43.5%) completed the survey at inclusion (122 were followed up at 3 months) and 59 participate to the follow-up study. At 16 months, 10.9% of healthcare workers had symptoms of PTSD and 17.4% at 18 months. At inclusion, 33.5% and 11.7% of healthcare workers had symptoms of anxiety and depression, respectively. A decrease in anxiety between inclusion and 16 months (p = 0.02) and an increase between 16 and 18 months (p = 0.009) was observed. At inclusion, 40.8% of all healthcare workers had symptoms of burnout. There was an increase in symptoms of burnout between inclusion and 18 months (p = 0.006). At inclusion, 43.2% and 29.5% of healthcare workers were exposed to jobstrain and isostrain, respectively. Jobstrain were higher among paramedics and administrative staff compared to physicians (p = 0.001 and p = 0.026, respectively). Successive outbreaks of COVID-19 led to long-term mental health consequences among ED healthcare workers that differed according to occupation. This must be taken into account to rethink the management of teams., (© 2024 The Author(s). Stress and Health published by John Wiley & Sons Ltd.)

Background: Cannabis use frequently starts during adolescence and young adulthood and can induce psychosocial and health consequences. Young people constitute hard-to-reach populations. Emergency departments could constitute a key care setting to identify cannabis use and its consequences among young people., Objectives: To estimate the rate of cannabis use in the 16- to 25-year-old population visiting the emergency department for any reason and to assess the psychosocial factors associated with cannabis use., Methods: This was a cross-sectional study among young people who attended the emergency department, over 5-months. Data were sociodemographic characteristics, self-administered questionnaires for problematic substance use screening, and urine drug screening samples. They were classified in the cannabis use (CU) group if they had a positive urine screen or reported cannabis use in the previous month. Characteristics of individuals in the CU and non-CU groups were compared., Results: A total of 460 participants were included, of whom 105 were in the CU group. Cannabis users were more likely to be male (aOR = 1.85; [1.18-2.90]), to be unemployed (aOR = 1.77; [1.03-3.04]), to have a lower mental health status score (aOR = 0. 82; [0.75-0.90]), to report a history of sexual abuse (aOR = 2.99; [1.70-5.25]), and to have a positive AUDIT screen (aOR = 4.23; [2.61-6.86])., Conclusions: The emergency department is a primary care setting for young people, which is conducive to screening for substance use. Cannabis users can be assessed and referred to adapt their treatment, given their lack of adherence to the traditional addictology care system.

Study Objective: The present study is aimed at providing an assessment of the changes in burnout, job strain, isostrain, sleepiness, and fatigue levels over time and identifying factors associated with these symptoms among healthcare workers in French emergency departments (EDs). Method: We conducted a prospective, multicenter study in four EDs and an emergency medical service. Participants completed questionnaires at inclusion and at 90 days to assess burnout, job strain, isostrain, sleepiness, and fatigue. Results : A total of 211 respondents (43.5%) completed the questionnaires at inclusion. At the beginning of the study, 84 (40.8%) participants presented symptoms of burnout, 86 (43.2%) had symptoms of job strain, and 58 (29.4%) of isostrain. Forty-two (20.1%) healthcare workers presented symptoms of sleepiness, and 8 (3.8%) had symptoms of fatigue. We found that symptoms of burnout were more frequent for healthcare workers with a previous psychiatric history (55.3% vs. 39.1%, p = 0.02) and were lower among participants who had at least one dependent child (33.1% vs. 48.3%, p = 0.013). Symptoms of job strain were higher among administrative staff compared to physicians (55.6% vs. 28.7%, p = 0.01) and among healthcare workers with managerial responsibilities compared to those without (45.6% vs. 28.8%, p = 0.015). Symptoms of isostrain were higher among administrative staff (42.3%) compared to paramedics (34.1%) and physicians (19.8%, p = 0.026). Conclusion: We identified that potential factors associated with the emergence of symptoms of burnout and job strain are suggested, underlining several areas of improvement for the prevention against mental health disorders in the specific population of ED healthcare workers. Trial Registration: ClinicalTrials.gov identifier: NCT04383886., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Marion Douplat et al.)

