BACKGROUND AND IMPORTANCE:Acute heart failure (AHF) is a frequent cause of emergency department (ED) admissions, yet the prognostic impact of infection as a trigger remains insufficiently characterized. OBJECTIVE:To evaluate the impact of infection as a trigger of AHF on in-hospital mortality and postdischarge survival. DESIGN:Retrospective observational cohort study. SETTINGS AND PARTICIPANTS:All adult patients presenting with AHF to the ED of Strasbourg University Hospital in 2020 were included. Clinical and outcome data were collected from 1296 ED visits. INTERVENTION OR EXPOSURE:Infection and other AHF triggers were defined through adjudication based on clinical, imaging, and microbiological data collected throughout the hospital stay. OUTCOME MEASURES AND ANALYSIS:The primary outcome was in-hospital mortality. Analyses were performed using inverse probability weighting (IPW). Postdischarge survival was assessed using IPW-weighted Kaplan-Meier estimates and Cox models. MAIN RESULTS:Infection was identified in 119 ED visits [9.2%, 95% confidence interval (CI): 7.7-10.9]. Patients with infection had higher in-hospital mortality than those without infection (30.3% vs. 9.0%, P  < 0.001). In IPW-weighted analyses, infection was independently associated with in-hospital mortality [odds ratio (OR) = 2.76, 95% CI: 1.64-4.66]. In contrast, atrial fibrillation (OR = 0.45, 95% CI: 0.23-0.87) and acute coronary syndrome (OR = 0.08, 95% CI 0.01-0.58) were associated with lower in-hospital mortality. Infection was also associated with reduced postdischarge survival (hazard ratio = 1.64, 95% CI: 1.14-2.37, P  = 0.008). CONCLUSION:Infection is a strong and independent predictor of short- and long-term mortality in patients presenting with AHF in the ED.

Bacterial infections remain a major cause of morbidity and mortality worldwide. In the Emergency Department (ED), timely diagnosis and initiation of appropriate antibiotics are crucial to improve patient outcomes. While leukocyte and neutrophil counts are routinely interpreted, eosinophils are rarely considered, despite being systematically available. We aimed to assess the discriminative performance of eosinopenia compared with standard leukocyte parameters for identifying bacterial infections in the ED. We conducted a prospective, multicenter study in five French EDs between March 2018 and September 2021. Adult patients with suspected or confirmed bacterial infection who underwent a differential blood count were included, alongside a control group of non-infected ED patients. Eosinophil counts were compared with leukocytes, neutrophils, and C-reactive protein (CRP). The diagnosis of infection was confirmed during hospital follow-up by independent expert review. A total of 770 patients were analyzed, including 422 infected and 348 controls. Median eosinophil count was significantly lower in patients with bacterial infection than in controls (10/mm3 vs 80/mm3, p<0.001). Eosinopenia ≤10/mm3 had a specificity of 88

Ectonucleotidases regulate extracellular purine signaling and play a key role in inflammation and thrombosis, two major components of COVID-19 pathophysiology. We investigated the enzymatic activities of CD39 (NTPDase1) and CD73 (ecto-5’-nucleotidase) as potential biomarkers of disease severity. Patients with RT-PCR-confirmed COVID-19 were enrolled between August 1st, 2020, and August 1st, 2021, and stratified into mild to moderate (MM, n = 55) or severe to critical (SC, n = 30) groups according to WHO criteria. Serum samples were collected on days 1, 3, and 7 following Emergency Department (ED) admission. CD39 and CD73 activities were measured by HPLC using etheno-fluorescent nucleotide substrates and compared to healthy volunteers (HV, n = 30) matched for age and sex. Serum CD73 activity was significantly elevated in COVID-19 patients compared to HV (MM: 76 ± 9.4; SC: 99 ± 21 vs. HV: 25 ± 2.7 pmol/min/µL; p < 0.0001), particularly in patients requiring ≥ 6 L/min oxygen (p = 0.005) or with a respiratory rate > 20/min (p = 0.02). CD73 activity remained elevated throughout hospitalization. Conversely, febrile patients (≥ 38 °C) and those with CRP ≥ 100 mg/L exhibited significantly lower CD73 activity (p = 0.023 and p = 0.004, respectively). CD39 activity was undetectable in 28.2% of patients and showed no association with disease severity or outcome. The lowest CD73 levels were observed in patients requiring oxygen therapy for ≥ 30 days and in those who died before day 7. Serum CD73 activity is associated with hypoxemia and oxygen requirements upon ED admission. Conversely, low CD73 activity reflects a hyperinflammatory state and worse outcomes, supporting its potential use in biomarker-based risk stratification for COVID-19.

