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Background: Optimizing access to recanalization therapies in acute ischemic stroke patients is crucial. Our aim was to measure the short and long term effectiveness, at the acute phase and 1 year after stroke, of four sets of actions implemented in the Rhône County.Methods: The four multilevel actions were 1) increase in stroke units bed capacity and development of endovascular therapy; 2) improvement in knowledge and skills of healthcare providers involved in acute stroke management using a bottom-up approach; 3) development and implementation of new organizations (transportation routes, pre-notification, coordination by the emergency call center physician dispatcher); and 4) launch of regional public awareness campaigns in addition to national campaigns. A before-and-after study was conducted with two identical population-based cohort studies in 2006-7 and 2015-16 in all adult ischemic stroke patients admitted to any emergency department or stroke unit of the Rhône County. The primary outcome criterion was in-hospital management times, and the main secondary outcome criteria were access to reperfusion therapy (either intravenous thrombolysis or endovascular treatment) and pre-hospital management times in the short term, and 12-month prognosis measured by the modified Rankin Scale (mRS) in the long term.Results: Between 2015-16 and 2006-7 periods ischemic stroke patients increased from 696 to 717, access to reperfusion therapy increased from 9 to 23% (p < 0.0001), calls to emergency call-center from 40 to 68% (p < 0.0001), first admission in stroke unit from 8 to 30% (p < 0.0001), and MRI within 24 h from 18 to 42% (p < 0.0001). Onset-to-reperfusion time significantly decreased from 3h16mn [2 h54-4 h05] to 2h35mn [2 h05-3 h19] (p < 0.0001), mainly related to a decrease in delay from admission to imaging. A significant decrease of disability was observed, as patients with mild disability (mRS [0-2]) at 12 months increased from 48 to 61% (p < 0.0001). Pre-hospital times, however, did not change significantly.Conclusions: We observed significant improvement in access to reperfusion therapy, mainly through a strong decrease of in-hospital management times, and in 12-month disability after the implementation of four sets of actions between 2006 and 2016 in the Rhône County. Reducing pre-hospital times remains a challenge. [ABSTRACT FROM AUTHOR]

Background and Importance: Traumatic brain injury (TBI) in patients on vitamin K antagonists (VKAs) is linked to a high rate of intracranial hemorrhage (ICH). Rapid reversal can reduce ICH progression and mortality, but its effectiveness depends on the time between bleeding onset and coagulation normalization., Objective: The PREVACT study aimed to assess the efficacy and safety of prompt systematic reversal of anticoagulation in patients presenting to emergency departments (EDs) for recent mild-TBI while receiving a VKA., Intervention: A randomized, open-label, blinded-endpoint clinical trial was conducted in 21 French EDs. Patients receiving a VKA, having experienced a TBI within the last 6 h, and presenting a Glasgow Coma Score ≥13 were included. Patients were randomized to systematic immediate VKA reversal with 25 IU/kg of four-factor prothrombin complex concentrate (4f-PCC) before any investigation (intervention group) or standard-of-care signifying reversal only if the initial cranial computed tomography (CT) scan indicated ICH (control group). The primary outcome was the rate of ICH detected on a cranial CT scan 24 h post-inclusion., Results: The study was prematurely stopped for logistic reasons after the randomization of 202 patients (101 and 101 in the intervention and control groups, respectively, mean age 90; 51.8% female). On the 24-h cranial CT scan, 6 of 98 patients (6.1%) in the intervention group manifested ICH vs. 12 of 99 patients (12.1%) in the control group [odds ratio: 0.47 (95% confidence interval: 0.14-1.44); P = 0.215]., Conclusion: In patients with recent mild-TBI receiving a VKA, systematic prompt reversal with 4f-PCC did not statistically significantly reduce ICH rate at 24 h. However, the study was prematurely stopped and does not exclude a clinically relevant benefit of the strategy tested., Trial Registration: Clinicaltrials.gov (NCT01961804)., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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.)

Because 20-30% of patients with sepsis deteriorate to critical illness, biomarkers that provide accurate early prognosis may identify which patients need more intensive treatment versus safe early discharge. The objective was to test the performance of sVEGFR2, suPAR and PCT, alone or combined with clinical signs and symptoms, for the prediction of clinical deterioration. This prospective observational study enrolled patients with suspected infection who met SIRS criteria without organ dysfunction (delta SOFA <2 from baseline) from 16 emergency departments. The primary endpoint was clinical deterioration (increased SOFA score ≥2 points, new or increased organ support, or death) within 72 hours of enrollment. Diagnosis and classification of infection status were adjudicated. 724 patients were enrolled, (54% men, median age 55 [38-70] y-o). Infection origin was abdominopelvic (21%), skin and soft tissues (17%), urinary (16%) and pulmonary (15%). 176 (24%) patients deteriorated, with a 28-day mortality of 1.4%. They had lower sVEGFR2 level (6.17 [5.00-7.40] vs 6.52 [5.40-7.84], p=0.024), higher circulating suPAR (5.25 [3.86-7.50] vs 4.18 [3.16-5.68], p<0.001) and higher PCT level (0.32 [0.08-1.80] vs 0.18 [0.05-0.98], p=0.004). suPAR demonstrated superior performance (AUC=0.65 [0.60-0.70]), compared to other biomarkers (PCT, AUC=0.57 [0.52-0.62] and sVEGFR2, AUC=0.58 [0.53-0.64]). Maximum accuracy was achieved from the combination of clinical information, sVEGFR2 and suPAR, yielding an AUC of 0.74 [0.69-0.78] and NPV 0.90 [0.88-0.94]. sVEGFR2 and suPAR were insufficiently accurate to rule out clinical deterioration. Panels of biomarkers will likely be needed to capture the heterogeneous mechanistic pathways involved in sepsis-related organ failure., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Background: In France, the COVID-19 vaccination campaign started in January 2021. This study reports the one-year experience of a multidisciplinary team from university hospital in operating a vaccination center created in a metropolitan sports arena., Materials and Methods: Some of the data derive from an online appointment scheduling software. Daily traceability sheets were utilized as a formalized method to gather data on non-conformities, adverse events, and to estimate the duration of the vaccination pathway. The professional satisfaction assessment was carried out via an anonymous online questionnaire. The collected data were examined with descriptive statistics., Results: We propose strengths of our organization to obtain efficient and safe vaccination pathway. In one year, 572,491 immunization shots were administered. The operational team size increased from 31 (500 vaccinations per day) to 71 (3000 vaccinations per day). In March 2021, the average duration to vaccination (excluding post-vaccination monitoring) was 12 [5-37] minutes for patients without medical consultation vs 16 [5-45] minutes for patients with medical consultation. 0.11 % non-conformities on vaccines got notified not allowing them to be used for vaccination. One error regarding the volume administered got reported. Among the professionals working in the vaccination center, 97 % were satisfied with the organization and 88 % with the quality of the information received from team leader or team project. Main difficulties encountered were managing the leftover doses at night and communicating with patients., Conclusions: Overall, the ability to vaccinate a population efficiently and safely on a large scale during a pandemic is based on the engagement of skilled multidisciplinary teams and securing the vaccination pathway., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

