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Delayed admission to the ICU is reported to be associated with worse outcomes in cancer patients.The main objective of this study was to compare the 180-day survival of cancer patients whether they were directly admitted to the ICU from the emergency department (ED) or secondarily from the wards after the ED visit.This was a retrospective observational study including all adult cancer patients that visited the ED in 2018 and that were admitted to the ICU at some point within 7 days from the ED visit.Delayed ICU admission.Survival at day 180 was plotted using Kaplan-Meier curves, and hazard ratio (HR) from Cox proportional-hazard models was used to quantify the association between admission modality (directly from the ED or later from wards) and survival at day 180, after adjustment to baseline characteristics.During the study period, 4560 patients were admitted to the hospital following an ED visit, among whom 136 (3%) patients had cancer and were admitted to the ICU, either directly from the ED in 101 (74%) cases or secondarily from the wards in 35 (26%) cases. Patients admitted to the ICU from the ED had a better 180-day survival than those admitted secondarily from wards (log-rank P = 0.006). After adjustment to disease status (remission or uncontrolled malignancy), survival at day 180 was significantly improved in the case of admission to the ICU directly from the ED with an adjusted HR of 0.50 (95% confidence interval, 0.26-0.95), P = 0.03.In ED patients with cancer, a direct admission to the ICU was associated with better 180-day survival compared with patients with a delayed ICU admission secondary from the wards. However, several confounders were not taken into account, which limits the validity of this result.

The coronavirus disease-2019 (COVID-19) pandemic has imposed unforeseen and unprecedented constraints on emergency departments (EDs). In this study, we detail the organizational and managerial tools recently implemented among 5 academic EDs in a French region particularly affected by COVID-19 and analyze how EDs responded to the COVID-19-related disease burden during different phases of the epidemic. Initially, they focused on the early detection of suspected cases by identifying 3 predominant COVID-19 syndromes. During this diagnostic process, patients were placed in respiratory isolation (facial mask before triage) and droplet isolation (ED rooms). A 3-level strategy for triage, clinical pathways in the EDs, and the organization of hospital spaces was based on the real-time polymerase chain reaction (RT-PCR) COVID-19 positivity rate, with ED strategies adapted to the exigencies of each level. This crisis demonstrated hospitals' adaptability and capacity to mobilize in the face of new risks, with hospitals and EDs coordinating their management to reallocate resources, optimize interoperability, and rethink patient pathways. This report on their processes may assist hospitals and EDs in areas currently spared by the new variants.

Background: We aimed to describe red blood cell (RBC) transfusions in the emergency department (ED) with a particular focus on the hemoglobin (Hb) level thresholds that are used in this setting. Methods: This was a cross-sectional study of 12 EDs including all adult patients that received RBC transfusion in January and February 2018. Descriptive statistics were reported. Logistic regression was performed to assess variables that were independently associated with a pre-transfusion Hb level ≥ 8 g/dL. Results: During the study period, 529 patients received RBC transfusion. The median age was 74 (59–85) years. The patients had a history of cancer or hematological disease in 185 (35.2%) cases. Acute bleeding was observed in the ED for 242 (44.7%) patients, among which 145 (59.9%) were gastrointestinal. Anemia was chronic in 191 (40.2%) cases, mostly due to vitamin or iron deficiency or to malignancy with transfusion support. Pre-transfusion Hb level was 6.9 (6.0–7.8) g/dL. The transfusion motive was not notified in the medical chart in 206 (38.9%) cases. In the multivariable logistic regression, variables that were associated with a higher pre-transfusion Hb level (≥8 g/dL) were a history of coronary artery disease (OR: 2.09, 95% CI: 1.29–3.41), the presence of acute bleeding (OR: 2.44, 95% CI: 1.53–3.94), and older age (OR: 1.02/year, 95% CI: 1.01–1.04). Conclusion: RBC transfusion in the ED was an everyday concern and involved patients with heterogeneous medical situations and severity. Pre-transfusion Hb level was rather restrictive. Almost half of transfusions were provided because of acute bleeding which was associated with a higher Hb threshold.