Noninvasive ventilation (NIV) effectively treats acute cardiogenic pulmonary oedema (ACPE), leading to quicker clinical improvement and reduced intubation needs than medical treatment alone. However, the impact of NIV on mortality in patients with ACPE is unclear. The primary objective was to evaluate the impact of NIV on 6-month mortality in older patients with ACPE compared with medical treatment. Secondary objectives included assessing the effects of NIV on length of hospital stay and rehospitalisation. This retrospective study included patients aged ≥ 75 years with ACPE (acute respiratory distress and/or RR ≥ 25 cycles/min and/or paCO2 ≥ 45 mmHg and/or pH < 7.35 and/or uncorrected hypoxemia). Exclusion criteria: positive for SARS-CoV-2 and contraindication to NIV. Of the 186 patients admitted to emergency care with ACPE and eligible for NIV, 104 received NIV and 82 received medical treatment. Survival analyses were performed using a multivariate Cox model and adjusting for confounding factors. NIV was not significantly linked to reduced mortality risk (HR = 0.82, p = 0.51), except for in the acidosis subgroup (HR = 0.24, p = 0.01). No difference was observed in the length of hospital stay or in terms of rehospitalisation. NIV in older patients with ACPE did not significantly decrease 6-month mortality, except in the subgroup with respiratory acidosis, when the risk of death was reduced by 75%. The use of NIV in older patients with ACPE should be limited to patients with acidosis, to see their risk of death significantly reduced. Trial registration : The study protocol has been retrospectively registered on ClinicalTrials.gov (NCT06107257, 2023-10-30).

The purpose of this study was to compare the length of stay (LOS) and costs of diagnostic workup by Ultra Low Dose (ULD) chest computed tomography and radiography for patients treated for a community-acquired pneumonia (CAP) in the emergency department (ED). We conducted a real-life retrospective study of patients treated for a CAP in two ED between March 1, 2019 and February 29, 2020. We estimated length of stay (LOS) as the difference between ED discharge and entry times, total hospital costs at 60 days including ED, initial admissions and readmissions. Patients with initial radiography were compared with patients with initial ULD CT using inverse probability weighing of the propensity score calculated from demographic variables, vital parameters and clinical presentation. We calculated the incremental cost effectiveness ratio as the difference between costs and the difference between LOS. Variability of the results was assessed using non-parametric bootstrapping. We included 1609 consecutive patients, 1476 patients with radiography and 133 patients with ULD CT. The average costs were respectively €4317 [3483; 5067] and €4223 [4034; 4612] with 11.9 [10.1; 13.2] and 11.7 [11.5; 12.2] hours of LOS in the ED for chest radiography and ULD chest CT respectively, resulting in lower costs of € -94 [-870; 819] and a decreased LOS of 12 [-108; 76.9] minutes in favor of ULD chest CT. In this real-life study, the management of CAP in ED by ULD chest CT compared with chest radiography resulted in lower costs without increasing LOS. This study was registered with the Clinical Trials Registry (NCT05140408).