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.)

Indonesia and French Guiana share many geographic and medical concerns regarding access to care. The organisational needs in emergency management, particularly in the prehospital phase, are similar. Whereas emergency medicine (EM) is an academic and entire speciality in France, it is still under construction in Indonesia. In the framework of the French and Indonesian academic cooperation, the Medical school in Jakarta University and the French Guiana University in Cayenne signed a Memorandum of Understanding encompassing education programmes, joint research work and students' and health professionals' exchanges in EM. This partnership represented the first medical cooperation programme between the two countries. The first student class was launched in August 2022 and involved 50 Indonesian doctors who graduated in August 2023. The implementation and success of this Franco-Indonesian cooperation were supported by political and academic partners from the two sides. Given the first student class's success, we aim to continue this programme, in line with Indonesia and World Health Organization's plan to establish a multi-country training hub for health emergency operational readiness and Emergency Medical Teams., (© 2024 Australasian College for Emergency Medicine.)

Background: Out of hospital cardiac arrest (OHCA) survival rates are very low. An association between institutional OHCA case volume and patient outcomes has been documented. However, whether this applies to prehospital emergency medicine services (EMS) is unknown., Objectives: To investigate the association between the volume of interventions by mobile intensive care units (MICU) and outcomes of patients experiencing an OHCA., Methods: A retrospective cohort study including adult patients with OHCA managed by medical EMS in five French centers between 2013 and 2020. Two groups were defined depending on the overall annual numbers of MICU interventions: low and high-volume MICU. Primary endpoint was 30-day survival. Secondary endpoints were prehospital return of spontaneous circulation (ROSC), ROSC at hospital admission and favorable neurological outcome. Patients were matched 1:1 using a propensity score. Conditional logistic regression was then used., Results: 2,014 adult patients (69% male, median age 68 [57-79] years) were analyzed, 50.5% (n = 1,017) were managed by low-volume MICU and 49.5% (n = 997) by high-volume MICU. Survival on day 30 was 3.6% in the low-volume group compared to 5.1% in the high-volume group. There was no significant association between MICU volume of intervention and survival on day 30 (OR = 0.92, 95%CI [0.55;1.53]), prehospital ROSC (OR = 1.01[0.78;1.3]), ROSC at hospital admission (OR = 0.92 [0.69;1.21]), or favorable neurologic prognosis on day 30 (OR = 0.92 [0.53;1.62])., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

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.)

Background: Shortness of breath is a common complaint among individuals contacting emergency communication center (EMCCs). In some prehospital system, emergency medical services include an advanced life support (ALS)-capable team. Whether such team should be dispatched during the phone call or delayed until the BLS-capable paramedic team reports from the scene is unclear. We aimed to evaluate the impact of delayed MMT dispatch until receiving the paramedic review compared to immediate dispatch at the time of the call on patient outcomes., Methods: A cross-sectional study conducted in Lyon, France, using data obtained from the departmental EMCC during the period from January to December 2019. We included consecutive calls related to adult patients experiencing acute respiratory distress. Patients from the two groups (immediate mobile medical team (MMT) dispatch or delayed MMT dispatch) were matched on a propensity score, and a conditional weighted logistic regression assessed the adjusted odds ratios (ORs) for each outcome (mortality on days 0, 7 and 30)., Results: A total of 870 calls (median age 72 [57-84], male 466 53.6%) were sought for analysis [614 (70.6%) "immediate MMT dispatch" and 256 (29.4%) "delayed MMT" groups]. The median time before MMT dispatch was 25.1 min longer in the delayed MMT group (30.7 [26.4-36.1] vs. 5.6 [3.9-8.8] min, p < 0.001). Patients subjected to a delayed MMT intervention were older (median age 78 [66-87] vs. 69 [53-83], p < 0.001) and more frequently highly dependent (16.3% vs. 8.6%, p < 0.001). A higher proportion of patients in the delayed MMT group required bag valve mask ventilation (47.3% vs. 39.1%, p = 0.03), noninvasive ventilation (24.6% vs. 20.0%, p = 0.13), endotracheal intubation (7.0% vs. 4.1%, p = 0.07) and catecholamine infusion (3.9% vs. 1.3%, p = 0.01). After propensity score matching, mortality at day 0 was higher in the delayed MMT group (9.8% vs. 4.2%, p = 0.002). Immediate MMT dispatch at the call was associated with a lower risk of mortality on day 0 (0.60 [0.38;0.82], p < 0.001) day 7 (0.50 [0.27;0.72], p < 0.001) and day 30 (0.56 [0.35;0.78], p < 0.001) CONCLUSIONS: This study suggests that the deployment of an MMT at call in patients in acute respiratory distress may result in decreased short to medium-term mortality compared to a delayed MMT following initial first aid assessment., (© 2024. The Author(s).)