ObjectivesWe sought to estimate the prevalence of patients with cancer presenting to the emergency department (ED) who are undergoing treatment with immune checkpoint blockade (ICB) therapy; report their chief complaints; describe and estimate the prevalence of immune-related adverse events (IRAEs).MethodsFour abstractors reviewed the medical records of patients with cancer treated with ICB who presented to an ED in Paris, France between January 2012 and June 2017. Chief complaints, underlying malignancy and ICB characteristics, and the final diagnoses according to the emergency physician were recorded. Abstractors noted if an emergency physician identified that a patient was receiving an ICB and if the emergency physician considered the possibility of an IRAE. The gold standard as to whether an IRAE was the cause was the patients’ referring oncologist’s opinion that the ED symptoms were attributed to ICB and IRAE according to post-ED medical records. Descriptive statistics were reported.ResultsAmong the 409 patients treated with ICB at our institution, 139 presented to the ED. Chief complaints were fatigue (25.2%), fever (23%), vomiting (13.7%), diarrhoea (13.7%), dyspnoea (12.2%), abdominal pain (11.5%), confusion (8.6%) and headache (7.9%). Symptoms were due to IRAEs in 20 (14.4%) cases. The most frequent IRAEs were colitis (40%), endocrine toxicity (30%), hepatitis (25%) and pulmonary toxicity (5%). Patients with IRAEs compared with those without them more frequently had melanoma; had received more distinct courses of ICB treatment, an increased number of ICB medications and ICB cycles; and had a shorter time course since the last infusion of ICB. Emergency physicians considered the possibility of an IRAE in 24 (17.3%) of cases and diagnosed IRAE in 10 (50%) of those with later confirmed IRAE. IRAE was more likely to be missed when the referring oncologist was not contacted or when the patient had respiratory symptoms, fatigue or fever.ConclusionsICB exposes patients to potentially severe IRAEs. Emergency physicians must identify patients treated with ICB and consider their toxicity when patients present to the ED with symptoms compatible with IRAEs.

Introduction Les objectifs de cette etude sont de decrire les transfusions en culots globulaires (CG) dans les services d’urgences (SU). Methodes Etude retrospective dans 12 SU incluant tous les patients adultes ayant ete transfuses en CG en janvier et fevrier 2018. Resultats Durant la periode d’inclusion, 529 patients ont ete transfuses en CG. L’âge median etait de 74 [59–85] ans. Ils avaient un antecedent de cancer ou d’hemopathie dans 185 (35,2 %) cas. Un signe de gravite et/ou une tachycardie et/ou un antecedent de cardiopathie ischemique etaient present chez 329 (62,4 %) patients. Un saignement etait objective aux urgences chez 242 (46 %) patients. L’hemoglobinemie (hb) avant transfusion etait de 6,9 [6,0–7,8] g/dL et variait peu qu’il y ait ou pas une hemorragie ou des signes de gravite. Huit (1,5 %) evenements indesirables etaient rapportes (6 OAP, 1 hemolyse, 1 poussee hypertensive). Dans 178 (33,6 %) cas, aucune justification de la transfusion n’etait notee dans le dossier. Trente-trois (6,2 %) patients n’avaient ni cardiopathie ischemique, ni signe de gravite, ni tachycardie, et avaient une hb initiale superieure a 7 g/dL. Cinq cent dix-huit patients (98,1 %) ont ete admis a l’hopital dont 438 (84,6 %) en unite d’hospitalisation de courte duree et, parmi eux, 120 (25,9 %) y sont restes moins de 24 heures. Vingt et un (4,1 %) patients sont decedes a l’hopital au decours de leur admission. Conclusion La transfusion de CG est un acte quasi quotidien dans un SU. Le seuil transfusionnel utilise aux urgences semble plutot bas et en accord avec les recommandations nationales. Une meilleure justification de l’indication de la transfusion dans le dossier medical serait souhaitable.

International audience; Background: Very little data are available concerning the prehospital emergency care of cancer patients. The objective of this study is to report the trajectories and outcomes of cancer patients attended by prehospital emergency services. Methods: This was an ancillary study from a three-day cross-sectional prospective multicenter study in France. Adult patients with cancer were included if they called the emergency medical dispatch center Service d’Aide Médicale Urgente (SAMU). The study was registered on ClinicalTrials.gov (NCT03393260, accessed on 8th January 2018). Results: During the study period, 1081 cancer patients called the SAMU. The three most frequent reasons were dyspnea (20.2%), neurological disorder (15.4%), and fatigue (13.1%). Among those patients, 949 (87.8%) were directed to the hospital, among which 802 (90.8%) were directed to an emergency department (ED) and 44 (5%) were transported directly to an intensive care unit (ICU). A mobile intensive care unit (MICU) was dispatched 213 (31.6%) times. The decision to dispatch an MICU seemed generally based on the patient’s reason for seeking emergency care and the presence of severity signs rather than on the malignancy or the patient general health status. Among the patients who were directed to the ED, 98 (16.1%) were deceased on day 30. Mortality was 15.4% for those patients directed to the ED but who were not admitted to the ICU in the next 7 days, 28.2% for those who were admitted to ICU in the next 7 days, and 56.1% for those patients transported by the MICU directly to the ICU. Conclusion: Cancer patients attending prehospital emergency care were most often directed to EDs. Patients who were directly transported to the ICU had a high mortality rate, raising the question of improving triage policies. View Full-Text