Introduction: The decisions of withholding or withdrawing life-sustaining treatments are difficult to make in the context of emergency departments (EDs) because most patients are unable to communicate. Relatives are thus asked to participate in the decision-making process, although they are unprepared to face such situations. We therefore aimed to develop a standardised intervention for announcing decisions of withholding or withdrawing life-sustaining treatments in EDs and assess the efficacy of the intervention on the stress of relatives., Methods and Analysis: The DISCUSS trial is a multicentre stepped-wedge cluster randomised study and will be conducted at nine EDs in France. A standardised intervention based on human simulation will be codesigned with partner families and implemented at three levels: the relatives, the healthcare professionals (HCP) and the EDs. The intervention will be compared with a control based on treatment as usual. A total of 538 families are planned to be included: 269 in the intervention group and 269 in the control group. The primary endpoint will be the symptoms of post-traumatic stress disorder (PTSD) at 90 days. The secondary endpoints will be symptoms of PTSD at 7 and 30 days, diagnosis of PTSD at 90 days and anxiety and depression scores at 7, 30 and 90 days. Satisfaction regarding the training, the assertiveness in communication and real-life stress of HCPs will be measured at 90 days., Ethics and Dissemination: This study was approved by the ethics committee Est III from Nancy and the French national data protection authority. All relatives and HCPs will be informed regarding the study objectives and data confidentiality. Written informed consent will be obtained from participants, as required by French law for this study type. The results from this study will be disseminated at conferences and in a peer-reviewed journal., Trial Registration Number: NCT06071078., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Importance: Several studies reported that violent behaviours were committed by patients against healthcare professionals in emergency departments (EDs). The presence of mediators could prevent or resolve situations of tension., Objective: To evaluate whether the presence of mediators in EDs would have an impact on violent behaviours committed by patients or their relatives against healthcare professionals. Design, settings and participants A 6-period cluster randomised crossover trial was performed in 4 EDs during 12 months. Patients aged ≥18 and their relatives were included., Intervention: In order to prevent or resolve situations of tension and conflict, four mediators were recruited.Outcome measure and analysis Using a logistic regression mixed model, the rate of ED visits in which at least one act of violence was committed by a patient or their relatives, reported by healthcare professionals, was compared between the intervention group and the control group., Results: A total of 50 429 ED visits were performed in the mediator intervention group and 50 851 in the control group. The mediators reported 1365 interventions; >50% of the interventions were to answer questions about clinical management or waiting time. In the intervention group, 173 acts of violence were committed during 129 ED visits, and there were 145 acts of violence committed during 106 ED visits in the control group. The rate of ED visits in which at least one act of violence was committed, was 0.26% in the intervention group and 0.21% in the control group (OR = 1.23; 95% CI [0.73-2.09]); on a 4-level seriousness scale, 41.6% of the acts of violence were rated level-1 (acts of incivility or rudeness) in the intervention group and 40.0% in the control group., Conclusion: The presence of mediators in the ED was not associated with a reduction in violent or uncivil behaviours committed by patients or their relatives. However, the study highlighted that patients had a major need for information regarding their care; improving communication between patients and healthcare professionals might reduce the violence in EDs., Trial Registration: Clinicaltrials.gov (NCT03139110)., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: This study aims to describe the use of patient partnership, as defined by the Montreal Model, in emergency departments (EDs) in France and report the perception of patient partnership from both the practitioner and patient perspectives., Methods: This cross-sectional study was conducted between July 2020 and October 2020. First, a survey was sent to 146 heads of EDs in both teaching hospitals and non-teaching hospitals in France to assess the current practices in terms of patient partnership in service organization, research, and teaching. The perceived barriers and facilitators of the implementation of such an approach were also recorded. Then, semi-structured telephone