Introduction: Young individuals constitute a key population for the screening of problematic use of substances (PUS), but they are not likely to seek support and are hard to reach. Targeted screening programs should thus be developed in the places of care they may attend for other reasons, including emergency departments (EDs). We aimed to explore the factors associated with PUS in young people attending an ED; we measured the subsequent access to addiction care after ED screening., Methods: This was a prospective interventional single-arm study which included any individual aged between 16 and 25 years who attended the main ED of Lyon, France. Baseline data were sociodemographic characteristics, PUS status using self-report questionnaires and biological measures, level of psychological health, and history of physical/sexual abuse. Quick medical feedback was provided to the individuals presenting a PUS; they were advised to consult an addiction unit, and contacted by phone at three months to ask whether they had sought treatment. Baseline data were used to compare PUS and non-PUS groups using multivariable logistic regressions, to provide adjusted odds ratios (aORs) and 95% confidence intervals (95% CI), with age, sex, employment status, and family environment as the adjustment variables. The characteristics of PUS subjects who subsequently sought treatment were also assessed using bivariable analyses., Results: In total, 460 participants were included; 320 of whom (69.6%) were presenting current substance use, and 221 (48.0%) with PUS. Compared to non-PUS individuals, PUS ones were more likely to be males (aOR=2.06; 95% CI [1.39-3.07], P<0.001), to be older (per one-year increase: aOR=1.09; 95% CI [1.01-1.17], P<0.05), to have an impaired mental health status (aOR=0.87; 95% CI [0.81-0.94], P<0.001), and to have a history of sexual abuse (aOR=3.33; 95% CI [2.03-5.47], P<0.0001). Only 132 (59.7%) subjects with PUS could be reached by phone at 3 months, among whom only 15 (11.4%) reported having sought treatment. Factors associated with treatment seeking were social isolation (46.7% vs. 19.7%; P=0.019), previous consultation for psychological disorders (93.3% vs. 68.4%; P=0.044), lower mental health score (2.8±1.6 vs. 5.1±2.6; P<0.001), and post-ED hospitalization in a psychiatric unit (73.3% vs. 19.7%; P<0.0001)., Discussion/conclusion: EDs are relevant places to screen PUS in youth, but the level of seeking further treatment needs to be substantially improved. Offering systematic screening during an emergency room visit could allow for more appropriate identification and management of youth with PUS., (Copyright © 2023 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

The transmission risk of SARS-CoV-2 within hospitals can exceed that in the general community because of more frequent close proximity interactions (CPIs). However, epidemic risk across wards is still poorly described. We measured CPIs directly using wearable sensors given to all present in a clinical ward over a 36-h period, across 15 wards in three hospitals in April-June 2020. Data were collected from 2114 participants and combined with a simple transmission model describing the arrival of a single index case to the ward to estimate the risk of an outbreak. Estimated epidemic risk ranged four-fold, from 0.12 secondary infections per day in an adult emergency to 0.49 per day in general paediatrics. The risk presented by an index case in a patient varied 20-fold across wards. Using simulation, we assessed the potential impact on outbreak risk of targeting the most connected individuals for prevention. We found that targeting those with the highest cumulative contact hours was most impactful (20% reduction for 5% of the population targeted), and on average resources were better spent targeting patients. This study reveals patterns of interactions between individuals in hospital during a pandemic and opens new routes for research into airborne nosocomial risk., (© 2024. The Author(s).)

Background and Importance: Although shoulder dislocation diagnosis is often solely based on clinical examination, physicians may order a radiograph to rule out a concomitant shoulder fracture before performing reduction. The Fresno-Québec decision rule aims to identify patients requiring a radiograph before reduction to avoid unnecessary systematic imaging. However, this novel approach needs further validation., Objective: To evaluate the performance of the Fresno-Québec rule in identifying patients who do not require a prereduction radiograph and assess the variables associated with a clinically significant fracture., Design, Settings, and Participants: A multicenter, retrospective cohort study from 2015 to 2021. Data were extracted from three ED university-affiliated tertiary-care centers. Patients aged ≥18 years with a final diagnosis of anterior glenohumeral dislocation were included., Outcomes Measure and Analysis: Accuracy metrics [sensitivity (Se), specificity (Sp), positive (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR)] of the Fresno-Québec rule were measured. Multivariable logistic regression model was used to identify variables associated with the presence of a concomitant clinically significant fracture., Main Results: A total of 2129 patients were included, among whom 9.7% had a concomitant fracture. The performance metrics of the Fresno-Québec rule were as follows: Se 0.96 95% confidence interval (0.92-0.98), Sp 0.36 (0.34-0.38), PPV 0.14 (0.12-0.16), NPV 0.99 (0.98-0.99), PLR 1.49 (1.42-1.55) and NLR 0.12 (0.06-0.23). A total of 678 radiographs could have been avoided, corresponding to a reduction of 35.2%. Age ≥40 years, first dislocation episode [odds ratio (OR) = 3.18 (1.95-5.38); P  < 0.001], the following mechanisms: road collision [OR = 6.26 (2.65-16.1)], low-level fall [OR = 3.49 (1.66-8.28)], high-level fall [OR = 3.95 (1.62-10.4)], and seizure/electric shock [OR = 10.6 (4.09-29.2)] were associated with the presence of a concomitant fracture., Conclusion: In this study, the Fresno-Québec rule has excellent Se in identifying concomitant clinically significant fractures in patients with an anterior glenohumeral dislocation. The use of this clinical decision rule may be associated with a reduction of approximately a third of unnecessary prereduction radiographs., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Patients in the emergency department (ED) who are waiting for hospital admission on a wheeled cot may be subject to harm. However, mortality and morbidity among older patients who spend the night in the ED while waiting for a bed in a medical ward are unknown., Objective: To assess whether older adults who spend a night in the ED waiting for admission to a hospital ward are at increased risk of in-hospital mortality., Design, Settings, and Participants: This was a prospective cohort study of older patients (≥75 years) who visited the ED and were admitted to the hospital on December 12 to 14, 2022, at 97 EDs across France. Two groups were defined and compared: those who stayed in the ED from midnight until 8:00 am (ED group) and those who were admitted to a ward before midnight (ward group)., Main Outcomes and Measures: The primary end point was in-hospital mortality, truncated at 30 days. Secondary outcomes included in-hospital adverse events (ie, falls, infection, bleeding, myocardial infarction, stroke, thrombosis, bedsores, and dysnatremia) and hospital length of stay. A generalized linear-regression mixed model was used to compare end points between groups., Results: The total sample comprised 1598 patients (median [IQR] age, 86 [80-90] years; 880 [55%] female and 718 [45%] male), with 707 (44%) in the ED group and 891 (56%) in the ward group. Patients who spent the night in the ED had a higher in-hospital mortality rate of 15.7% vs 11.1% (adjusted risk ratio [aRR], 1.39; 95% CI, 1.07-1.81). They also had a higher risk of adverse events compared with the ward group (aRR, 1.24; 95% CI, 1.04-1.49) and increased median length of stay (9 vs 8 days; rate ratio, 1.20; 95% CI, 1.11-1.31). In a prespecified subgroup analysis of patients who required assistance with the activities of daily living, spending the night in the ED was associated with a higher in-hospital mortality rate (aRR, 1.81; 95% CI, 1.25-2.61)., Conclusions and Relevance: The findings of this prospective cohort study indicate that for older patients, waiting overnight in the ED for admission to a ward was associated with increased in-hospital mortality and morbidity, particularly in patients with limited autonomy. Older adults should be prioritized for admission to a ward.