Objectives Environmental contamination by patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through respiratory droplets suggests that surfaces and equipment could be a medium of transmission. We aimed to assess the surface and equipment contamination by SARS-COV-2 of an emergency department (ED) during the coronavirus infectious disease-2019 (COVID-19) outbreak. Methods We performed multiple samples from different sites in ED patients care and non-patient care areas with sterile premoistened swabs and used real-time reverse transcriptase polymerase chain reaction (RT-PCR) to detect the presence of SARS-CoV-2 ribonucleic acid (RNA). We also sampled the personal protective equipment (PPE) from health care workers (HCWs). Results Among the 192 total samples, 10 (5.2%) were positive. In patient care areas, 5/46 (10.9%) of the surfaces directly in contact with COVID-19 patients revealed the presence of SARS-CoV-2 RNA, and 4/56 (7.1%) of the surfaces that were not directly in contact with COVID-19 patients were positive. SARS-CoV-2 RNA was present only in the patients’ examination and monitoring rooms. Before decontamination SARS-CoV-2 RNA was present on the saturation clip, the scuff for blood pressure measurement, the stretcher, the plastic screens between patients and the floor. After decontamination, SARS-CoV-2 RNA remained on the scuff, the stretcher and the trolleys. All samples from non-patient care areas or staff working rooms were negative. Only one sample from the PPE of the HCWs was positive. Conclusions Our findings suggest that surfaces and equipment contamination by SARS-CoV-2 RNA in an ED during the COVID-19 outbreak is low and concerns exclusively patients’ examination and monitoring rooms, preserving non-patient care areas.

Study objective We seek to describe the medical history and clinical findings of patients attending the emergency department (ED) with suspected coronavirus disease 2019 (COVID-19) and estimate the diagnostic accuracy of patients' characteristics for predicting COVID-19. Methods We prospectively enrolled all patients tested for severe acute respiratory syndrome coronavirus 2 by reverse-transcriptase polymerase chain reaction in our ED from March 9, 2020, to April 4, 2020. We abstracted medical history, physical examination findings, and the clinical probability of COVID-19 (low, moderate, and high) rated by emergency physicians, depending on their clinical judgment. We assessed diagnostic accuracy of these characteristics for COVID-19 by calculating positive and negative likelihood ratios. Results We included 391 patients, of whom 225 had positive test results for severe acute respiratory syndrome coronavirus 2. Reverse-transcriptase polymerase chain reaction result was more likely to be negative when the emergency physician thought that clinical probability was low, and more likely to be positive when he or she thought that it was high. Patient-reported anosmia and the presence of bilateral B lines on lung ultrasonography had the highest positive likelihood ratio for the diagnosis of COVID-19 (7.58, 95% confidence interval [CI] 2.36 to 24.36; and 7.09, 95% CI 2.77 to 18.12, respectively). The absence of a high clinical probability determined by the emergency physician and the absence of bilateral B lines on lung ultrasonography had the lowest negative likelihood ratio for the diagnosis of COVID-19 (0.33, 95% CI 0.25 to 0.43; and 0.26, 95% CI 0.15 to 0.45, respectively). Conclusion Anosmia, emergency physician estimate of high clinical probability, and bilateral B lines on lung ultrasonography increased the likelihood of identifying COVID-19 in patients presenting to the ED.

