Abstract Background Pain and anxiety are common in emergency department (ED) patients, yet their management is often focused on pharmacological interventions. Art therapy, a non-pharmacological approach, has shown promise in alleviating psychological distress, but its effectiveness in acute care settings remains understudied. Methods This study aimed to evaluate the impact of art therapy on pain and anxiety in ED patients presenting with acute pain. A randomized controlled trial was conducted in a single ED with patients randomized to art therapy or a control group. Participants in the intervention group engaged in a 15–20-minutes art therapy session, while the control group waited without intervention. Pain and anxiety were measured using the Visual Analog Scale (VAS) and the State-Trait Anxiety Inventory (STAI-Y) at baseline and after the intervention. Exploratory analyses examined interactions between morphine use, baseline pain, and art therapy effectiveness. Results Of the 340 patients screened, 103 completed the study (48 in the AT group, 55 in the control group). There were no significant differences in anxiety levels between the art therapy and control groups (mean difference − 2 mm, p = 0.610). Pain intensity was significantly lower in the control group (p = 0.011). In exploratory analyses, patients treated with morphine and experiencing high baseline pain levels had a significant reduction in anxiety (VAS − 18.6 mm, p = 0.004). Conclusion Art therapy did not significantly reduce anxiety or pain in the general ED population. However, it showed potential as an adjunctive therapy for patients with severe pain and anxiety, particularly those receiving morphine. Further research is needed to explore the effectiveness of art therapy in this subset of patients and its potential as part of non-pharmacological pain management strategies in acute care settings. Trial registration The study was approved by the regional ethic committee (CERVD 2021 − 01344) and registered on https://clinicaltrials.gov (NCT04997434) on 19 July 2021.

Background: Nurse-initiated pain protocols (NIPPs) at emergency department (ED) triage remain underused. This study investigated factors associated with patient refusal and nurse use of NIPP, accounting for triage operational context. Methods: This retrospective observational study combined prospectively collected nurse characteristics with retrospective data on NIPP use over 15 months in a tertiary university hospital ED. Outcomes included rates of NIPP refusal and use, documented reasons for refusal, and associations with patient characteristics, nurse characteristics, crowding, and operational pressure. Results: Sixty-three triage nurses managed 16,137 adult patients; 6.2% refused the NIPP. Among consenting patients, NIPP was used in one-third of encounters. Multi-level logistic regression revealed significant variation between nurses in both refusal and use. Refusal was more likely in patients with lower acuity and among nurses trained in Europe or concerned about prescribing responsibility, but less frequent with severe pain or longer triage duration. NIPP use was more frequent with lower acuity, higher pain intensity, longer triage duration, crowding, and among nurses with European training, but decreased in older patients and those arriving by ambulance. Conclusions: NIPP refusal and use at triage were both low, with marked variability between nurses. Patient characteristics and triage operational factors were most strongly associated with outcomes, while nurse-related factors contributed less. These findings support prospective implementation studies to clarify drivers of practice variation and optimize analgesia delivery at triage.

Background and importanceThe high prevalence of acute pain in the emergency department (ED) underscores the need for accurate pain assessment to guide effective interventions. A pain assessment tool for ED patients with acute pain should enable clinicians to distinguish those who require analgesia from those who do not. However, a universally accepted definition of the 'need for analgesia' is lacking.ObjectiveTo identify predictors of the need for analgesia in ED patients through a consensus-based interdisciplinary approach.Design/setting and participantsA three-stage modified Delphi was conducted. In stage 1, 63 international panel members, including clinicians, researchers, patients, and patient representatives from 15 countries, answered three open-ended questions to generate candidate predictor variables. In stage 2, the same participants rated these variables using a five-point Likert scale. In stage 3, randomly selected clinicians and patients were recruited internationally to complete a survey rating the consensus-derived variables.Outcome measures and analysisThe primary outcome was the identification of variables defining the need for analgesia in ED patients without communication or cognitive impairments. Consensus was defined a priori as more than or equal to 80% of participants selecting 'agree' or 'strongly agree' after stage 2. Variables meeting this threshold were considered in the final consensus-derived items. Stage 3 aimed to evaluate agreement with these variables among a broader panel of frontline clinicians and patients, to assess alignment with the expert panel, primarily composed of researchers, while also addressing potential geographic and professional biases.ResultsStage 1 generated 20 potential clinical predictor variables to define the need for analgesia. In stage 2, the six consensus-derived variables were: (a) patient's perception of pain, (b) patient's desire for analgesia, (c) pain tolerance, (d) patient observation, (e) caregiver/relative's perception of the patient's pain, and (f) provider's perception of the patient's pain. In stage 3, the rating of these variables reached combined agreement ('agree' or 'strongly agree') ranging from 72% to 91%.ConclusionThe six consensus-derived variables provide a foundation for a multidimensional, patient-centered pain assessment framework, which will serve as the basis for developing and validating a new tool to improve analgesia for ED patients with acute pain.