Background: Inter-facility transport of patients with acute respiratory distress syndrome (ARDS) in the prone position (PP) is a high-risk situation, compared to other strategies. We aimed to quantify the prevalence of complications during transport in PP, compared to transports with veno-venous extracorporeal membrane oxygenation (VV-ECMO) or in the supine position (SP)., Methods: We performed a retrospective, single center cohort study in Lyon university hospital, France. We included patients ≥ 16 years with ARDS (Berlin definition) transported to an ARDS referral center between 01/12/2016 and 31/12/2021. We compared patients transported in PP, to those transported in SP without VV-ECMO, and those transported with VV-ECMO (in SP), by a multidisciplinary and specialized medical transport team, including an emergency physician and an intensivist. The primary outcome was the rate of transport-related complications (hypoxemia, hypotension, cardiac arrest, cannula or tube dislodgement) in each study groups, compared using a Fisher test., Results: One hundred thirty-four patients were enrolled (median PaO 2 /FiO 2 70 [58-82] mmHg), of which 11 (8%) were transported in PP, 44 (33%) with VV-ECMO, and 79 (59%) in SP. The most frequent risk factor for ARDS in the PP group was bacterial pneumonitis, and viral pneumonitis in the other 2 groups. Transport-related complications occurred in 36% (n = 4) of transports in PP, compared to 39% (n = 30) in SP and 14% (n = 6) with VV-ECMO, respectively (p = 0.33). VV-ECMO implantation after transport was not different between SP and PP patients (n = 7, 64% vs. n = 31, 39%, p = 0.19)., Conclusions: In the context of a specialized multi-disciplinary ARDS transport team, transport-related complication rates were similar between patients transported in PP and SP, while there was a trend of lower rates in patients transported with VV-ECMO., (© 2023. The Author(s).)

Mobile emergency and resuscitation teams are confronted with death on a daily basis. In the home, the management of a death is complex. It raises ethical questions and sometimes destabilizes personal or collective values. Our single-center qualitative survey, conducted over a one-month period (2022), questioned 64/154 caregivers about the moral burden and challenges of such situations. The consequences of operational experience are discussed: time, fatigue, emotions and training. The quality of presence is an alternative to the success or failure of cardiac arrest care at home., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: The population of older trauma patients is increasing. Those patients have heterogeneous presentations and need senior-friendly triaging tools. Systolic blood pressure (SBP) is commonly used to assess injury severity, and some authors advocated adjusting SBP threshold for older patients. We aimed to describe and compare the relationship between mortality and SBP in older trauma patients and their younger counterparts., Methods: We included patients admitted to three level-I trauma centres and performed logistic regressions with age and SBP to obtain mortality curves. Multivariable Logistic regressions were performed to measure the association between age and mortality at different SBP ranges. Subgroup analyses were conducted for major trauma and severe traumatic brain injury admissions., Results: A total of 47,661 patients were included, among which 12.9% were aged 65-74 years and 27.3% were ≥ 75 years. Overall mortality rates were 3.9%, 8.1%, and 11.7% in the groups aged 16-64, 65-74, and ≥ 75 years, respectively. The relationship between prehospital SBP and mortality was nonlinear (U-shape), mortality increased with each 10 mmHg SBP decrement from 130 to 50 mmHg and each 10-mmHg increment from 150 to 220 mmHg across all age groups. Older patients were at higher odd for mortality in all ranges of SBP. The highest OR in patients aged 65-74 years was 3.67 [95% CI: 2.08-6.45] in the 90-99 mmHg SBP range and 7.92 [95% CI: 5.13-12.23] for those aged ≥ 75 years in the 100-109 mmHg SBP range., Conclusion: The relationship between SBP and mortality is nonlinear, regardless of trauma severity and age. Older age was associated with a higher odd of mortality at all SBP points. Future triage tools should therefore consider SBP as a continuous rather than a dichotomized predictor., (© 2023. BioMed Central Ltd., part of Springer Nature.)

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.)