interviews were carried out with patients involved in a service re-organization project., Results: A total of 48 answers (response rate 32.9%) to the survey were received; 33.3% of respondents involved patients in projects relating to service re-organization, 20.8% involved patients in teaching projects, and 4.2% in research projects. Overall, 60.4% of the respondents were willing to involve patients in re-organization or teaching projects. The main barriers mentioned for establishing patient partnership were difficulties regarding patient recruitment and lack of time. The main advantages mentioned were the improvement in patient/caregiver relationship and new ideas to improve healthcare. When interviewed, patients mentioned the desire to improve healthcare and the necessity to involve people with different profiles and backgrounds. A too important personal commitment was the most frequently raised barrier to their engagement. All the patients recognized their positive role, and more generally, the positive role of patient engagement in service re-organization., Conclusion: Although this preliminary study indicates a rather positive perception of patient partnership among heads of EDs in France and partner patients, this approach is still not widely applied in practice., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objective: The aim of the study was to describe and analyze the risk factors associated with patient safety events (PSEs), defined as adverse events (AEs), preventable AEs (PAEs), and near-miss events (NMEs), in the emergency department (ED)., Methods: It was a retrospective cohort study using ED patients' data retrieved from January 2010 to December 2016. Quality assurance issues (QAIs) used as triggers included the following: issues during procedural sedation, death within 24 hours of admission, patients' and physicians' complaints, returns to the ED within 72 hours, and transfers to an intensive care unit within 24 hours., Results: Of 383,586 ED visits, 6519 (1.7%) QAIs were reported with a PSEs incidence of 6.1%. Among the 397 PSEs, 258 were AEs including 82 PAEs, and 139 NMEs. During the 7-year period, we observed a fourfold increase in NMEs, and despite a decrease in the rate of AEs with the highest (3.1%) and lowest (0.8%) incidence in 2011 and 2016, respectively, the incidence of PAEs events remained relatively constant. Unadjusted analysis showed that ED waiting time, boarding time, ED length of stay (LOS), ED disposition, as well as diagnostic and QAIs were significantly related to PSEs (P < 0.05). Multivariable analysis showed that the type of QAIs and diagnostic were associated with PSEs (P < 0.001). Type of QAIs was a risk factor for AEs and PAEs occurrence and factors involved in NMEs were type of QAIs (P = 0.02) and ED LOS (P < 0.001). "The odds of a PSE occurring increased by 0.2% for each additional minute increase in the ED waiting time, by 5.2% for each additional boarding hour, and by 4.5% for each ED LOS hour.", Conclusions: This study showed several potential risk factors for PSEs, especially ED LOS, type of QAIs, and diagnostic. Systematic interventions might have more impact on risk of PSE., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: We hypothesized that monitoring the volume of activity and overall performance indicators is not sufficient to understand the underlying differences between emergency departments. We aimed to understand the underlying common characteristics of emergency departments and map their typology in order to propose adaptive solutions, that would take into account territorial specificities and manage existing resources., Methods: We applied a multifactorial analysis based on input data at three levels; 1) the health care available in the area surrounding the emergency departments, 2) the level of medical technicality of the hospitals and 3) the profile of emergency department visits., Results: We included 73 emergency departments in this study, representing 93.6% of the emergency departments in our region and seven groups were retained. The smallest group (n = 5) included both public and private structures with low volumes of activity. These medical structures were associated with the shortest length of stay and one of the lowest hospitalisation rates. The largest group (n = 21) included only public structures in peri-urban areas, which were associated with the highest rate of hospitalization in the region. The surrounding population was representative of the regional population, but the patients were older., Conclusions: This approach represents a systemic response to target the organisational needs and constraints, propose appropriate solutions and adjust the financial resources allocated to hospitals. Future policies to improve care delivery may benefit from stratifying solutions and performance objectives depending on these groups.