BACKGROUND:Guidelines recommend therapeutic anticoagulation for select patients with suspected pulmonary embolism (PE) while awaiting confirmatory imaging. International practice regarding preemptive anticoagulation in the emergency department (ED) is not well understood. We aimed to describe emergency physician use of preemptive anticoagulation in patients with suspected PE and identify characteristics associated with its use. METHODS:We conducted an international survey of emergency physicians. The survey was distributed between November 2024 and May 2025. Physicians were asked about use of preemptive anticoagulation, factors associated with use, knowledge of international guidelines, and availability of local protocols. A clinical vignette examined decision making surrounding initiation of preemptive anticoagulation. Multivariable logistic regression models were used to examine factors associated with (1) sometimes/always using preemptive anticoagulation and (2) with use in the vignette. RESULTS:There were 413 responses (27.6% response rate) from 13 countries. Among respondents, 23.1% reported never providing preemptive anticoagulation, 73.9% reported sometimes using it, and 2.9% reported always using it. Over two-thirds of respondents were unaware of recommendations for using preemptive anticoagulation and half reported their institution did not have protocols for preemptive anticoagulation. In multivariable regression, more clinical experience (OR: 1.81, 95% CI: 1.38-2.38), higher self-rated knowledge about PE (OR: 2.05, 95% CI: 1.03-4.06), and more concern for cardiovascular deterioration (OR: 3.21, 95% CI: 1.88-5.49) were positively associated with sometimes/always using preemptive anticoagulation. More concern for bleeding was associated with a lower odds of sometimes or always using preemptive anticoagulation. In the vignette, respondents with institutional protocols for preemptive anticoagulation had higher odds of starting preemptive anticoagulation and those with more concern for bleeding had lower odds of starting it. CONCLUSION:Use of preemptive anticoagulation for patients with suspected PE was low. Most physicians were unaware of guidelines supporting its use and do not have institutional protocols to guide use of preemptive anticoagulation. Implementation and use of institutional protocols may increase guideline-directed preemptive anticoagulation in select patients.