Purpose: To assess the incidence of undertriage in major trauma, its determinant, and association with mortality., Methods: A multicentre retrospective cohort study was conducted using data from a French regional trauma registry (2011-2017). All major trauma (Injury Severity Score ≥ 16) cases aged ≥ 18 years and managed by a physician-led mobile medical team were included. Those transported to a level-II/III trauma centre were considered as undertriaged. Multivariable logistic regression was used to identify factors associated with undertriage., Results: A total of 7110 trauma patients were screened; 2591 had an ISS ≥ 16 and 320 (12.4%) of these were undertriaged. Older patients had higher risk for undertriage (51-65 years: OR = 1.60, 95% CI [1.11; 2.26], p = 0.01). Conversely, injury mechanism (fall from height: 0.62 [0.45; 0.86], p = 0.01; gunshot/stab injuries: 0.45 [0.22; 0.90], p = 0.02), on-scene time (> 60 min: 0.62 [0.40; 0.95], p = 0.03), prehospital endotracheal intubation (0.53 [0.39; 0.71], p < 0.001), and prehospital focussed assessment with sonography [FAST] (0.15 [0.08; 0.29], p < 0.001) were associated with a lower risk for undertriage. After adjusting for severity, undertriage was not associated with a higher risk of mortality (1.22 [0.80; 1.89], p = 0.36)., Conclusions: In our physician-led prehospital EMS system, undertriage was higher than recommended. Advanced aged was identified as a risk factor highlighting the urgent need for tailored triage protocol in this population. Conversely, the potential benefit of prehospital FAST on triage performance should be furthered explored as it may reduce undertriage. Fall from height and penetrating trauma were associated with a lower risk for undertriage suggesting that healthcare providers should remain vigilant of the potential seriousness of trauma associated with low-energy mechanisms., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

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

Importance: Pediatric traumatic brain injuries (TBIs) are a leading cause of death and disability. The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide a framework for requesting head computed tomography (HCT) after pediatric head trauma (PHT); however, quantitative data are lacking regarding both TBIs found on HCT and justification of the HCT request according to the PECARN guidelines., Objectives: To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request., Design, Setting, and Participants: This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022., Exposure: All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines., Main Outcomes and Measures: Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture., Results: Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians., Conclusion and Relevance: In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.

Aim: To evaluate the impact of the 2015 European Resuscitation Council (ERC) guidelines on patient outcomes following traumatic cardiac arrest (TCA) and on advanced life support interventions carried out by physician-staffed ambulances., Methods: Data of TCA patients aged ≥18 years were extracted from the French nationwide cardiac arrest registry. A pre- (2011-2015) and a post-publication period (2016-2020) were defined. In the guidelines, a specific TCA management algorithm was introduced to prioritise the treatment of reversible causes. Its impact was evaluated using adjusted interrupted time series analysis., Results: 4,980 patients were treated (2,145 during the pre-publication period and 2,739 during the post-publication period). There was no significant change in the rates of prehospital ROSC (22.4% vs. 20.2%, p = 0.07 in the pre- and post- intervention respectively), survival (1.4% vs. 1.4%, p = 0.87) or good neurological outcome (71.4% vs. 66.7%, p = 0.93) or in the incidence of organ donation (1.6% vs. 1.3%, p = 0.50). There were nonsignificant changes in the adjusted temporal trend for ROSC (aOR 0.88; 95% CI [0.77; 1.00]), survival (aOR 1.34; 95% CI [0.83;2.17]), good neurological outcome (aOR 1.57; 95% CI [0.82;3.05]), and organ donation (aOR 1.06; 95% CI [0.71;1.60]). The use of intraosseous catheters (13.0% vs. 19.2%, p < 0.001), external haemorrhage control measures (23.9% vs. 64.8%, p < 0.001), bilateral chest decompression (13.7% vs. 16.5%, p = 0.009), and packed red cell transfusion (2.7% vs. 6.5%, p < 0.001) increased in the post-publication period., Conclusions: Despite the increased frequency of trauma rescue interventions performed by on-scene physicians, no change in patient-centred outcomes was associated with the publication of the 2015 ERC guidelines in France., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Lung point-of-care ultrasonography (L-POCUS) is highly effective in detecting pulmonary peripheral patterns and may allow early identification of patients who are likely to develop an acute respiratory distress syndrome (ARDS). We hypothesized that L-POCUS performed within the first 48 hours of non-critical patients with suspected COVID-19 would identify those with a high-risk of worsening., Methods: POCUSCO was a prospective, multicenter study. Non-critical adult patients who presented to the emergency department (ED) for suspected or confirmed COVID-19 were included and had L-POCUS performed within 48 hours following ED presentation. The lung damage severity was assessed using a previously developed score reflecting both the extension and the intensity of lung damage. The primary outcome was the rate of patients requiring intubation or who died within 14 days following inclusion., Results: Among 296 patients, 8 (2.7%) met the primary outcome. The area under the curve (AUC) of L-POCUS was 0.80 [95%CI:0.60-0.94]. The score values which achieved a sensibility >95% in defining low-risk patients and a specificity >95% in defining high-risk patients were <1 and ≥16, respectively. The rate of patients with an unfavorable outcome was 0/95 (0%[95%CI:0-3.9]) for low-risk patients (score = 0), 4/184 (2.17%[95%CI:0.8-5.5]) for intermediate-risk patients (score 1-15) and 4/17 (23.5%[95%CI:11.4-42.4]) for high-risk patients (score ≥16). In confirmed COVID-19 patients (n = 58), the AUC of L-POCUS was 0.97 [95%CI:0.92-1.00]., Conclusion: L-POCUS performed within the first 48 hours following ED presentation allows risk-stratification of patients with non-severe COVID-19., Competing Interests: Pr. Christophe Aubé declares personal scientific collaborations with Siemens Ultrasound, outside the submitted work. Pr. Francis Couturaud declares personal consulting fees and other from BMS, personal consulting fees and other from Bayer, personal consulting fees and other from MSD, outside the submitted work. Pr. Pierre-Marie Roy declares personal fees and other from Aspen, personal fees and other from Boehringer Ingelheim, personal fees and other from Bristol Myers Squibb, other from Bayer Health Care, outside the submitted work. Other authors declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Morin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Aims: To describe the outcomes and associated factors in a population of patients admitted to emergency departments with at least one condition of oxygen supply/demand imbalance, regardless of the troponin result or restrictive criteria for type 2 myocardial infarction., Methods: We constituted a retrospective cohort of 824 patients. Medical records of patients having undergone a troponin assay were reviewed for selection and classification, and data including in-hospital stay and readmissions were collected. The reported outcomes are in-hospital mortality, 3-year mortality, and major adverse cardiovascular events., Results: Patients with myocardial infarction or injury, either chronic or acute, were older, with more history of hypertension and chronic heart or renal failure but not for other cardiovascular risk factors and medical history. Acute myocardial injury and type 2 myocardial infarction were significantly associated with in-hospital mortality [odds ratio (OR) 3.71 95% confidence interval (CI) 1.90-7.33 and OR 3.15 95% CI 1.59-6.28, respectively]. However, the long-term mortality does not differ in comparison with patients presenting chronic myocardial injury or nonelevated troponin, ranging from 26.9 to 34.3%. Patients with chronic myocardial injury and type 2 myocardial infarction had more long-term major cardiovascular events (39.3 and 38.8%), but only for acute heart failure, and none was associated with this outcome after adjustment., Conclusion: Among patients admitted to emergency departments with an oxygen supply/demand imbalance, acute myocardial injury and type 2 myocardial infarction are strongly associated with in-hospital mortality. However, they are not associated with higher long-term mortality or major cardiovascular events after discharge, which tend to occur in elderly people with comorbidities., (Copyright © 2023 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Background: Older adults have become a significant portion of the trauma population. Exploring their specificities is crucial to better meet their specific needs. The primary objective was to evaluate the temporal changes in the incidence, demographic and trauma characteristics, injury pattern, in-hospital admission, complications, and outcome of older trauma patients., Methods: A multicenter retrospective cohort study was conducted using the Quebec Trauma Registry. Patients aged ≥16 years admitted to one of the three adult level-I trauma centers between 2003 and 2017 were included. Descriptive analyses and trend-tests were performed to describe temporal changes., Results: A total of 53,324 patients were included, and 24,822 were aged ≥65 years. The median [IQR] age increased from 57[36-77] to 67[46-82] years, and the proportion of older adults rose from 41.8% in 2003 to 54.1% in 2017. Among those, falls remain the main mechanism (84.7%-88.3%), and the proportion of severe thorax (+8.9%), head (+8.7%), and spine (+5%) injuries significantly increased over time. The proportion of severely injured older patients almost doubled (17.6%-32.3%), yet their mortality decreased (-1.0%). Their average annual bed-days consumption also increased (+15,004 and +1,437 in non-intensive care wards and ICU, respectively)., Conclusions: Since 2014, older adults have represented the majority of admissions in Level-I trauma centers in Québec. Their bed-days consumption has greatly increased, and their injury pattern and severity have deeply evolved, while we showed a decrease in mortality., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Benhamed et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background : Prehospital trauma triage tools are not tailored to identify severely injured older adults. Our trauma triage protocol based on a three-tier trauma severity grading system (A, B, and C) has never been studied in this population. The objective was to assess its accuracy in predicting in-hospital mortality among older adults (≥65 years) and to compare it to younger patients. Methods : A retrospective multicenter cohort study, from 2011 to 2021. Consecutive adult trauma patients managed by a mobile medical team were prospectively graded A, B, or C according to the initial seriousness of their injuries. Accuracy was evaluated using sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios. Results : 8888 patients were included (14.1% were ≥65 years). Overall, 10.1% were labeled Grade A (15.2% vs. 9.3% among older and younger adults, respectively), 21.9% Grade B (27.9% vs. 20.9%), and 68.0% Grade C (56.9% vs. 69.8%). In-hospital mortality was 7.1% and was significantly higher among older adults regardless of severity grade. Grade A showed lower sensitivity (50.5 (43.7; 57.2) vs. 74.6 (69.8; 79.1), p < 0.0001) for predicting mortality among older adults compared to their younger counterparts. Similarly, Grade B was associated with lower sensitivity (89.5 (84.7; 93.3) vs. 97.2 (94.8; 98.60), p = 0.0003) and specificity (69.4 (66.3; 72.4) vs. 74.6 (73.6; 75.7], p = 0.001) among older adults. Conclusions : Our prehospital trauma triage protocol offers high sensitivity for predicting in-hospital mortality including older adults.

Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest.

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

Objectives: We evaluated the contribution of lung lesion quantification on chest CT using a clinical Artificial Intelligence (AI) software in predicting death and intensive care units (ICU) admission for COVID-19 patients., Methods: For 349 patients with positive COVID-19-PCR test that underwent a chest CT scan at admittance or during hospitalization, we applied the AI for lung and lung lesion segmentation to obtain lesion volume (LV), and LV/Total Lung Volume (TLV) ratio. ROC analysis was used to extract the best CT criterion in predicting death and ICU admission. Two prognostic models using multivariate logistic regressions were constructed to predict each outcome and were compared using AUC values. The first model ("Clinical") was based on patients' characteristics and clinical symptoms only. The second model ("Clinical+LV/TLV") included also the best CT criterion., Results: LV/TLV ratio demonstrated best performance for both outcomes; AUC of 67.8% (95% CI: 59.5 - 76.1) and 81.1% (95% CI: 75.7 - 86.5) respectively. Regarding death prediction, AUC values were 76.2% (95% CI: 69.9 - 82.6) and 79.9% (95%IC: 74.4 - 85.5) for the "Clinical" and the "Clinical+LV/TLV" models respectively, showing significant performance increase (+ 3.7%; p-value<0.001) when adding LV/TLV ratio. Similarly, for ICU admission prediction, AUC values were 74.9% (IC 95%: 69.2 - 80.6) and 84.8% (IC 95%: 80.4 - 89.2) respectively corresponding to significant performance increase (+ 10%: p-value<0.001)., Conclusions: Using a clinical AI software to quantify the COVID-19 lung involvement on chest CT, combined with clinical variables, allows better prediction of death and ICU admission., Competing Interests: The authors declare the following competing interest: Anna Vlachomitrou, Olivier Nempont, Heike Carolus, Alexander Schmidt-Richberg, Peng Jin, Pedro Rodrigues are Tobias Klinder are employees of Philips Healthcare., (© 2022 The Authors. Published by Elsevier Masson SAS on behalf of Société française de radiologie.)