Objectives: Identify the strategies implemented by emergency care professionals when facing tension and interpersonal violence from patients and their friends and family., Design: Descriptive qualitative study based on 38 semidirective interviews., Participants: Doctors, nurses, nursing assistants and administrative staff., Setting: Four emergency departments (EDs) from three French university hospitals., Results: According to the medical professionals interviewed, the difficulties that they encounter with patients or their accompanying family members can be explained by a lack of understanding of the functioning of EDs, by a general increase in individualistic behaviours leading to a lack of civility or by deviant behaviours (related to toxic substance abuse or mental illness). While managing deviant behaviours may sometimes require a collective intervention, ED staff also implement what are essentially individual communication strategies (with the use of rational explanation, seduction and empathy), confrontation or flight to deal with interpersonal difficulties., Conclusions: Strategies used by staff members tend to be individualised for the most part, and some, such as confrontational or escape strategies, may not be adapted to all situations. In the face of difficulties between staff and patients, mediators, specialised in resolving conflict, could entrust some cases to professionals., Trial Registration Number: ClinicalTrials.gov Registry (NCT03139110)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature., Study Objective: We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France., Method: In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process., Results: There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives., Conclusion: The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.

Background: Acute trauma pain is poorly managed in the emergency department (ED). The reasons are partly organizational: ED crowding and rare trauma care pathways contribute to oligoanalgesia. Anticipating the organizational impact of an innovative care procedure might facilitate the decision-making process and help to optimize pain management., Methods: We used a multiple criteria decision analysis (MCDA) approach to consider the organizational impact of methoxyflurane (self-administered) in the ED, introduced alone or supported by a trauma care pathway. A MCDA experiment was designed for this specific context, 8 experts in emergency trauma care pathways (leading physicians and pharmacists working in French urban tertiary hospitals) were recruited. The study involved four steps: (i) Selection of organizational criteria for evaluating the innovation's impact; (ii) assessment of the relative weight of each criterion; (iii) choice of appropriate scenarios for exploring the organizational impact of MEOX under various contexts; and (iv) software-assisted simulation based on pairwise comparisons of the scenarios. The final outcome measure was the expected overall organizational impact of methoxyflurane on a 0-to-100 scale (score >50: positive impact)., Results: Nine organizational criteria were selected. "Mean length of stay in the ED" was the most weighted. Methoxyflurane alone obtained 59 as a total score, with a putative positive impact for eight criteria, and a neutral effect on one. When a trauma care pathway was introduced concomitantly, the impact of methoxyflurane was greater overall (score: 75) and for each individual criterion., Conclusions: Our model highlighted the putative positive organizational impact of methoxyflurane in the ED-particularly when supported by a trauma care pathway-and the relevance of expert consensus in this particular pharmacoeconomic context. The MCDA approach could be extended to other research fields and healthcare challenges in emergency medicine., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: VEL has individually received occasional travel grants from Mundipharma for participation in national and international congresses, and for advice on pain management communications. MM received fees for board and conference from Mundipharma and Purdue. MM also received a grant to conduct a trial on pain management in the ED (NCT03380247). KT received fees for board and conference from Mundipharma. MLD received fees from Mundipharma. FL received fees from Mundipharma, Novartis, Serb, Teleflex. CD, NPK, CHB declared no potential competing interest with respect to the research, authorship, and/or publication of this article. These competing interests do not alter our adherence to PLOS ONE policies on sharing data and materials. This work was funded by Mundipharma SAS (Paris, France; www.mundipharma.fr). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: In emergency departments, for some patients, death is preceded by a decision of withholding or withdrawing life-sustaining treatments. This concerns mainly patients over 80, with many comorbidities. The decision-making process of these decisions in emergency departments has not been extensively studied, especially for noncommunicating patients., Aim: The purpose of this study is to describe the decision-making process of withholding and withdrawing life-sustaining treatments in emergency departments for noncommunicating patients and the outcome of said patients., Design: We conducted a prospective multicenter study in three emergency departments of university hospitals from September 2015 to January 2017., Results: We included 109 patients in the study. Fifty-eight (53.2%) patients were coming from nursing homes and 52 (47.7%) patients had dementia. Decisions of withholding life-sustaining treatment concerned 93 patients (85.3%) and were more frequent when a surrogate decision maker was present 61 (65.6%) versus seven (43.8%) patients. The most relevant factors that lead to these decisions were previous functional limitation (71.6%) and age (69.7%). Decision was taken by two physicians for 80 patients (73.4%). The nursing staff and general practitioner were, respectively, involved in 31 (28.4%) and two (1.8%) patients. A majority of the patients had no advance directives (89.9%), and the relatives were implicated in the decision-making process for 96 patients (88.1%). Death in emergency departments occurred for 47 patients (43.1%), and after 21 days, 84 patients (77.1 %) died., Conclusion: There is little anticipation in end-of-life decisions. Discussion with patients concerning their end-of-life wishes and the writing of advance directives, especially for patients with chronic diseases, must be encouraged early., (© 2019 John Wiley & Sons, Ltd.)