Background: We aimed to estimate the prevalence of cancer patients who presented to Emergency Departments (EDs), report their chief complaint and identify the predictors of 30-day all-cause mortality. Patients and methods: we undertook a prospective, cross-sectional study during three consecutive days in 138 EDs and performed a logistic regression to identify the predictors of 30-day mortality in hospitalized patients. Results: A total of 1380 cancer patients were included. The prevalence of cancer patients among ED patients was 2.8%. The most frequent reasons patients sought ED care were fatigue (16.6%), dyspnea (16.3%), gastro-intestinal disorders (15.1%), trauma (13.0%), fever (12.5%) and neurological disorders (12.5%). Patients were admitted to the hospital in 64.9% of cases, of which 13.4% died at day 30. Variables independently associated with a higher mortality at day 30 were male gender (Odds Ratio (OR), 1.63, 95% CI, 1.04&ndash, 2.56), fatigue (OR, 1.65, 95% CI, 1.01&ndash, 2.67), poor performance status (OR, 3.00, 95% CI, 1.87&ndash, 4.80), solid malignancy (OR, 3.05, 95% CI, 1.26&ndash, 7.40), uncontrolled malignancy (OR, 2.27, 95% CI, 1.36&ndash, 3.80), ED attendance for a neurological disorder (OR, 2.38, 4.19), high shock-index (OR, 1.80, 95% CI, 1.03&ndash, 3.13) and oxygen therapy (OR, 2.68, 95% CI, 1.68&ndash, 4.29). Conclusion: Cancer patients showed heterogeneity among their reasons for ED attendance and a high need for hospitalization and case fatality. Malignancy and general health status played a major role in the patient outcomes. This study suggests that the emergency care of cancer patients may be complex. Thus, studies to assess the impact of a dedicated oncology curriculum for ED physicians are warranted.

International audience; INTRODUCTION:The benefit of reducing the time of antibiotic initiation in the emergency department (ED) for neutropenic patients is controversial and the research on the impact of antibiotic adherence to international guidelines in the ED is scarce. We aimed to investigate the effect of antibiotic timing and appropriateness on outcomes in patients with febrile neutropenia (FN) and to assess the performance of the MASCC risk-index to risk-stratify such patients in the ED.METHODS:We prospectively identified patients with FN who presented to our ED and assessed their Multinational Association of Supportive Care in Cancer (MASCC) risk-index. The time to parenteral antibiotic initiation and the appropriateness of the antibiotic regimen according to international guidelines were retrospectively abstracted. The performance of the MASCC risk-index in predicting the absence of complication was assessed with sensitivity, specificity and the area under the receiver operating characteristics curve (AUC). We investigated the effect of the time to antibiotic initiation and the appropriateness of the antibiotic regimen on the outcome (ICU admission or death) by logistic regression analyses.RESULTS:We included 249 patients. Median age was 60 years and 67.9% had hematological malignancies, 26 (10.4%) were admitted to the ICU and 23 (9.8%) died during hospital stay. Among the 173 patients at low risk according to the MASCC risk-index, 56 (32.4%) presented at least one complication including 11 deaths. The MASCC risk-index had a sensitivity and a specificity of 0.78% and 0.43%, respectively, in predicting the absence of complication and the AUC was 0.67. The time to antibiotic initiation in the ED was not associated with the outcome after adjusting for performance status and shock-index. Conversely, an inadequate ED antibiotic regimen was associated with higher ICU admission or death during hospital stay (OR = 3.50; 95% CI = 1.49 to 8.28).CONCLUSION:An inadequate ED antibiotic regimen in patients with FN was significantly associated with higher ICU admission or death during hospital stay.

Central venous oxygen saturation (ScvO2) is easily observable in oncology patients with long-term central venous catheters (CVC), and has been studied as a prognostic factor in patients with sepsis. We sought to investigate the association between ScvO2 and early complications in cancer patients presenting to the ED. We prospectively enrolled adult cancer patients with pre-existing CVC who presented to the ED. ScvO2 was measured on their CVC. The outcome was admission to the intensive care unit (ICU) or mortality by day 7. ScvO2 was first studied as a continuous variable (%) with a ROC analysis and as a categorical variable (cut-off at 1 and a performance status > 2 (OR 4.76; 95% CI 1.81–12.52 and OR 6.23, 95% CI 2.40–16.17, respectively). This study does not support the use of ScvO2 to risk stratify cancer patients presenting to the ED.

Background Ultrasound (US) has been a regular practice in emergency departments for several decades. Thus, train our students to US is of prime interest. Because US image acquisition ability can be very different from a patient to another (depending on image quality), it seems relevant to adapt US learning curves (LCs) to patient image quality using tools based on cumulative summation (CUSUM) as the risk-adjusted LC CUSUM (RLC). Objectives The aim of this study was to monitor LC of medical students for the acquisition of abdominal emergency US views and to adapt these curves to patient image quality using RLC. Methods We asked medical students to perform abdominal US examinations with the acquisition of 11 views of interest on emergency patients after a learning session. Emergency physicians reviewed the student examinations for validation. LCs were plotted and the student was said proficient for a specific view if his LC reached a predetermined limit fixed by simulation. Results Seven students with no previous experience in US were enrolled. They performed 19 to 50 examinations of 11 views each. They achieve proficiency for a median of 9 (6-10) views. Aorta and right pleura views were validated by seven students; inferior vena cava, right kidney, and bladder by six; gallbladder and left kidney by five; portal veins and portal hilum by four; and subxyphoid and left pleura by three. The number of US examinations required to reach proficiency ranged from five to 41 depending on the student and on the type of view. LC showed that students reached proficiency with different learning speeds. Conclusions This study suggests that, when monitoring LCs for abdominal emergency US, there is some heterogeneity in the learning process depending on the student skills and the type of view. Therefore, rules based on a predetermined number of examinations to reach proficiency are not satisfactory.