Aim: To compare walking access times to automated external defibrillators (AEDs) between area-level quintiles of socioeconomic status (SES) in out-of-hospital cardiac arrest (OHCA) cases occurring in 2 major urban regions of Canada and France., Methods: This was an international, multicenter, retrospective cohort study of adult, non-traumatic OHCA cases in the metropolitan Vancouver (Canada) and Rhône County (France) regions that occurred between 2014 and 2018. We calculated area-level SES for each case, using quintiles of country-specific scores (Q5 = most deprived). We identified AED locations from local registries. The primary outcome was the simulated walking time from the OHCA location to the closest AED (continuous and dichotomized by a 3-minute 1-way threshold). We fit multivariate models to analyze the association between OHCA-to-AED walking time and outcomes (Q5 vs others)., Results: A total of 6,187 and 3,239 cases were included from the Metro Vancouver and Rhône County areas, respectively. In Metro Vancouver Q5 areas (vs Q1-Q4), areas, AEDs were farther from (79 % over 400 m from case vs 67 %, p < 0.001) and required longer walking times to (97 % above 3 min vs 91 %, p < 0.001) cases. In Rhône Q5 areas, AEDs were closer than in other areas (43 % over 400 m from case vs 50 %, p = 0.01), yet similarly poorly accessible (85 % above 3 min vs 86 %, p = 0.79). In multivariate models, AED access time ≥ 3 min was associated with decreased odds of survival at hospital discharge in Metro Vancouver (odds ratio 0.41, 95 % CI [0.23-0.74], p = 0.003)., Conclusions: Accessibility of public AEDs was globally poor in Metro Vancouver and Rhône, and even poorer in Metro Vancouver's socioeconomically deprived areas., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Study Objective: Assess the changes in anxiety, depression, and stress levels over time and identify risk factors among healthcare workers in French emergency departments (EDs) during the first COVID-19 outbreak., Method: A prospective, multicenter study was conducted in 4 EDs and an emergency medical service (SAMU). During 3 months, participants completed fortnightly questionnaires to assess anxiety, depression, and stress using the Hospital Anxiety and Depression and the Chamoux-Simard scale. The changes in anxiety, depression, and stress levels over time were modelled by a linear mixed model including a period effect and a continuous time effect within periods., Results: A total of 211 respondents (43.5 %) completed the survey at inclusion. There was a decrease in mean anxiety (from 7.33 to 5.05, p < 0.001), mean depression (from 4.16 to 3.05, p = 0.009), mean stress at work (from 41.2 to 30.2, p = 0.008), and mean stress at home (from 33.0 to 26.0, p = 0.031) at the beginning of each period. The mean anxiety level was higher for administrative staff (+0.53) and lower for paramedics (-0.61, p = 0.047) compared to physicians. The anxiety level increased with the number of day and night shifts (0.13/day, p < 0.001, 0.12/night, p = 0.025) as did stress at work (1.6/day, p < 0.001, 1.1/night, p = 0.007). Reassigned healthcare workers were at higher risk of stress particularly compared to SAMU workers (stress at work: p = 0.015, at home: p = 0.021, in life in general: p = 0.018)., Conclusion: Although anxiety, depression, and stress decreased over time, anxiety was higher among physicians and administrative staff. Reassignment and working hours were identified as potential risk factors for mental health distress in EDs., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: Describe prehospital tranexamic acid (TXA) use and appropriateness within a major trauma pediatric population, and identify the factors associated with its use., Design: Multicenter, retrospective study, 2014-2020., Setting: Data were extracted from a multicenter French trauma registry including nine trauma centers within a physician-led prehospital emergency medical services (EMS) system., Patients: Patients less than 18 years old were included. Those who did not receive prehospital intervention by a mobile medical team and those with missing data on TXA administration were excluded., Interventions: None., Measurements and Main Results: Nine-hundred thirty-four patients (median [interquartile range] age: 14 yr [9-16 yr]) were included, and 68.6% n = 639) were male. Most patients were involved in a road collision (70.2%, n = 656) and suffered a blunt trauma (96.5%; n = 900). Patients receiving TXA (36.6%; n = 342) were older (15 [13-17] vs 12 yr [6-16 yr]) compared with those who did not. Patient severity was higher in the TXA group (Injury Severity Score 14 [9-25] vs 6 [2-13]; p < 0.001). The median dosage was 16 mg/kg (13-19 mg/kg). TXA administration was found in 51.8% cases ( n = 256) among patients with criteria for appropriate use. Conversely, 32.4% of patients ( n = 11) with an isolated severe traumatic brain injury (TBI) also received TXA. Age (odds ratio [OR], 1.2; 95% CI, 1.1-1.2), A and B prehospital severity grade (OR, 7.1; 95% CI, 4.1-12.3 and OR, 4.5; 95% CI, 2.9-6.9 respectively), and year of inclusion (OR, 1.2; 95% CI, 1.1-1.3) were associated with prehospital TXA administration., Conclusions: In our physician-led prehospital EMS system, TXA is used in a third of severely injured children despite the lack of high-level of evidence. Only half of the population with greater than or equal to one criteria for appropriate TXA use received it. Conversely, TXA was administered in a third of isolated severe TBI. Further research is warranted to clarify TXA indications and to evaluate its impact on mortality and its safety profile to oversee its prescription., Competing Interests: Dr. Claustre’s institution received funding from the Regional Agency for Health. Dr. Fraticelli disclosed work for hire. Dr. Jacquet disclosed the off-label product use of Tranexamic acid. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Introduction: Few studies have investigated the management of COVID-19 cases from the operational perspective of the emergency department (ED), We sought to compare the management and outcome of COVID-19 positive and negative patients who presented to French EDs., Methods: We conducted a prospective, multicenter, observational study in four EDs. Included in the study were adult patients (≥18 years) between March 6-May 10, 2020, were hospitalized, and whose presenting symptoms were evocative of COVID-19. We compared the clinical features, management, and prognosis of patients according to their confirmed COVID-19 status., Results: Of the 2,686 patients included in this study, 760 (28.3%) were COVID-19 positive. Among them, 364 (48.0%) had hypertension, 228 (30.0%) had chronic cardiac disease, 186 (24.5%) had diabetes, 126 (16.6%) were obese, and 114 (15.0%) had chronic respiratory disease. The proportion of patients admitted to intensive care units (ICU) was higher among COVID-19 positive patients (185/760, 24.3%) compared to COVID-19 negative patients (206/1,926, 10.7%; P <0.001), and they required mechanical ventilation (89, 11.9% vs 37, 1.9%; P <0.001) and high-flow nasal cannula oxygen therapy (135, 18.1% vs 41, 2.2%; P < 0.001) more frequently. The in-hospital mortality was significantly higher among COVID-19 positive patients (139, 18.3% vs 149, 7.7%; P <0.001)., Conclusion: Emergency departments were on the frontline during the COVID-19 pandemic and had to manage potential COVID-19 patients. Understanding what happened in the ED during this first outbreak is crucial to underline the importance of flexible organizations that can quickly adapt the bed capacities to the incoming flow of COVID-19 positive patients.