Objectives: Violence in emergency services has become a central issue in the daily work of hospital employees. While the use of video surveillance and the training of professionals in conflict management are the most common methods used, there are few cases using the setting up of a third part such as a mediator. We conducted a qualitative study with professionals to examine their representations associated with mediation., Method: Semi-directive interviews were conducted with professionals from four emergency units. The topics discussed in interviews were the definition of mediation and the missions that the mediators should fulfil. The content of 38 semi-directive interviews was analysed according to the inductive approach of the grounded theory. A content analysis was made, followed by an analysis aiming to bring out types and convergences/divergences., Results: Professionals were not aware of the definition of mediation and of its missions. They linked to it an instrumental theme, making mediation a tool for conflict prevention and management, a tool for communication with patients about their care, and about the organisation of emergency unit. The upcoming presence of mediators was seen as an help. A potential competition between professionals and mediators in the tasks performed was identified., Conclusion: The study shows a favourable opinion towards mediation. It has allowed to identify obstacles to the well-functioning of the missions assigned to mediators. One of the challenges is the integration of this new actor, the mediator.

Background: Recent data suggest that 10-20% of injury patients will suffer for several months after the event from diverse symptoms, generally referred to as post-concussion-like symptoms (PCLS), which will lead to a decline in quality of life. A preliminary randomized control trial suggested that this condition may be induced by the stress experienced during the event or emergency room (ER) stay and can be prevented in up to 75% of patients with a single, early, short eye movement desensitization and reprocessing (EMDR) psychotherapeutic session delivered in the ER. The protocol of the SOFTER 3 study was designed to compare the impact on 3-month PCLS of early EMDR intervention and usual care in patients presenting at the ER. Secondary outcomes included 3-month post-traumatic stress disorder, 12-month PCLS, self-reported stress at the ER, self-assessed recovery expectation at discharge and 3 months, and self-reported chronic pain at discharge and 3 months., Methods: This is a two-group, open-label, multicenter, comparative, randomized controlled trial with 3- and 12-month phone follow-up for reports of persisting symptoms (PCLS and post-traumatic stress disorder). Those eligible for inclusion were adults (≥18 years old) presenting at the ER departments of the University Hospital of Bordeaux and University Hospital of Lyon, assessed as being at high risk of PCLS using a three-item scoring rule. The intervention groups were a (1) EMDR Recent Traumatic Episode Protocol intervention performed by a trained psychologist during ER stay or (2) usual care. The number of patients to be enrolled in each group was 223 to evidence a 15% decrease in PCLS prevalence in the EMDR group., Discussion: In 2012, the year of the last national survey in France, 10.6 million people attended the ER, some of whom did so several times since 18 million visits were recorded in the same year. The SOFTER 3 study therefore addresses a major public health challenge., Trial Registration: Clinical Trials. NCT03400813 . Registered 17 January 2018 - retrospectively registered.

Introduction: The French Agency for Health Safety of Products published recommendations of good practices (RGP) for the treatment of venous thromboembolic disease in 2009. Four of these recommendations apply to the initial management of the disease, with the objective of this study is to determine whether the development and diffusion of the four RGP has had an impact on the practice., Methods: A retrospective before/after study comparing 132 patients treated in emergency department of the Civil Hospices of Lyon for pulmonary embolism (PE) and/or deep venous thrombosis (DVT) in 2008-2009 ("before") and 153 patients in 2010-2011 ("after")., Results: In the "before" period, 70 patients were treated for DVT and 62 patients for PE. In the "after" period, 50 patients were treated for DVT and 103 patients for PE. The compliance rate was not significantly different for the two periods for each RGP except for the indication of low molecular weight Heparin (LMWH) or fondaparinux in the absence of severe renal failure (21% "before" vs. 45% "after"; P=0.02) for patients with PE. Management for the four recommendations was conform for 5.6% of eligible patients in the "before" period and for 3.7% for the "after" period., Conclusion: Our study shows that globally there is no impact of RGP. The reasons appear multiple with first, the mere dissemination and the absence of implementation of these guidelines., (Copyright © 2017 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Importance: The safety of the pulmonary embolism rule-out criteria (PERC), an 8-item block of clinical criteria aimed at ruling out pulmonary embolism (PE), has not been assessed in a randomized clinical trial., Objective: To prospectively validate the safety of a PERC-based strategy to rule out PE., Design, Setting, and Patients: A crossover cluster-randomized clinical noninferiority trial in 14 emergency departments in France. Patients with a low gestalt clinical probability of PE were included from August 2015 to September 2016, and followed up until December 2016., Interventions: Each center was randomized for the sequence of intervention periods. In the PERC period, the diagnosis of PE was excluded with no further testing if all 8 items of the PERC rule were negative., Main Outcomes and Measures: The primary end point was the occurrence of a thromboembolic event during the 3-month follow-up period that was not initially diagnosed. The noninferiority margin was set at 1.5%. Secondary end points included the rate of computed tomographic pulmonary angiography (CTPA), median length of stay in the emergency department, and rate of hospital admission., Results: Among 1916 patients who were cluster-randomized (mean age 44 years, 980 [51%] women), 962 were assigned to the PERC group and 954 were assigned to the control group. A total of 1749 patients completed the trial. A PE was diagnosed at initial presentation in 26 patients in the control group (2.7%) vs 14 (1.5%) in the PERC group (difference, 1.3% [95% CI, -0.1% to 2.7%]; P = .052). One PE (0.1%) was diagnosed during follow-up in the PERC group vs none in the control group (difference, 0.1% [95% CI, -∞ to 0.8%]). The proportion of patients undergoing CTPA in the PERC group vs control group was 13% vs 23% (difference, -10% [95% CI, -13% to -6%]; P < .001). In the PERC group, rates were significantly reduced for the median length of emergency department stay (mean reduction, 36 minutes [95% CI, 4 to 68]) and hospital admission (difference, 3.3% [95% CI, 0.1% to 6.6%])., Conclusions and Relevance: Among very low-risk patients with suspected PE, randomization to a PERC strategy vs conventional strategy did not result in an inferior rate of thromboembolic events over 3 months. These findings support the safety of PERC for very low-risk patients presenting to the emergency department., Trial Registration: clinicaltrials.gov Identifier: NCT02375919.

Objective: To assess compliance and impact of a teaching program on guidelines for the management of severe bleeding under oral anticoagulation therapy in emergency departments (EDs)., Design and Setting: Multicenter, before-after observational studies in six French EDs., Patients: Forty-five patients in 2003 and 54 patients in 2005 consecutively admitted with severe bleeding under oral anticoagulation therapy., Interventions: A specific teaching program on management of severe bleeding under oral anticoagulation therapy, performed by an expert physician., Measurements and Results: Primary end-point was the use of prothrombin complex concentrate-vitamin K association between the two study periods. Nine patients (20%) in 2003 and 29 patients (54%) in 2005 received this association (P < 0.01). Almost one-third of patients had only withholding oral anticoagulation therapy. Adverse events and mortality rate did not differ between the two phases., Conclusions: Compliance with guidelines on the management of severe bleeding under oral anticoagulation remains poor and might be improved by specific teaching program.