INTRODUCTION:For large primary spontaneous pneumothorax (PSP), drainage or simple aspiration are the two first-line treatment options. Outpatient ambulatory strategies have a success rate of almost 80% with few complications. New French recommendations suggest that an outpatient strategy should be preferred if an appropriate care network is in place. However, establishing this care network remains the main obstacle to the use of this strategy. Thus, outpatient management of PSP remains rare, which is neither optimal for the patient, with a likely impact on quality of life (QOL) and satisfaction with care, nor for the healthcare system, with increased costs. We hypothesise that outpatient treatment of PSP compared with usual inpatient management could improve quality of care and represent a more efficient, generalisable and sustainable strategy. METHODS AND ANALYSIS:In this multicentre, cluster-controlled, randomised interventional study with stepped wedge implementation, patients aged 18-50 presenting to the emergency department (ED) with a first episode of large PSP will be enrolled in seven university hospitals in France. The main objective of this study is to evaluate the impact on changes in QOL of an ambulatory strategy for the management of large PSP in the ED compared with usual inpatient management. The primary outcome is the difference in QOL as measured by SF-36 score, between drain placement and 6 months. Clinical criteria (pulmonary expansion at 6 days, pain, dyspnoea, complications, recurrence), perceived quality of care (satisfaction, patient preference, anxiety) and ease of implementation of the care pathway will also be assessed. A cost-utility analysis will be carried out to evaluate the incremental cost-utility ratio at 1 year, defined as the difference in costs divided by the difference in utility estimated by the EQ-5D scores. ETHICS AND DISSEMINATION:Ethics approval has been obtained by the Comité de Protection des Personnes Nord Ouest III N° 2024-36. Study findings will be disseminated by publication in a high-impact international journal. Results will be presented at national and international emergency healthcare meetings, and participating patients notified of the main conclusions. TRIAL REGISTRATION NUMBER:This trial is registered with Clinical Trials Registry NCT06471608. The trial protocol and statistical design are fully described in this study protocol. Additional data can be provided on reasonable request to the sponsor. PROTOCOL VERSION:V2.1 - 21/11/2024.

Abstract Background At present, the diagnosis of acute coronary syndrome (ACS) can be made by emergency physicians using the usual complementary tests, since the current troponin and electrocardiogram (ECG) protocols have been extensively tested for their safety. However, the detection of coronary calcifications on CT associated with coronary obstruction may be of interest for the diagnostic strategy in the emergency department (ED). The aim of this study was to evaluate a strategy combining a non-ischemic ECG with an initial normal troponin assay and the diagnostic accuracy of chest CT in detecting coronary calcifications to rule out the presence of an acute coronary event in patients presenting with chest pain in the ED. Methods This was a retrospective, single-center study carried out in an ED in France and included all patients over 18 years of age presenting with chest pain between 1 June 2021 and 31 December 2021 with a non-ischemic ECG and a negative first troponin assay. The primary endpoint was the diagnostic performance of the combing strategy in ruling out ACS. The secondary endpoints were the sensitivity and specificity of calcifications in acute coronary syndrome, comparison with the diagnostic performance of a second troponin assay and the rate of reconsultation, rehospitalisation and investigations within 2 months of the ED. Results Of the 280 patients included, 141 didn’t have calcifications. A total of 14 events were found with a negative predictive value for the combining strategy of 99.8% [95%CI: 98.2 – 100]. Sensitivity and specificity were 98.4% [95%CI: 83.8 – 100] and 53% [95%CI: 47 – 58.9], respectively. Among patients with no calcification, 8.2% were admitted to hospital and none suffered an acute coronary event. A total of 36 patients (12.8%) consulted a doctor within 2 months, with 23 investigations, all of which were negative in the non-calcification group. Conclusions A strategy combining the detection of coronary calcifications on chest CT in patients with a non-ischemic ECG and a single troponin assay is effective to rule out ACS in the ED, and may perform better then ECG and troponin alone.

