Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France

<p>Abstract</p> <p>Background</p> <p>For several decades, emergency departments (EDs) utilization has increased, inducing ED overcrowding in many countries. This phenomenon is related partly to an excessive number of nonurgent patients. To resolve ED overcrowding and to decrease nonurgent visits, the most common solution has been to triage the ED patients to identify potentially nonurgent patients, i.e. which could have been dealt with by general practitioner. The objective of this study was to measure agreement among ED health professionals on the urgency of an ED visit, and to determine if the level of agreement is consistent among different sub-groups based on following explicit criteria: age, medical status, type of referral to the ED, investigations performed in the ED, and the discharge from the ED.</p> <p>Methods</p> <p>We conducted a multicentric cross-sectional study to compare agreement between nurses and physicians on categorization of ED visits into urgent or nonurgent. Subgroups stratified by criteria characterizing the ED visit were analyzed in relation to the outcome of the visit.</p> <p>Results</p> <p>Of 1,928 ED patients, 350 were excluded because data were lacking. The overall nurse-physician agreement on categorization was moderate (kappa = 0.43). The levels of agreement within all subgroups were variable and low. The highest agreement concerned three subgroups of complaints: cranial injury (kappa = 0.61), gynaecological (kappa = 0.66) and toxicology complaints (kappa = 1.00). The lowest agreement concerned two subgroups: urinary-nephrology (kappa = 0.09) and hospitalization (kappa = 0.20). When categorization of ED visits into urgent or nonurgent cases was compared to hospitalization, ED physicians had higher sensitivity and specificity than nurses (respectively 94.9% versus 89.5%, and 43.1% versus 30.9%).</p> <p>Conclusions</p> <p>The lack of physician-nurse agreement and the inability to predict hospitalization have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues. Managed care organizations should be cautious when applying such criteria to restrict access to EDs.</p

Comparison of the Airtraq® and Truview® laryngoscopes to the Macintosh laryngoscope for use by Advanced Paramedics in easy and simulated difficult intubation in manikins

<p>Abstract</p> <p>Background</p> <p>Paramedics are frequently required to perform tracheal intubation, a potentially life-saving manoeuvre in severely ill patients, in the prehospital setting. However, direct laryngoscopy is often more difficult in this environment, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Airtraq^®and Truview^®laryngoscopes may reduce this risk.</p> <p>Methods</p> <p>We compared the efficacy of these devices to the Macintosh laryngoscope when used by 21 Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Airtraq^®and Truview^®laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan^®manikin.</p> <p>Results</p> <p>The Airtraq^®reduced the number of optimization manoeuvres and reduced the potential for dental trauma when compared to the Macintosh, in both the normal and simulated difficult intubation scenarios. In contrast, the Truview^®increased the duration of intubation attempts, and required a greater number of optimization manoeuvres, compared to both the Macintosh and Airtraq^®devices.</p> <p>Conclusion</p> <p>The Airtraq^®laryngoscope performed more favourably than the Macintosh and Truview^®devices when used by Paramedics in this manikin study. Further studies are required to extend these findings to the clinical setting.</p

Comparison of the Airtraq® and Truview® laryngoscopes to the Macintosh laryngoscope for use by Advanced Paramedics in easy and simulated difficult intubation in manikins

<p>Abstract</p> <p>Background</p> <p>Paramedics are frequently required to perform tracheal intubation, a potentially life-saving manoeuvre in severely ill patients, in the prehospital setting. However, direct laryngoscopy is often more difficult in this environment, and failed tracheal intubation constitutes an important cause of morbidity. Novel indirect laryngoscopes, such as the Airtraq^®and Truview^®laryngoscopes may reduce this risk.</p> <p>Methods</p> <p>We compared the efficacy of these devices to the Macintosh laryngoscope when used by 21 Paramedics proficient in direct laryngoscopy, in a randomized, controlled, manikin study. Following brief didactic instruction with the Airtraq^®and Truview^®laryngoscopes, each participant took turns performing laryngoscopy and intubation with each device, in an easy intubation scenario and following placement of a hard cervical collar, in a SimMan^®manikin.</p> <p>Results</p> <p>The Airtraq^®reduced the number of optimization manoeuvres and reduced the potential for dental trauma when compared to the Macintosh, in both the normal and simulated difficult intubation scenarios. In contrast, the Truview^®increased the duration of intubation attempts, and required a greater number of optimization manoeuvres, compared to both the Macintosh and Airtraq^®devices.</p> <p>Conclusion</p> <p>The Airtraq^®laryngoscope performed more favourably than the Macintosh and Truview^®devices when used by Paramedics in this manikin study. Further studies are required to extend these findings to the clinical setting.</p

Nonurgent patients in the emergency department? A French formula to prevent misuse