Background: Urban mobility has drastically evolved over the last decade and micromobility rapidly became an expanding segment of contemporary daily transportation routines. E-scooter riders and bicyclists may share similar trauma characteristics, but this has been little explored. The objective was to describe and compare the characteristics of e-scooter and bicycle-related trauma., Methods: We conducted a cross-sectional analysis of data from the Rhône road collision registry (January 1, 2019 to December 31, 2019). We included all e-scooter or bicycle riders injured in traffic collisions during the study period; there were no exclusion criterion., Results: A total of 2,779 patients were included; 825 (29.7%) were e-scooter riders and 1,954 (70.3%) were bicyclists. E-scooter riders were younger (median [IQR]: 24 [20-32] vs 29 [20-45] years, p < 0.001) and less frequently male (64.2% vs 73.4%, p < 0.001). Most e-scooter and bicycle road collisions were consequent to a fall or loss of vehicle control (74.2% vs 67.7%, p < 0.001). E-scooter riders were less frequently wearing a helmet at the time of the road collision (6.1% vs 30.7%, p < 0.001) and had more frequently head (24.2% vs 19.9%, p = 0.01) and face (30.6 vs 20.5%, p < 0.001) injuries compared to bicyclists. The median injury severity score was 2 [1-4] in both groups with no significant difference (p = 0.77)., Conclusions: E-scooter and bicycle-related trauma patients were mainly young males with minor injuries and most of them sustained a road collision with no third-party. However, they suffered from different injury patterns; e-scooter riders suffered more frequently face and head injuries than bicycle riders, which may be at least partly the consequence of less frequent helmet use among e-scooter riders compared to bicyclists. Hence the two groups of users should not be considered as a single trauma entity. This issue should be promptly addressed to bring down the incidence of preventable injuries and avoid healthcare costs., (© 2022. The Author(s).)

France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Thoracic trauma is a major cause of death in trauma patients and road traffic accident (RTA)-related thoracic injuries have different characteristics than those with non-RTA related thoracic traumas, but this have been poorly described. The main objective was to investigate the epidemiology, injury pattern and outcome of patients suffering a significant RTA-related thoracic injury. Secondary objective was to investigate the influence of serious thoracic injuries on mortality, compared to other serious injuries., Methods: We performed a multicenter observational study including patients of the Rhône RTA registry between 1997 and 2016 sustaining a moderate to lethal (Abbreviated Injury Scale, AIS≥2) injury in any body region. A subgroup (AISThorax≥2 group) included those with one or more AIS≥2 thoracic injury. Descriptive statistics were performed for the main outcome and a multivariate logistic regression was computed for our secondary outcome., Results: A total of 176,346 patients were included in the registry and 6,382 (3.6%) sustained a thoracic injury. Among those, median age [IQR] was 41 [25-58] years, and 68.9% were male. The highest incidence of thoracic injuries in female patients was in the 70-79 years age group, while this was observed in the 20-29 years age group among males. Most patients were car occupants (52.3%). Chest wall injuries were the most frequent thoracic injuries (62.1%), 52.4% of which were multiple rib fractures. Trauma brain injuries (TBI) were the most frequent concomitant injuries (29.1%). The frequency of MAISThorax = 2 injuries increased with age while that of MAISThorax = 3 injuries decreased. A total of 16.2% patients died. Serious (AIS≥3) thoracic injuries (OR = 12.4, 95%CI [8.6;18.0]) were strongly associated with mortality but less than were TBI (OR = 27.9, 95%CI [21.3;36.7])., Conclusion: Moderate to lethal RTA-related thoracic injuries were rare. Multiple ribs fractures, pulmonary contusions, and sternal fractures were the most frequent anatomical injuries. The incidence, injury pattern and mechanisms greatly vary across age groups., Competing Interests: The authors declare that they have no competing interests.