Immune checkpoint inhibitors (ICIs) are of growing importance in new cancer therapies, exposing patients to various and potentially severe immune-related adverse events and placing emergency physicians on the front line when they occur. If endocrine toxicity is a well-known complication of ICIs, fulminant diabetes with diabetic ketoacidosis is exceptional. We present a case of fulminant diabetes after only two cycles of pembrolizumab in a 53-year-old man with a history of metastatic lung cancer who presented to our emergency department with coma and acidosis revealing diabetic ketoacidosis. The patient was rehydrated and treated with insulin and recovered quickly. Lung toxicity was also suspected on CT-scan findings. This rare and life-threatening complication that developed unusually early during the treatment course may be challenging in a cancer patient. Therefore, emergency physicians should investigate symptoms in patients treated with checkpoint inhibitors and consider toxicity when they present to the ED with complaints compatible with an immune-related adverse event.

IntroductionThis study protocol describes a trial designed to investigate whether antihistamine alone in patients with acute urticaria does not increase the 7-day Urticaria Activity Score (UAS7) in comparison with an association of antihistamine and glucocorticoids and reduces short-term relapses and chronic-induced urticaria.Methods and analysisThis is a prospective, double-blind, parallel-group, multicentre non-inferiority randomised controlled trial. Two-hundred and forty patients with acute urticaria admitted to emergency department will be randomised in a 1:1 ratio to receive levocetirizine or an association of levocetirizine and prednisone. Randomisation will be stratified by centre. The primary outcome will be the UAS7 at day 7. The secondary outcomes will encompass recurrence of hives and/or itch at day 7; occurrence of spontaneous hives or itch for >6 weeks; patients with angioedema at day 7, and 2, 6, 12 and 24 weeks; new emergency visits for acute urticaria recurrences at days 7 and 14, and 3 months; Dermatology Life Quality Index at days 7 and 14, and 3 and 6 months; and Chronic Urticaria Quality of Life Questionnaire at 6 weeks.Ethics and disseminationThe protocol has been approved by the Comité de Protection des PersonnesSud-Méditerranée II and will be carried out in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. A steering committee will oversee the progress of the study. Findings will be disseminated through national and international scientific conferences and publication in peer-reviewed journals.Trial registration numberNCT03545464

Background: The updated French guidelines for the management of antimicrobial therapy and site-of-care for adults’ community-acquired pneumonia (CAP) were published in July, 2010, stratifying patients in 6 groups depending on age, significant underlying disorders and organ failure. Objectives: We conducted the first national audit of adherence to the latest CAP guidelines. Methods: A web-based audit tool was developed as part of the guidelines. French Emergency Departments (EDs) were invited to participate in the audit capturing data on adults visiting EDs with suspected CAP within the study period(15th October-15th December, 2010). Results: A total of 3.166 cases were provided from 72 EDs. Median age was 75 years (range 15-106 years), 55% were male. CRB65 score was 0 in 22.9 %, 1-2 in 67.8%, and 3-4 in 9.2%; 2630 (83.5%) patients were admitted after ED visit including 335 (12.7%) in intensive care units. Median delay to first antibiotics was 3h45min. Initial empirical antimicrobial treatment was in accordance with French CAP guidelines in 895 (28.3 %) patients. However, adherence widely varied (0%-66.9%) in the patient groups. Of note, 354 (11.2%) did not receive any antibiotics and antimicrobial agents were not in adherence with guidelines in 1917 (60.5%) patients. Conclusions: Management of CAP often differs from guidelines in French emergency departments. This result questions whether emergency physicians are aware of the recommendations or whether recommendations are adequate for emergency CAP patients. Keywords: Audit; Antimicrobial agent; Emergency department; Community-Acquired pneumonia; Site of care