ContexteLa douleur reste encore insuffisamment prise en charge dans les services d’urgences. Des protocoles antalgiques et des formulaires d’enregistrement de la prise en charge de la douleur ont été validés par le comité de lutte contre la douleur (CLUD) de l’établissement pour améliorer cette prise en charge.ObjectifsÉvaluer la prise en charge précoce de la douleur des patients se présentant aux urgences adultes.MéthodeC’est une étude observationnelle réalisée en septembre 2023 pour chaque patient accueilli aux urgences durant plusieurs sessions d’observation à l’aide d’une grille de recueil comprenant ces éléments :– évaluation de la douleur par l’infirmier organisateur de l’accueil (IOA) : modalité et score -d’évaluation et réévaluation à 60minutes ;– traitement antalgique proposé ;– taux d’administration des antalgiques ;– enregistrement des données par l’IOA dans le dossier informatisé du patient.Un questionnaire a été transmis aux médecins et infirmiers pour évaluer leur connaissance du protocole suivi par les IOA et du formulaire d’enregistrement associé.RésultatsLe recueil a concerné 50 patients sur une durée totale de 14h d’observation. La douleur a été évaluée pour 88 % (n=44) d’entre eux par une échelle numérique ou d’hétéroévaluation. Parmi eux, 80 % sont douloureux (n=35). Une prise en charge antalgique a été proposée à 85 % (n=30) des patients douloureux, 47 % (n=14) l’ont acceptée. Celle-ci était non conforme au protocole dans 50 % (n=7) des cas : 6 de ces patients ont reçu un traitement de puissance inférieure à celui recommandé.Pour les patients dont la douleur n’a pas été évaluée, les raisons sont la barrière de la langue et les troubles cognitifs.Aucune réévaluation de la douleur à 60minutes n’a été observée pendant ce recueil.Le protocole antalgique IOA est connu de 89 % des médecins/IDE (n=43). Le formulaire complété par les IOA est connu par 95 % d’entre eux, mais seulement 76 % savent comment le consulter, et 58 % le consultent avant d’administrer ou de prescrire un nouvel antalgique. Sept professionnels ont répondu ne jamais le consulter.Discussion - ConclusionCette évaluation montre des non-conformités aux protocoles établis par le CLUD : absence d’évaluation de la douleur chez certains patients non communicants, refus de l’antalgique par certains patients et administration d’antalgiques qui ne sont pas ceux recommandés.Les médecins/infirmiers du service d’accueil des urgences n’ont qu’une connaissance partielle du protocole et ne consultent pas l’historique d’administration des antalgiques par l’IOA avant prise en charge du patient. Il en résulte un risque de redondance ou de surdosage médicamenteux.Il est prévu de communiquer auprès des équipes sur l’existence du protocole et sur l’importance de l’évaluation de la douleur. L’identification des réticences des IOA à recourir aux morphiniques est une piste à explorer par les médecins et pharmaciens afin de mettre en place les actions de formation adaptées.

BACKGROUND AND IMPORTANCE:Endotracheal intubation is a lifesaving procedure that is reportedly associated to a significant risk of adverse events. Recent trials have reported that the use of videolaryngoscope and of a stylet might limit this risk during emergency intubation. OBJECTIVES:The objective of this study was to provide a national description of intubation practices in French Emergency Departments (EDs). SETTINGS AND PARTICIPANTS:We conducted an online nationwide survey by sending an anonymous 37-item questionnaire via e-mail to 629 physicians in French EDs between 2020 and 2022. INTERVENTION:A single questionnaire was sent to a sole referent physician in each ED. OUTCOME MEASURES AND ANALYSIS:The primary endpoint was to assess the proportion of French EDs in which videolaryngoscopy was available for emergency intubation and its use in routine practice. Secondary endpoints included the presence of local protocol or standard of procedure for intubation, availability of capnography, and routine use of a stylet. MAIN RESULTS:Of the surveyed EDs, 342 (54.4%) returned the completed questionnaire. A videolaryngoscope was available in 193 (56%) EDs, and direct laryngoscopy without a stylet was majorly used as the primary approach in 280 (82%) EDs. Among the participating EDs, 74% had an established protocol for intubation and 92% provided a capnography device for routine verification of tube position. In cases of difficult intubation, the use of a bougie was recommended in 227 (81%) EDs, and a switch to a videolaryngoscope in 16 (6%) EDs. The most frequently used videolaryngoscope models were McGrath Mac Airtraq (51%), followed by Airtraq (41%), and Glidescope (14%). CONCLUSION:In this large French survey, the majority of EDs recommended direct laryngoscopy without stylet, with seldom use of videolaryngoscopy.

BACKGROUND:The assessment of acute heart failure (AHF) prognosis is primordial in emergency setting. Although AHF management is exhaustively codified using mortality predictors, there is currently no recommended scoring system for assessing prognosis. The European Society of Cardiology (ESC) recommends a comprehensive assessment of global AHF prognosis, considering in-hospital mortality, early rehospitalization rates and the length of hospital stay. OBJECTIVE:We aimed to prospectively evaluate the performance of the Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF (MEESSI-AHF) score in estimating short prognosis according to the ESC guidelines. DESIGN, SETTINGS AND PATIENTS:A multicenter study was conducted between November 2020, and June 2021. Adult patients who presented to eleven French hospitals for AHF were prospectively included. OUTCOME MEASURES AND ANALYSIS:According to MEESSI-AHF score, patients were stratified in four categories corresponding to mortality risk: low-, intermediate-, high- and very high-risk groups. The primary outcome was the number of days alive and out of the hospital during the 30-day period following admission to the Emergency Department (ED). RESULTS:In total, 390 patients were included. The number of days alive and out of the hospital decreased significatively with increasing MEESSI-AHF risk groups, ranging from 21.2 days (20.3-22.3 days) for the low-risk, 20 days (19.3-20.5 days) for intermediate risk,18.6 days (17.6-19.6 days) for the high-risk and 17.9 days (16.9-18.9 days) very high-risk category. CONCLUSION:Among patients admitted to ED for an episode of AHF, the MEESSI-AHF score estimates with good performance the number of days alive and out of the hospital.