<p>Abstract</p> <p>Background</p> <p>Overcrowding in emergency department (EDs) is partly due to the use of EDs by nonurgent patients. In France, the authorities responded to the problem by creating primary care units (PCUs): alternative structures located near hospitals. The aims of the study were to assess the willingness of nonurgent patients to be reoriented to a PCU and to collect the reasons that prompted them to accept or refuse.</p> <p>Methods</p> <p>We carried out a cross sectional survey on patients' use of EDs. The study was conducted in a French hospital ED. Patients were interviewed about their use of health services, ED visits, referrals, activities of daily living, and insurance coverage status. Patients' medical data were also collected.</p> <p>Results</p> <p>85 patients considered nonurgent by a triage nurse were asked to respond to a questionnaire. Sex ratio was 1.4; mean age was 36.3 +/- 11.7 years.</p> <p>Most patients went to the ED autonomously (76%); one third (31.8%) had consulted a physician. The main reasons for using the ED were difficulty to get an appointment with a general practitioner (22.3%), feelings of pain (68.5%), and the availability of medical services in the ED, like imaging, laboratory tests, and drug prescriptions (37.6%). Traumatisms and wounds were the main medical reasons for going to the ED (43.5%).</p> <p>More than two-thirds of responders (68%) were willing to be reoriented towards PCUs. In the multivariate analysis, only employment and the level of urgency perceived by the patient were associated with the willingness to accept reorientation. Employed persons were 4.5 times more likely to accept reorientation (OR = 4.5 CI (1.6-12.9)). Inversely, persons who perceived a high level of urgency were the least likely to accept reorientation (OR = 0.9 CI (0.8-0.9).</p> <p>Conclusions</p> <p>Our study provides information on the willingness of ED patients to accept reorientation and shows the limits of its feasibility. Alternative structures such as PCUs near the ED seem to respond appropriately to the growing demands of nonurgent patients. Reorientation, however, will be successful only if the new structures adapt their opening hours to the needs of nonurgent patients and if their physicians can perform specific technical skills.</p

Aquatic plant decline in Lake Ellesmere : a case for macrophyte management in a shallow New Zealand lake : a case for macrophyte management in a shallow New Zealand lake : a thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Philosophy in the University of Canterbury [Lincoln College]

The biology and ecology of aquatic Ellesmere, a shallow coastal lake submerged plants were studied in Lake in the South Island of New Zealand. The aim of the study was to understand previous declines of macrophytes in the lake as well as their non-regeneration after a major disturbance event. Such an understanding was assumed to play a central role in the overall management of the lake. Declines of aquatic plants were first reviewed world wide to identify potential sources of perturbation or stress for macrophyte communities. In Lake Ellesmere, wave action, grazing, sediment accretion, water level fluctuations, inorganic and organic turbidity, and salinity were identified as having a potential negative effect on plant growth. The effects of salinity and light on the growth of Ruppia megacarpa and Ruppia polycarpa seedlings were investigated in glasshouse experiments. Both factors were shown to affect growth. Poor light reduced rhizome elongation which may prevent the anchoring of seedlings that are continuously exposed to a turbid and turbulent environment. Growth was also found to be reduced under salinities above 10 PPT. Such salinities occur in the field after prolonged lake openings. A study of the underwater lake environment showed that inorganic suspensoids were mainly responsible for the high turbidity of the lake. About 40% of the reduction in light penetration in the water column was due to shading by phytoplankton. Levels of inorganic suspensoids were highly correlated to wind velocity. Relationships between clarity determinants and optical properties were also established. Their potential use for future management is evaluated. Standing crops of the main species were obtained from two areas in the lake in the summers of 1985-1986 and 1986-1987 during a sudden period of macrophyte regeneration. This allowed the potential for aquatic plant reestablishment to be assessed. Recent developments in ecological theory and plant population biology were used in this assessment and proved to be very valuable. Measures that could favour re-establishment are presented and their integration in future especially in regard lake management is discussed. A new strategy, to lake level fluctuations, was found desirable. Experimental management, where any alternative measure is in the nature of an experiment rather than being a programme with predetermined results, is finally suggested as a very appropriate approach to macrophyte management that may reduce uncertainty in the future management of shallow lakes

Validity of the Université de Montréal Track Test to assess the velocity associated with peak oxygen uptake for adolescents.

International audienceThe purpose of the study was to test the ability to determine the velocity associated with peak oxygen uptake for adolescents by means of a simple field test, the Université de Montréal Track Test (UMTT). Fifteen adolescents, 13.4 +/- 1.0 years, performed two maximal field tests where oxygen uptake and heart rate were continuously monitored. The first test (graded field test, first stage 8 km.h-1, increment 1.5 km.h-1, duration 3 min) allowed the subjects to reach a steady-state oxygen uptake. Then, the velocity associated with peak oxygen uptake was calculated from the ratio between peak oxygen uptake above resting level to energy cost of running. The calculated velocity was kept as the criterion velocity. For the second test (UMTT, first stage 8 km.h-1; increment 1 km.h-1; duration 2 min), the velocity measured at the last completed stage was retained. The measured peak oxygen uptake for the graded field test (51.8 +/- 6.5 ml.kg-1.min-1) and for the UMTT (51.0 +/- 7.9 ml.kg-1.min-1) were not significantly different. The calculated velocity (12.9 +/- 1.0 km.h-1) and the measured velocity (12.7 +/- 0.9 km.h-1) were not significantly different and were significantly correlated (r = 0.80, p < 0.001). It was concluded that, for adolescents, the velocity measured at the last completed stage of the UMTT allows a valid estimation of the velocity associated with peak oxygen uptake