Friday, Nov 13, 2015. It's 2130 h when the Assistance Publique-Hopitaux de Paris (APHP) is alerted to the explosions that have just occurred at the Stade de France, a stadium in Saint-Denis just outside Paris. Within 20 min, there are shootings at four sites and three bloody explosions in the capital. At 2140 h, a massacre takes place and hundreds of people are held hostage for 3 h in Bataclan concert hall. The emergency medical services (service d'aide medicale d'urgence, SAMU) are immediately mobilised and the crisis cell at the APHP is opened. The APHP crisis unit is able to coordinate 40 hospitals, the biggest entity in Europe with a total of 100 000 health professionals, a capacity of 22 000 beds, and 200 operating rooms. It is very quickly confirmed that the attacks are multiple and that the situation is highly scalable and progressing dangerously. These facts led to a first decision: the activation of the “White Plan” (by the APHP Director General) at 2234 h—mobilising all hospitals, recalling staff, and releasing beds to cope with a large influx of wounded people. The concept of the White Plan was developed 20 years ago, but this is the first time that the plan has been activated. It is a big decision, and timing is key: it would lose its effectiveness if taken too late. On the night of Friday Nov 13 to Saturday Nov 14, the activation of the White Plan had a critical effect. At no time during the emergency was there a shortage of personnel. During these hours, as the number of victims increased, with a sharp increase after the assault was launched inside the Bataclan, we were able to reassure the public and government that our abilities matched the demand. And when we felt that it might be necessary to deal with an influx of severely injured people, two further “reservoir” capacities were prepared: other hospitals in the area were put on alert, together with some university hospitals, more distant from Paris, but with the ability to mobilise ten helicopters to organise the transport of the wounded... Language: en

Introduction Le dossier pharmaceutique (DP), mis en place en 2007, est un dossier electronique present sur la carte vitale, recensant, pour chaque beneficiaire de l’assurance maladie qui le souhaite, tous les medicaments delivres au cours des 4 derniers mois. D’abord reserve aux pharmaciens d’officine, son utilisation a ete etendue aux medecins et pharmaciens exercant dans les etablissements de sante. Afin de connaitre l’interet potentiel de la consultation du DP, nous avons voulu evaluer la place du DP parmi les autres sources disponibles sur les traitements medicamenteux a l’accueil de patients consultant dans un service d’urgences. Materiels et methode Etude prospective monocentrique realisee sur 3 mois, d’octobre a decembre 2016 a l’accueil du service des urgences de l’hopital Saint-Louis (AP–HP). Critere principal : pourcentage de presence d’un DP accessible et renseigne a l’accueil des urgences parmi d’autres sources comme une ordonnance ou un courrier medical precisant les traitements, ou un dossier informatise disponible a l’hopital (compte rendu d’hospitalisation [CRH]) avec traitement cite datant de moins d’1 an. Criteres secondaires : pourcentage de DP renseigne comme seule source d’information disponible et pourcentage de medicaments consideres comme a risque (anticoagulant/antiagregant plaquettaire, antibiotiques, antidiabetique) presents dans le DP lorsqu’il represente la seule source disponible. Resultats et discussion Sur les 260 patients inclus, 80 % d’entre eux avaient une carte vitale dont 63,5 % avec un DP renseigne. Une ordonnance/courrier ou un CRH informatif etaient disponibles dans 27 % des cas chacun. Dans 96 cas (37 %), il n’existait qu’une seule source disponible. Cette source unique etait le DP dans 72 % des cas, le CRH dans 16 % des cas et une ordonnance/courrier dans 12 % des cas. Quand le DP est la seule source disponible, 49 % d’entre eux contient au moins un medicament considere a risque (26 patients avaient un antibiotique, 6 un antidiabetique et 9 un anticoagulant/antiagregant plaquettaire). Conclusion Dans cette etude, le DP est la source documentaire de traitements medicamenteux la plus frequemment accessible a l’accueil des patients aux urgences et parfois la seule source documentaire accessible. La consultation du DP nous semble utile dans le cadre de la conciliation medicamenteuse dans un contexte d’urgence ou le patient peut-etre ininterrogeable. Des travaux complementaires sont necessaires pour evaluer l’impact du DP sur la prise en charge medicale des patients.