A 75-year-old woman with a history of chronic hydrocephalus due to stenosis of the aqueduct of Sylvius was examined at the emergency department for altered mental status. There was placement of a ventriculoperitoneal shunt in 1970 complicated by meningitis, leading to removal of the material and ventriculociternostomy as definitive treatment in 2004. About one month previously, she had undergone a laparoscopic cholecystectomy complicated by an intra-abdominal collection. Clinical examination at the emergency department revealed a Glasgow score of 8 (E3 V1 M4). In the emergency department the patient presented a tonic-clonic seizure before a cerebral CT scan was performed showing a massive compressive pneumocephalus, then a second seizure. The patient was finally admitted to the neurosurgery department and underwent surgery.

The last 20 years have seen a dramatic increase worldwide in the number of emergency department (ED) visits, and resulted in overcrowding and increased stress in the workplace [1]. The increase in ED visits has also contributed to longer waiting room times and lengths of stay, and has had resulted in worsening morbidity and mortality [2,3]. Some health systems, such as the Swedish National Healthcare Service, have strategized to respond better to the increase in volume. In the Swedish model, triage nurses aided by digital tools act as gatekeepers by limiting admissions through iterative decision-making [4]. It seems necessary; however, to evaluate any new strategy for combatting overcrowding in a reliable and reproducible manner both between hospitals and within a single hospital over time. To our knowledge, there is no current method for comparing how EDs are organized. The organization of an ED can be effective in one hospital and not in another for a variety of reasons (e.g., patient population, disease prevalence, supporting infrastructure, etc.). When assessing the value of a given strategy for making appropriate comparisons, it is, therefore, difficult to limit oneself to a few indicators. Some indicators have been proposed by national regulatory bodies overseeing hospital EDs, but they are ineffective at allowing comparisons both over time and between institutions [5]. Further, these government-proposed indicators have not reached consensus among experts, and hence, do not adequately address the underlying problem [6]. Our objective was to survey a group of experts in the management and organization of EDs to develop a standardized questionnaire to make appropriate comparisons regarding capacity, staffing needs, patient demographics, and other parameters. We conducted a Delphi study in order to obtain consensus among experts about relevant indicators that can affect ED overcrowding. This study was completed in accordance with the accepted Delphi methodology [7]. We selected clinical directors of French EDs as the most appropriate personnel to respond to the survey. These professionals, in addition to their expertise as managers, also represent the diversity of EDs in terms of patient volume, beds per hospital, and whether university-affiliated or not. We carried out four rounds of surveying utilizing the Delphi method. Thirteen experts responded to all four rounds of questioning. More than half of the experts (7/13) had more than 15 years of management experience, four had 10–15 years, one had 5–10 years, and one had less than 5 years. The EDs they managed varied in size with an average of 68 000 patients/year (range 36 000–100 000 patients/year). Forty-nine indicators were proposed by the experts; among them 40 were agreed upon by consensus (Table 1). Table 1 - Indicators with consensus • Average number of ED visits per year • Percentage of patients admitted to an ICU • Percentage of patients over 75 years old • Percentage of patients hospitalized or transferred • Average length of stay in the ED • Average length of stay in a CDU • Number of patients waiting for a bed at 8 a.m. • Average of visits per week • Percentage of patients admitted to the CDU • Percentage of patients left without being seen • Percentage of patients per triage acuity range (1–5) • Filling rate for the monitoring unit • Number of visits during daytime, evening, and overnight • Percentage of patients for each ED area/zone • Specific sectors (resuscitation area, bedded zone, and ambulatory zone, etc.) • Upstream presence of an emergency service call center • Existence of an on-duty general practitioner: on-duty medical center, on-call doctors, urgent care center, availability of nearby emergency departments, public or private systems • ED call center medical advice • Percentage undergoing blood tests • Percentage undergoing radiology imaging studies • Percentage of patients receiving point-of-care testing • Number of establishments accepting transfers • Availability of Emergency Medical Services (EMS) transport • Active city-hospital system • Physician shift duration • Number of examination rooms • Number of temporary workers • Number of overtime periods • Organization of rest periods • Working hours • Seasonality of staffing in the ED • Number of practitioners needed versus actual number • Time to nurse triage • Time to nurse evaluation • Time between admission and disposition (admit versus discharge) • Average door-to-physician time • Waiting time for test results (blood tests, imaging studies, etc.) • Time between decision to disposition (admission versus discharge) and effective discharge • Total length of stay • Time for sub-specialty consultation (orthopedics, cardiology, etc.) CDU, clinical decision unit; ED, emergency department; ICU, intensive care unit. Existing tools for the ED director to make objective observations are still limited in their functionality. The indicators we propose offer a tool for evaluating the activity and organization of an ED, allowing comparisons over time and between hospitals. In addition, our questionnaire allows for insights into an ED's staffing needs. Indeed, understaffing is a factor that leads to overcrowding. Other factors are an ED's organizational structure, its level of preparation for unplanned challenges, and its ability to manage disturbances both upstream and downstream, such as availability of primary care, healthcare worker strikes, holidays, and bed capacity [8]. In France, most of the indicators used by regulatory authorities to finance the number of emergency physicians at a given ED are based on population level or on the institution's number of ED visits per year [9]. This assessment often results in a mismatch between perceived needs and actual needs and can result in overcrowding [10]. Other essential external factors exacerbating the problem include nonurgent visits, medical nomadism, epidemics, and shortages of hospital beds [11]. These factors in combination have resulted in overworked caregivers and crowded conditions for ED patients [12,13]. Our questionnaire may assist ED directors in considering daily needs and assessing the potential impact of newly implemented strategies to combat overcrowding. Additionally, these indicators may potentially be used to anticipate hospitalizations and unscheduled care needs and may serve as tools for predicting ED flow [14,15]. In addition to providing organizational value to ED directors and hospital administrators, these indicators may assist in setting expectations for ED providers and patients by being displayed in real-time in the ED and in waiting areas. Patients may potentially rely on data from these indicators to generate more precise estimates of waiting times. Finally, the concept of a reliable list of indicators to guide decision-making to address ED overcrowding could be utilized elsewhere in Europe, in order to better understand the similarities and functioning of EDs throughout the continent and make improvements to their organizational structure. This important topic was discussed in Berlin by the European Society of Emergency Medicine (EUSEM) professional committee and is awaiting publication. Acknowledgements The authors would like to thank all the experts who participated in this Delphi method: Karim Tazarourte, Pascal Bilbault, Enrique Casalino, Pierre Géraud Claret, Christophe Choquet, Marc Noizet, Philippe Alarcon, Yannick Gottwales, Arnaud Depil Duval, François Braun, and our late Mikaël Martinez. The authors also thank James Moak for his invaluable help with translation. Conflicts of interest There are no conflicts of interest.

IntroductionIn the context of budgetary constraints faced by healthcare systems, the medical-economic evaluation of care strategies becomes essential. In particular, valuing consumed resources in the overcrowded emergency departments (EDs) has become a priority to adopt more efficient approaches in treating the growing number of patients. However, precisely measuring the cost of care is challenging. While bottom-up micro-costing is considered the gold standard, its practical application remains limited.ObjectiveThe objective was to accurately estimate the ED care cost for patients consulting in a French ED for suspected lower respiratory tract infection.MethodsThe authors conducted a cost analysis using a bottom-up micro-costing method. Patients were prospectively included between January 1, and March 31, 2023. The primary endpoint was the mean cost of ED care. Resources consumed were collected using direct observation method and cost data were obtained from information available at Strasbourg University Hospital.ResultsThe mean cost of ED care was €411.68 (SD = 174.49). The cost elements that made the greatest contribution to the total cost were laboratory tests, labor, latency time, imaging and consumables. Considering this cost and the current epidemiological data on respiratory infections in France, the absence of valuation for outpatient care represents an annual loss of over 17 million euros for healthcare facilities.ConclusionMicro-costing is a key element in valuing healthcare costs. The importance of accurately measuring costs, along with measuring the health outcomes of a defined care pathway, is to enhance the relevance of health economic evaluations and thus ensure efficient care.

Purpose:To determine the impact of an artificial intelligence software predicting malignancy in the management of incidentally discovered lung nodules. Materials and methods:In this retrospective study, all lung nodules ≥ 6 mm and ≤ 30 mm incidentally discovered on emergency CT scans performed between June 1, 2017 and December 31, 2017 were assessed. Artificial intelligence software using deep learning algorithms was applied to determine their likelihood of malignancy: most likely benign (AI score < 50%), undetermined (AI score 50-75%) or probably malignant (AI score > 75%). Predictions were compared to two-year follow-up and Brock's model. Results:Ninety incidental pulmonary nodules in 83 patients were retrospectively included. 36 nodules were benign, 13 were malignant and 41 remained indeterminate at 2 years follow-up.AI analysis was possible for 81/90 nodules. The 34 benign nodules had an AI score between 0.02% and 96.73% (mean = 48.05 ± 37.32), while the 11 malignant nodules had an AI score between 82.89% and 100% (mean = 93.9 ± 2.3). The diagnostic performance of the AI software for positive diagnosis of malignant nodules using a 75% malignancy threshold was: sensitivity = 100% [95% CI 72%-100%]; specificity = 55.8% [38-73]; PPV = 42.3% [23-63]; NPV = 100% [82-100]. With its apparent high NPV, the addition of an AI score to the initial CT could have avoided a guidelines-recommended follow-up in 50% of the benign pulmonary nodules (6/12 nodules). Conclusion:Artificial intelligence software using deep learning algorithms presents a strong NPV (100%, with a 95% CI 82-100), suggesting potential use for reducing the need for follow-up of nodules categorized as benign.

Background: Non-ST elevation acute coronary syndrome (NSTE-ACS) is one of the most frequent manifestations of coronary artery disease. The occurrence of serious heart rhythm disorders (SHRDs) in NSTE-ACS is not well documented. However, continuous heart rhythm monitoring is recommended during the initial management of NSTE-ACS. The targeted monitoring of patients at greater risk for SHRDs could facilitate patients’ care in emergency departments (EDs) where the flow of patients is continuously increasing. Methods: This retrospective single-center study included 480 patients from emergency and cardiology departments within the Strasbourg University Hospital between 1 January 2019 and 31 December 2020. The objective was to estimate the frequency of the occurrence of SHRDs among patients with NSTE-ACS. The secondary objective was to highlight the factors associated with a higher risk of SHRDs. Results: The proportion of SHRDs during the first 48 h of hospital care was 2.3% (CI95%: 1.2–4.1%, n = 11). Two time periods were considered: before coronary angiography (1.0%), and during, or after coronary angiography (1.3%). In the first group, two patients required immediate treatment (0.4% of the patients) and no death occurred. In the univariate analysis, the variables significantly associated with SHRDs were age, anticoagulant medication, a decrease in glomerular filtration rate, plasmatic hemoglobin, and left ventricle ejection fraction (LVEF), and an increase in plasmatic troponin, BNP, and CRP levels. In the multivariable analysis, plasmatic hemoglobin > 12 g/dL seemed to be a protective factor for SHRDs. Conclusions: In this study, SHRDs were rare and, most often, spontaneously resolved. These data challenge the relevance of systematic rhythm monitoring during the initial management of patients with NSTE-ACS.