Importance Although the YEARS algorithm is a safe and efficient way to rule out acute pulmonary embolism (PE), robust evidence on its accuracy in patients with cancer is lacking, and current guidelines suggest proceeding directly to computed tomographic pulmonary angiography (CTPA). Objective To compare the safety and efficiency of the YEARS algorithm with CTPA only to rule out acute PE in patients with active cancer. Design, Setting, and Participants The Hydra study was an open-label, randomized, investigator-initiated, noninferiority trial with blinded central outcome adjudication conducted from August 22, 2019, to August 21, 2025, the date of final follow-up. Patients with active cancer and suspected acute PE were recruited from emergency departments or medical units in 21 hospitals in the Netherlands, Italy, Switzerland, Belgium, France, and Spain. Interventions Patients were randomly assigned in a 1:1 ratio to receive diagnostic management by the YEARS algorithm (n = 352)—consisting of assessing YEARS items, D-dimer levels, and performing risk-dependent CTPA—or by CTPA only (n = 346). Main Outcomes and Measures The primary outcome was centrally adjudicated symptomatic venous thromboembolism or (possible) PE-related death within 90 days after ruling out PE at baseline, assessed in a per-protocol noninferiority analysis with a 2.6% margin for the upper bound of a 1-sided 99.9% CI. The key secondary outcome was the proportion of negative CTPA results at baseline, assessed in a superiority analysis. Results A total of 698 patients were randomized (median age, 65 years [IQR, 56-72 years], 422 female [60%]), and 104 patients (15%) had PE diagnosed at baseline. One patient was lost to follow-up. Of those in whom PE was considered excluded, 5 of 282 patients (1.8%) in the per-protocol YEARS group vs 15 of 273 patients (5.5%) in the per-protocol CTPA-only group had a primary outcome (absolute risk difference, −3.7%; 99.9% CI, −8.8% to 1.4%; P = 3.4 × 10 −5 for noninferiority). In the intention-to-diagnosis analysis, the absolute risk difference between the YEARS algorithm and CTPA only was −2.6% (99.9% CI, −7.5% to 2.4%; P = 5.9 × 10 −4 for noninferiority). Diagnostic management of PE was carried out for 77 of 352 patients (22%) in the YEARS group without CTPA. No difference in the proportion of negative CTPA ( P = .93) was observed between the groups. Conclusions and Relevance In patients with cancer and suspected PE, a diagnostic strategy using the YEARS diagnostic algorithm was as safe as using CTPA only, thus, obviating the need to perform CTPA in 22% of patients. Trial Registration ccmo.nl Identifier: NL-OMON52383

Importance:Although the YEARS algorithm is a safe and efficient way to rule out acute pulmonary embolism (PE), robust evidence on its accuracy in patients with cancer is lacking, and current guidelines suggest proceeding directly to computed tomographic pulmonary angiography (CTPA). Objective:To compare the safety and efficiency of the YEARS algorithm with CTPA only to rule out acute PE in patients with active cancer. Design, Setting, and Participants:The Hydra study was an open-label, randomized, investigator-initiated, noninferiority trial with blinded central outcome adjudication conducted from August 22, 2019, to August 21, 2025, the date of final follow-up. Patients with active cancer and suspected acute PE were recruited from emergency departments or medical units in 21 hospitals in the Netherlands, Italy, Switzerland, Belgium, France, and Spain. Interventions:Patients were randomly assigned in a 1:1 ratio to receive diagnostic management by the YEARS algorithm (n = 352)-consisting of assessing YEARS items, D-dimer levels, and performing risk-dependent CTPA-or by CTPA only (n = 346). Main Outcomes and Measures:The primary outcome was centrally adjudicated symptomatic venous thromboembolism or (possible) PE-related death within 90 days after ruling out PE at baseline, assessed in a per-protocol noninferiority analysis with a 2.6% margin for the upper bound of a 1-sided 99.9% CI. The key secondary outcome was the proportion of negative CTPA results at baseline, assessed in a superiority analysis. Results:A total of 698 patients were randomized (median age, 65 years [IQR, 56-72 years], 422 female [60%]), and 104 patients (15%) had PE diagnosed at baseline. One patient was lost to follow-up. Of those in whom PE was considered excluded, 5 of 282 patients (1.8%) in the per-protocol YEARS group vs 15 of 273 patients (5.5%) in the per-protocol CTPA-only group had a primary outcome (absolute risk difference, -3.7%; 99.9% CI, -8.8% to 1.4%; P = 3.4 × 10-5 for noninferiority). In the intention-to-diagnosis analysis, the absolute risk difference between the YEARS algorithm and CTPA only was -2.6% (99.9% CI, -7.5% to 2.4%; P = 5.9 × 10-4 for noninferiority). Diagnostic management of PE was carried out for 77 of 352 patients (22%) in the YEARS group without CTPA. No difference in the proportion of negative CTPA (P = .93) was observed between the groups. Conclusions and Relevance:In patients with cancer and suspected PE, a diagnostic strategy using the YEARS diagnostic algorithm was as safe as using CTPA only, thus, obviating the need to perform CTPA in 22% of patients. Trial Registration:ccmo.nl Identifier: NL-OMON52383.

INTRODUCTION:The high prevalence of pain in the emergency department (ED) highlights the importance of accurate assessments to provide effective interventions. However, common pain scales such as the Numerical Pain Rating Scale have shown limitations in assessing analgesic requirements and adequacy. The ideal outcome for evaluating a pain scale predicting analgesic requirements would be the 'need for analgesia', for which there is no universally accepted definition. Accordingly, the primary aim of this study is to define the 'need for analgesia' using an interdisciplinary approach. The secondary aim is to define the 'adequacy of analgesia'. METHODS AND ANALYSIS:A two-stage modified Delphi process will be conducted by a core study group chosen for its expertise in ED pain management. A larger expert panel, identified through a comprehensive search in Scopus and CINAHL databases, will be invited to participate in the study and will be supplemented by patients recruited via international patient organisations or snowballing. In stage 1, the expert panel will complete a written survey to collect potential clinical variables for defining the 'need for analgesia' and 'adequacy of analgesia'. The core study group will elaborate on these variables. In stage 2, the same participants will use a five-point Likert scale to achieve consensus defined as ≥80% of combined agreement on the proposed variables, over a maximum of three rounds. The same process will be used to define the 'adequacy of analgesia'. ETHICS AND DISSEMINATION:The Ethics Committee of Northwestern and Central Switzerland exempted the project from committee approval under the Human Research Act. Written consent will be obtained from all participants. Results will be disseminated through publication in peer-reviewed journals and conferences.

Occlusion myocardial infarction (OMI) on the ECG can present as STEMI, NSTEMI, ST depression, or other patterns (e.g., de Winter T-waves, hyperacute T waves), posing a diagnostic challenge. Even experienced physicians may overlook OMI on ECG, leading to delays in catheterization laboratory activation. Recently, smartphone applications utilizing artificial intelligence (AI) have been shown to exhibit a promising accuracy in ECG interpretation in large datasets. The objective of our study was to retrospectively compare the diagnostic performance of an AI-based application (PMCardio®) with that of interventional cardiologists in interpreting non-pathognomonic ECGs that generated debates about diagnosis. In total, 33 ECGs that were diagnostically challenging upon patient admission to the emergency department were included. A group of 3 interventional cardiologists, blinded to the final diagnosis, independently assessed whether the ECG suggested OMI requiring immediate invasive coronary angiography. The diagnostic performance of the cardiologists was compared to that of the AI application, using the results of coronary angiography as the gold standard and considering any lesion with ≥90% stenosis as positive. Overall, 29 (88%) patients had a final diagnosis of cardiac origin for their chest pain, including 23 acute coronary syndromes, of which 13 (57%) were OMI. The 3 cardiologists achieved sensitivities of 62%,85%,62%, negative predictive values of 74%,83%,69%, specificities of 70%, 50%, 55%, and positive predictive values of 57%52% and 47%, respectively. Their overall misclassification rates were 33%, 36% and 42%. In contrast, AI analysis demonstrated a sensitivity and NPV of 100%, a specificity of 60%, a PPV of 62%, and an overall misclassification rate of 24%. In this retrospective study of challenging ECGs, an AI application demonstrated better diagnostic performance of OMI as compared to cardiologists, underscoring its reliability for clinical use. These findings highlight the potential of AI to enhance diagnostic accuracy and support clinical decision-making.

AIMS: The literature from Canada, the UK and the USA reports health inequities among people experiencing homelessness; however little is known about this population’s health in Switzerland. Our study is the first to comprehensively assess health needs, expectations and experiences of people experiencing homelessness in Switzerland. METHODS: We describe the health needs, expectations and experiences of people experiencing homelessness in French-speaking Switzerland, using both quantitative and qualitative methods. From May to August 2022, 123 people experiencing homelessness completed quantitative questionnaires about health needs, expectations and experiences. Recruitment took place in 10 homeless-serving institutions across four cities in the Canton of Vaud. A total of 18 people experiencing homelessness and 13 professionals involved in the homeless-serving sector completed qualitative interviews. For the qualitative strand, we selected people experiencing homelessness using quota sampling based on health insurance, residency status and sex representativeness according to the study population. For homeless-serving sector professionals, we used quota sampling by professions (i.e. night watcher in shelters; social/healthcare workers) ensuring balance. In addition, we aimed to recruit at least one homeless-serving sector professional from each of the ten institutions included in the parent research project. RESULTS: The most common health issues reported were musculoskeletal, dental and psychiatric. Thirty-one percent of people experiencing homelessness had visited emergency rooms and 27% a community health centre in the prior 6 months. People experiencing homelessness reported low quality of life according to the WHOQOL, especially in social and environmental domains; 33% reported moderate and 17% high grade of psychological distress. Findings indicated that up to 32% of participants reported facing difficulties in reaching out to the healthcare system. In qualitative interviews, people experiencing homelessness described positive perceptions about the Swiss healthcare system. However, people experiencing homelessness reported various barriers encountered while seeking healthcare (e.g., health insurance, financial barriers, appointment delays, hesitancy in accessing care, prioritising other needs). Both groups commonly reported that social situations impacted the health and healthcare use of people experiencing homelessness. CONCLUSION: People experiencing homelessness in Switzerland are not spared by the common health inequities reported in Canada, the USA and the UK. Our results provide interesting foundations on which to build public health actions towards health equity for people experiencing homelessness in Switzerland and suggest that they could benefit from additional medical follow-up and tailored interventions.

Background Emergency triage, which involves complex decision-making under stress and time constraints, may suffer from inaccuracies due to workplace distractions. A serious game was developed to simulate the triage process and environment. A pilot study was undertaken to collect preliminary data on the effects of distractors on emergency nurse triage accuracy. Method A 2 × 2 factorial randomized controlled trial (RCT) was designed for the study. A sample of 70 emergency room nurses was randomly assigned to three experimental groups exposed to different distractors (noise, task interruptions, and both) and one control group. Nurses had two hours to complete a series of 20 clinical vignettes, in which they had to establish a chief complaint and assign an emergency level. Results Fifty-five nurses completed approximately 15 vignettes each during the allotted time. No intergroup differences emerged in terms of triage performance. Nurses had a very favorable appreciation of the serious game focusing on triage. Conclusion The results show that both the structure of our study and the serious game can be used to carry out a future RCT on a larger scale. The lack of a distractor effect raises questions about the frequency and intensity required to find a significant impact on triage performance.

Background: Out-of-hospital cardiac arrest (OHCA) incidence and survival often vary within regions according to patient-related and contextual factors. This study aims to establish the overall spatial dependence of incidence, bystander cardiopulmonary resuscitation (BCPR) and 48-h survival of OHCA with their associated demographic and socioeconomic characteristics in a Swiss region. Methods: We conducted a retrospective study using data of all OHCAs recorded between 2007 and 2019 in the canton of Vaud and, more specifically, in the Lausanne area. Provision of BCPR and 48-h survival were analysed using Getis-Ord Gi statistics and OHCA incidence by local Moran’s I with empirical Bayes standardised rates. Demographic and socioeconomic characteristics were compared between incidence clusters generated by local Moran’s I method. Results: Significant spatial variations of OHCA incidence, BCPR and 48-h mortality were observed. Although BCPR was statistically more likely in rural areas, 48-h survival was improved in a few main cities. At the cantonal level, postcode areas with a higher incidence of OHCAs were less densely inhabited with lower salary levels, more Swiss citizens, and an older population. At city level, small area variations were detected within urban neighbourhoods. The more affected hectares with more OHCAs were less inhabited, with a better median salary, more Swiss citizens, and off-centre. Conclusions: Spatial variations associated with demographic and socioeconomic factors were observed for OHCA incidence and survival, with sparsely populated areas particularly at risk. These data suggest an unmet need for targeted prevention interventions and structural modifications of the existing prehospital system at the cantonal level.

AIMS OF THE STUDY: Health equity is a key component of quality of care and an objective for a growing number of quality improvement projects for deontological, ethical, public health and economic reasons. To monitor equity in the delivery of health services in Switzerland, there is a need to implement valid, measurable and actionable equity indicators, along with vulnerability stratifiers such as migrant status, which could lead to differences in quality of care. The aim of this study was to develop a set of healthcare equity indicators and stratifiers targeting inpatient and outpatient populations and to test their feasibility. METHODS: A scoping literature review and inputs from a national interprofessional expert taskforce provided a set of indicators and vulnerability stratifiers. The most valid and measurable indicators and stratifiers were retained using a Delphi process. They were then operationalised, and their implementation tested in three Swiss hospitals from the three language regions. RESULTS: A taskforce of 18 experts, including a patient representative, selected 11 indicators that evaluate structures, processes and outcomes, and five vulnerability stratifiers. Although most indicators and stratifiers could be implemented in all three hospitals, data availability was limited for some variables, including patient satisfaction and access to interpreters for foreign-language patients. CONCLUSIONS: The equity indicators and stratifiers identified by this two-stage process have content validity, wide patient coverage and are focused on inequities in the healthcare system that are actionable through improvement projects. Both the indicators and the project methodology could be replicated in institutions aiming for more equitable care.

INTRODUCTION:Cancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE. METHODS:In the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization. RESULTS:Patients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15-21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15-9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48-42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15-9.74). CONCLUSIONS:Among patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes.

BACKGROUND AND AIMS:Home treatment is considered safe in acute pulmonary embolism (PE) patients selected by a validated triage tool (e.g. simplified PE severity index score or Hestia rule), but there is uncertainty regarding the applicability in underrepresented subgroups. The aim was to evaluate the safety of home treatment by performing an individual patient-level data meta-analysis. METHODS:Ten prospective cohort studies or randomized controlled trials were identified in a systematic search, totalling 2694 PE patients treated at home (discharged within 24 h) and identified by a predefined triage tool. The 14- and 30-day incidences of all-cause mortality and adverse events (combined endpoint of recurrent venous thromboembolism, major bleeding, and/or all-cause mortality) were evaluated. The relative risk (RR) for 14- and 30-day mortalities and adverse events is calculated in subgroups using a random effects model. RESULTS:The 14- and 30-day mortalities were 0.11% [95% confidence interval (CI) 0.0-0.24, I2 = 0) and 0.30% (95% CI 0.09-0.51, I2 = 0). The 14- and 30-day incidences of adverse events were 0.56% (95% CI 0.28-0.84, I2 = 0) and 1.2% (95% CI 0.79-1.6, I2 = 0). Cancer was associated with increased 30-day mortality [RR 4.9; 95% prediction interval (PI) 2.7-9.1; I2 = 0]. Pre-existing cardiopulmonary disease, abnormal troponin, and abnormal (N-terminal pro-)B-type natriuretic peptide [(NT-pro)BNP] at presentation were associated with an increased incidence of 14-day adverse events [RR 3.5 (95% PI 1.5-7.9, I2 = 0), 2.5 (95% PI 1.3-4.9, I2 = 0), and 3.9 (95% PI 1.6-9.8, I2 = 0), respectively], but not mortality. At 30 days, cancer, abnormal troponin, and abnormal (NT-pro)BNP were associated with an increased incidence of adverse events [RR 2.7 (95% PI 1.4-5.2, I2 = 0), 2.9 (95% PI 1.5-5.7, I2 = 0), and 3.3 (95% PI 1.6-7.1, I2 = 0), respectively]. CONCLUSIONS:The incidence of adverse events in home-treated PE patients, selected by a validated triage tool, was very low. Patients with cancer had a three- to five-fold higher incidence of adverse events and death. Patients with increased troponin or (NT-pro)BNP had a three-fold higher risk of adverse events, driven by recurrent venous thromboembolism and bleeding.

Background Lower respiratory tract infections (LRTIs) are among the most frequent infections and a significant contributor to inappropriate antibiotic prescription. Currently, no single diagnostic tool can reliably identify bacterial pneumonia. We thus evaluate a multimodal approach based on a clinical score, lung ultrasound (LUS), and the inflammatory biomarker, procalcitonin (PCT) to guide prescription of antibiotics. LUS outperforms chest X-ray in the identification of pneumonia, while PCT is known to be elevated in bacterial and/or severe infections. We propose a trial to test their synergistic potential in reducing antibiotic prescription while preserving patient safety in emergency departments (ED). Methods The PLUS-IS-LESS study is a pragmatic, stepped-wedge cluster-randomized, clinical trial conducted in 10 Swiss EDs. It assesses the PLUS algorithm, which combines a clinical prediction score, LUS, PCT, and a clinical severity score to guide antibiotics among adults with LRTIs, compared with usual care. The co-primary endpoints are the proportion of patients prescribed antibiotics and the proportion of patients with clinical failure by day 28. Secondary endpoints include measurement of change in quality of life, length of hospital stay, antibiotic-related side effects, barriers and facilitators to the implementation of the algorithm, cost-effectiveness of the intervention, and identification of patterns of pneumonia in LUS using machine learning. Discussion The PLUS algorithm aims to optimize prescription of antibiotics through improved diagnostic performance and maximization of physician adherence, while ensuring safety. It is based on previously validated tests and does therefore not expose participants to unforeseeable risks. Cluster randomization prevents cross-contamination between study groups, as physicians are not exposed to the intervention during or before the control period. The stepped-wedge implementation of the intervention allows effect calculation from both between- and within-cluster comparisons, which enhances statistical power and allows smaller sample size than a parallel cluster design. Moreover, it enables the training of all centers for the intervention, simplifying implementation if the results prove successful. The PLUS algorithm has the potential to improve the identification of LRTIs that would benefit from antibiotics. When scaled, the expected reduction in the proportion of antibiotics prescribed has the potential to not only decrease side effects and costs but also mitigate antibiotic resistance. Trial registration This study was registered on July 19, 2022, on the ClinicalTrials.gov registry using reference number: NCT05463406. Trial status Recruitment started on December 5, 2022, and will be completed on November 3, 2024. Current protocol version is version 3.0, dated April 3, 2023.

OBJECTIVE:The COVID-19 pandemic had a profound negative impact on the psychological wellbeing of healthcare providers (HPs), but little is known about the factors that positively predict mental health of primary care staff during these dire situations.METHODS:We conducted an online questionnaire survey among 702 emergency department workers across 10 hospitals in Switzerland and Belgium following the first COVID-19 wave in 2020, to explore their psychological vulnerability, perceived concerns, self-reported impact and level of pandemic workplace preparedness. Participants included physicians, nurses, psychologists and nondirect care employees (administrative staff). We tested for predictors of psychological vulnerability through both an exploratory cross-correlation with rigorous correction for multiple comparisons and model-based path modelling.RESULTS:Findings showed that the self-reported impact of COVID-19 at work, concerns about contracting COVID-19 at work, and a lack of personal protective equipment were strong positive predictors of Depression, Anxiety, and Stress, and low Resilience. Instead, knowledge of the degree of preparedness of the hospital/department, especially in the presence of a predetermined contingency plan for an epidemic and training sessions about protective measures, showed the opposite effect, and were associated with lower psychological vulnerability. All effects were confirmed after accounting for confounding factors related to gender, age, geographical location and the role played by HPs in the hospital/department.CONCLUSIONS:Difficult working conditions during the pandemic had a major impact on the psychological wellbeing of emergency department HPs, but this effect might have been lessened if they had been informed about adequate measures for minimizing the risk of exposure.

Dabigatran is an oral anticoagulant that is mainly renally excreted. Despite its efficacy in preventing thromboembolic events, concerns arise regarding bleeding complications in patients with acute kidney injury. Idarucizumab is its specific antidote and reverses quickly and effectively dabigatran anticoagulation effects in situations of severe bleeding or pending surgical procedures, but its benefit beyond these two indications remains uncertain. We present a case of a woman with atrial fibrillation anticoagulated by dabigatran and admitted with Streptococcus agalactiae meningitis, acute kidney injury and dabigatran accumulation. Idarucizumab was not administered initially as she did not meet its current strict indications. However, subsequently, significant bleeding necessitated its use. A rebound increase in dabigatran concentration was associated with an intracranial hemorrhage, but the combination of additional doses of idarucizumab with hemodialysis lowered the dabigatran concentration and prevented significant rebound increases. Further investigation into the optimal management of dabigatran accumulation and acute kidney injury-associated bleeding is needed to enhance patient outcomes and safety. Early initiation of hemodialysis together with idarucizumab administration may be crucial in preventing life-threatening bleeding events in these patients.