International audience; BackgroundThe impact of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (ESBL-EC) bacteraemia on outcome remains controversial.MethodsA retrospective analysis of the prevalence, risk factors, clinical features, and outcomes of all ESBL-EC bacteraemia in one French hospital over a 5-year period was performed. A case–control study was undertaken: cases had at least one ESBL-EC bacteraemia and controls a positive non-ESBL-EC bacteraemia.ResultsThe prevalence of ESBL-EC bacteraemia increased from 5.2% of all positive E. coli blood cultures in 2005 to 13.5% in 2009 (p < 0.003). CTX-M represented 70% of ESBL-EC bacteraemia strains, and strains were not clonally related. On adjusted analysis, the only significant risk factor for ESBL-EC bacteraemia was a previous ESBL-EC colonization (odds ratio 11.3, 95% confidence interval 1.2–107; p = 0.003). Initial antimicrobial therapy was less frequently adequate in the ESBL-EC group (48% vs. 85%; p = 0.003). The presence of ESBL-EC bacteraemia was not associated with a longer hospital stay (p = 0.088). Day 30 mortality was high, but not significantly different in the two groups (30% vs. 27%; p = 0. 82).ConclusionThe prevalence of ESBL-EC bacteraemia has been increasing dramatically. Previous colonization with ESBL-EC was a strong risk factor for ESBL-EC bacteraemia. More inadequate initial antimicrobial therapy was noted in the ESBL-EC group, but mortality and length of hospital stay were not significantly different from those of patients with non-ESBL-EC bacteraemia.

We compared the semiquantitative measurement of acetoacetate using urinary dipsticks with the bedside quantitative fingerprick measurement of the principal ketone bodies 3-beta-hydroxybutyrate, for the diagnosis of ketoacidosis.This is a one year retrospective study of patients who presented with hyperglycemia levels of 250 mg/l or greater in the Emergency Department setting. We compared the sensitivity, specificity, and predictive value of ketonuria and ketonemia for the diagnosis of ketoacidosis (urine or blood ketone bodies, blood bicarbonates20 mmol/l, anion gap16 meq/l) in a sample of patients for whom the levels of ketone bodies in the blood and urine as well as serum electrolytes were available.We studied 355 hyperglycemic patients. The median time between arrival and dipstick testing was 21 min, and was greater than 2 h in more than 10% of cases. Comparison between ketonuria and ketonemia was performed in 173 patients (6% with diabetic ketoacidosis). Ketonuria equal to or less than one cross or a 3-beta-hydroxybutyrate value lower than 3 mmol/l enabled ketoacidosis to be excluded (negative predictive value 100%). At two-cross cutoff points for ketonuria and at the 3 mmol/l cutoff point for ketonemia, the two tests had the same sensitivity (100%), but the specificity of 3-beta-hydroxybutyrate (94%) was significantly higher (P0.0001) than that of ketonuria (77%). The best positive predictive value for ketonemia was obtained at the 5 mmol/l cutoff point (100%) and for ketonuria at the three-cross cutoff point (26%). At the three-cross cutoff point for ketonuria and at the 5 mmol/l cutoff point for ketonemia, the two tests had the same negative likelihood ratio (0.1), but the positive likelihood ratio of 3-beta-hydroxybutyrate (infinite) was higher than that of ketonuria.The measurement of 3-beta-hydroxybutyrate in capillary blood is faster and more effective than the use of dipsticks in the urine to detect ketoacidosis in the Emergency Department setting.

Les marqueurs cardiaques sont des enzymes, des proteines ou des peptides qui sont presents dans le tissu cardiaque et liberes dans la circulation sanguine lors d’une pathologie cardiaque. Leur dosage dans le sang en urgence a un interet diagnostique et/ou pronostique variable selon leur specificite et leur pharmacocinetique.

Introduction L’utilisation du dossier pharmaceutique (DP), cree et deploye en officine depuis 2007, est en experimentation nationale pilotee par le Conseil national de l’Ordre des pharmaciens et la direction generale de l’Offre de soins depuis 2013 dans des services d’anesthesie, de geriatrie et des urgences des hopitaux volontaires. Le service des urgences de notre etablissement participe a cette experimentation. Apres une phase de travail d’amelioration d’accessibilite au logiciel de consultation du DP, puis du positionnement du DP parmi les sources documentaires medicamenteuses pour des patients admis dans l’unite d’hospitalisation des urgences, une etude a ete realisee a l’accueil des urgences. Materiels et methode Enquete prospective menee par un externe en pharmacie entre le 1er avril et le 30 juin 2015 aupres de tous les entrants entre 9 h et 12 h 30, du lundi au vendredi. L’evaluation a porte sur : l’accessibilite du DP via la carte vitale necessaire a la connexion, l’accord du patient pour sa consultation, la presence effective du DP a l’aide du logiciel « Fast.Dossier-Pharmaceutique.fr », la connaissance des patients (pts) de leur DP et le temps necessaire a la consultation. Resultats et discussion Sept cents patients ont ete interroges : 433 (62 %) avaient leur carte vitale ; 426 patients (61 %) ont donne leur accord pour consultation des donnees de la carte vitale, 265 (61 %) avaient un DP ouvert dont 247 (93 %) etaient renseignes. Seuls 47/265 patients (18 %) avaient ete informes de l’ouverture dans une officine de leur propre DP. Le temps median de consultation du DP a ete de 1,7 min. Cette etude met en evidence une meconnaissance generale des patients vis-a-vis du DP et notamment de l’ouverture de celui-ci. Il n’est pas exclu qu’un certain nombre de patients se disant non informes l’aient effectivement ete, puis ont oublie, neanmoins, cela souleve un probleme ethique. A noter, que lorsqu’un DP est ouvert, il est quasi-constamment renseigne. Notre etude n’a pas porte sur l’exhaustivite des donnees contenues dans le DP. Un temps de consultation de moins de 2 min nous parait compatible avec une consultation quasi-systematique du DP et un externe en pharmacie dedie le permet avec la limite d’une presence a mi-temps. Conclusion Ce travail qui a permis d’assurer une information sur le DP sera complete par une analyse de la connaissance des patients de leur(s) traitement(s). Parallelement, l’apport du DP en tant que source d’information a l’admission aux urgences sera examine, dans l’optique d’une optimisation de la prise en charge des patients.

The FRench Emergency Nurses Classification in Hospital scale (FRENCH) is the first French triage tool for patients visiting an emergency department. The FRENCH scale modified in 2006, based on about 100 determinants (complaints, signs, and vital parameters), allows the triage of adult patients according to five increasing levels of complexity/severity. We evaluated FRENCH version 2 (v.2) in our emergency department.Reliability was evaluated on 300 prospectively selected patient records (50% of patients admitted). Three nurse pairs, blinded with respect to the original triage, retrospectively and independently triaged 100 patients. Interrater reliability within the pairs was measured with a weighted kappa. Validity was evaluated on all triaged patients (N=941) over 14 days by studying the relationships between the original triage category assigned by the triage nurse and resource consumption and the admission rate.Interrater reliability was good [K=0.77 (95% confidence interval: 0.71-0.82)]. Distribution of the 941 patients included in the validation study (18% of whom were admitted) was as follows [n (%)]: 2 (0.2), 33 (4), 258 (27), 451 (48), and 197 (21) for a triage from 1 to 5, respectively. Resource consumption correlated well with case severity as assessed by the triage category (R=-0.643, P0.0001). Finally, the area under the receiver operating characteristic curve for prediction of admission as a function of triage was 0.858 (95% confidence interval: 0.831-0.885).FRENCH v.2 is a reliable and validated triage tool to predict the complexity/severity of a patient in our emergency department.

Aims To facilitate the transition from urine ketones (acetoacetate) to capillary blood ketones (3-beta-hydroxybutyrate), we studied the correlation between these two tests. Methods Retrospective study of all patients with blood glucose greater than or equal to 2.5 g/l on arrival in the Emergency Department. We studied the correlation between urine ketones (Clinitek 50, Bayer) and capillary blood ketones (Optium, Abbott). We then compared the relative risks (RR) of ketoacidosis and hospitalization associated with each of these tests. Results In 33 months, 529 adult patients with both urine and blood testing for ketones were enrolled (ketoacidosis 8%, admission rate 49%). Urine ketones scored as +, ++ and +++ corresponded to median capillary blood ketone levels of 0.5 mmol/l (IQR: 0.1–0.9), 0.7 mmol/l (IQR: 0.2–1.8) and 3 mmol/l (IQR: 1.4–5.2), respectively. RRs of ketoacidosis or hospitalization associated with blood ketones greater than or equal to 3 mmol/l were higher than those associated with +++ urine ketones: 74 (95% confidence interval [CI]: 48–88) and 2.9 (95% CI: 2.5–3) versus 31 (95% CI: 18–45) and 2 (95% CI: 1.7–2.1), respectively. Conclusions In hyperglycaemic patients in the Emergency Department, a good correlation was observed between urine ketones and capillary blood ketones for low values, but a poor correlation was observed for high values. Either test can therefore be used to exclude ketosis, but the capillary blood ketones test is more accurate to confirm ketoacidosis.