Background and objectives: Venous thromboembolism (VTE) represents a health and economic burden with consequent healthcare resource utilization. Direct oral anticoagulants (DOACs) have emerged as the mainstay option for VTE treatment but few data exist on their cost-effectiveness as compared to the standard therapy (vitamin K antagonists (VKAs)). This study aimed to assess the cost-effectiveness of rivaroxaban compared to VKAs in VTE treatment by calculating the incremental cost effectiveness ratio (ICER). Materials and methods: We conducted a prospective observational study based on the REMOTEV registry, including patients hospitalized for VTE from 23 October 2013 to 31 July 2015, to evaluate the impact of the anticoagulant treatment (DOACs versus VKAs) on 6-month complications: major or clinically relevant non-major bleeding, VTE recurrence and all-cause death. Rivaroxaban was the only DOAC prescribed in this study. The ICER was calculated as the difference in costs divided by the difference in effectiveness. Results: Among the 373 patients included, 279 were treated with rivaroxaban (63.1 ± 17.9 years old; 49% men) and 94 with VKAs (71.3 ± 16.6 years old; 46% men). The mean cost was EUR 5662 [95% CI 6606; 9060] for rivaroxaban and EUR 7721 [95% CI 5130; 6304] for VKAs, while effectiveness was 0.0586 95% CI [0.0114; 0.126] for DOACs and 0.0638 [95% CI 0.0208; 0.109] for VKAs. The rivaroxaban treatment strategy was dominant with costs per patient EUR 2059 lower [95% CI −3582; −817] and a higher effectiveness of 0.00527 [95% CI −0.0606; 0.0761] compared to VKAs. Conclusions: This study provides real-world evidence that rivaroxaban is not only an efficient and safe alternative to VKAs for eligible VTE patients, but also cost-saving.

Background and Objectives: Chest radiography remains the most frequently used examination in emergency departments (ED) for the diagnosis of community-acquired pneumonia (CAP), despite its poor diagnostic accuracy compared with ultra-low-dose (ULD) chest computed tomography (CT). However, although ULD CT appears to be an attractive alternative to radiography, its organizational impact in ED remains unknown. Our objective was to compare the relevant timepoints in ED management of CT and chest radiography. Materials and Methods: We conducted a retrospective study in two ED of a University Hospital including consecutive patients consulting for a CAP between 1 March 2019 and 29 February 2020 to assess the organizational benefits of ULD chest CT and chest radiography (length of stay (LOS) in the ED, time of clinical decision after imaging). Overlap weights (OW) were used to reduce covariate imbalance between groups. Results: Chest radiography was performed for 1476 patients (mean age: 76 years [63; 86]; 55% men) and ULD chest CT for 133 patients (mean age: 71 [57; 83]; 53% men). In the weighted population with OW, ULD chest CT did not significantly alter the ED LOS compared with chest radiography (11.7 to 12.2; MR 0.96 [0.85; 1.09]), although it did significantly reduce clinical decision time (6.9 and 9.5 h; MR 0.73 [0.59; 0.89]). Conclusion: There is real-life evidence that a strategy with ULD chest CT can be considered to be a relevant approach to replace chest radiography as part of the diagnostic workup for CAP in the ED without increasing ED LOS.

Introduction Both non-contrast Computed Tomography (CT) and ultrasound (US) are used for the diagnosis of renal colic in the emergency department (ED). Although US reduces radiation exposure, its diagnostic accuracy is inferior to that of CT. In this context, data regarding the cost and organizational impact of these strategies represent essential elements in the choice of imaging; however, they remain poorly documented. Aim of the study The aim of this study was to compare the costs and effectiveness of diagnostic workup by US and CT for patients consulting with renal colic in the ED. Methods We conducted a monocentric real-life retrospective study of patients consulting for a renal colic in an ED between 1 July 2018 and 31 December 2018. We estimated length of stay (LOS), total hospital costs at 60 days including ED, and initial and repeat admissions. Patients with initial US in the ED were compared to patients with initial CT using inverse probability weighting of the propensity score calculated from demographic variables, vital parameters, and clinical presentation. We calculated the incremental cost effectiveness ratio as the difference in costs by the difference in LOS. The variability of the results was assessed using non-parametric bootstrapping. Results In this study, of the 273 patients included, 67 were patients assessed with US and 206 with CT. The average costs were €1159 (SD 1987) and €956 (SD 1462) for US and CT, respectively, and the ED LOS was 8.9 [CI 95% 8.1; 9.4] and 8.7 [CI 95% 7.9; 9.9] hours for US and CT, respectively. CT was associated with a decreased LOS by 0.139 [CI 95% −1.1; 1.5] hours and was cost-saving, with a €199 [CI 95% −745; 285] reduction per patient. Conclusion When imaging is required in the ED for suspected renal colic as recommended, there is real-life evidence that CT is a cost-effective strategy compared to US, reducing costs and LOS in the ED.