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

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

Céphalées aux urgences (un symptôme somatique et psychogène)

AIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Comparatif du coût moyen dans la prise en charge d'un patient aux urgences et par SOS médecins au travers de deux pathologies

AIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Contribution de l'étude du mélange hélium-oxygène à la prise en charge des patients atteints de broncho-pneumopathie chronique obstructive

Objectifs : 1ʿ) Etudier sur banc d'essai le comportement de sondes endotrachéales lors de l'utilisation de mélanges hélium-oxygène (absence d'effet seuil, régimes d'écoulement des fluides) (sept sondes, neuf mélanges, dix débits différents) ; 2ʿ) Etudier l'impact de mélanges hélium-oxygène sur des sujets BPCO soumis à une ventilation mécanique contrôlée à débit constant (absence d'effet seuil, évolution des constantes ventilatoires) ; 3ʿ) Etudier l'impact de mélanges hélium-oxygène sur le pronostic de sujets BPCO en hypoventilation aiguë d'origine obstructive (81 sujets). Résultats : 1ʿ) Les résistances à l'écoulement et les pressions diminuent significativement dès l'introduction d'hélium dans le mélange gazeux. Cette diminution se majore conjointement au pourcentage d'hélium dans le mélange. L'équation de Rohrer n'est pas adaptée à l'étude des écoulements lors de la convection respiratoire, ceux étant principalement en régime turbulent lisse ; 2ʿ) Les pressions, les résistances et le travail respiratoire diminuent significativement dès l'introduction d'hélium dans le mélange gazeux inspiré. Cette diminution se majore conjointement à l'augmentation de la fraction inspiratoire d'hélium. Cette diminution varie en fonction du degré d'obstruction bronchique de chaque sujet ; 3ʿ) L'utilisation de mélanges hélium-oxygène lors de la prise en charge des exacerbations de BPCO avec hypoventilation aiguë permet de diminuer significativement le recours à l'intubation, le taux de mortalité et les durées de séjour à l'hôpital ou en unité de soins intensifs. Conclusions : L'impact des mélanges hélium-oxygène sur les sondes endotrachéales et les constantes ventilatoires de sujets BPCO est proportionnel à son pourcentage dans le mélange, au débit, et inversement proportionnel au degré d'obstruction existant. L'équation de Rohrer est inadaptée à l'étude des mécanismes convectifs chez l'être humain. L'utilisation de mélanges hélium-oxygène dans le traitement des obstructions respiratoires aiguës avec hypoventilation permet d'en améliorer le pronosticObjectives: 1ʿ) To study, under laboratory conditions, the effects of helium-oxygen mixtures on endo-tracheal tubes (absence of threshold, flow regimen) (seven endotracheal tubes, nine gaseous mixtures, ten flows) ; 2ʿ) To study, under clinical conditions, the effects of helium-oxygen mixtures on COPD patients undergoing mechanical ventilation (no threshold, evolution of respiratory constants) ; 3ʿ) To study, under clinical conditions, the effect of helium-oxygen mixtures on prognosis of severe acute exacerbation of COPD (acute hypoventilation) (eighty-one patients). Results: 1ʿ) Resistances and pressures decrease as soon as helium is present in the gaseous mixture. The more helium is present, the more diminution is important. The Rohrer formula is useless while studying respiratory convection. In endotracheal tubes, flow are mainly smooth and turbulent. 2ʿ) Pressures, resistances and respiratory work decrease as soon as helium is present in the gaseous mixture. The more helium is present, the more diminution is important. The more obstruction is present, the more diminution is important. 3ʿ) Using helium-oxygen mixtures in patients with severe acute exacerbation of COPD allows a significant decrease in intubation, mortality rate, intensive care unit stay and in-hospital stay. Conclusions: The effect of helium-oxygen mixtures on endotracheal tubes and COPD patients undergoing mechanical ventilation is dependant on helium percentage, flow, and obstruction degree. Rohrer formula is ineffective while studying respiratory convection. Use of helium-oxygen mixtures seems to improve prognosis in patients with severe acute exacerbation of COPDAIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF

Dosage de la protéine-C-Réactive aux urgences (quel intérêt ?)

AIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Tentative d'application des recommandations de la 10ème conférence de consensus sur la prise en charge de la personne âgée de plus de 75 ans aux urgences de l'hôpital de la Conception à Marseille

AIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Le devenir des patients non hospitalisés présentant des douleurs abdominales après leur passage aux urgences

La douleur abdominale non traumatique est un enjeu majeur de l urgence. Elle représente un motif de consultation très fréquent et la décision d hospitaliser le patient ou non est délicate dans les nombreux cas atypiques. Des consensus et recommandations de bonne pratique clinique aident le praticien dans sa démarche. Le but de notre travail est d analyser les conséquences du retour à domicile d un patient se présentant aux urgences pour douleur abdominale non traumatique comme plainte principale. Nous avons recontacté les patients qui étaient rentrés à domicile à la sortie de leur prise en charge aux urgences, à distance de leur admission. Il apparaît que les erreurs médicales, représentées par une hospitalisation précoce après la sortie, sont rares (2%). De plus, les consensus et recommandations de bonne pratique clinique ne sont que rarement pris en défaut (1%). L étude souligne également que 42% des patients non hospitalisés sont encore symptomatiques à distanceAIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF