Skip to main content
SpringerLink
Log in

Impact de la seniorisation et du rappel des bonnes indications sur la prescription d’examens d’hémostase aux urgences pour adultes

Impact of attending prescription and recall of good indications of blood coagulation tests on their prescription in an adult emergency department

  • Article Original
  • Published:
Annales françaises de médecine d'urgence

Résumé

Objectifs

De nombreux examens complémentaires sont prescrits inutilement aux urgences médicochirurgicales adultes. Nous avons testé l’hypothèse que la seniorisation de la prescription et le rappel des bonnes indications permettent de réduire la prescription des examens d’hémostase.

Méthodes

Dans une étude rétrospective monocentrique « avant-après », nous avons comparé le nombre d’examens d’hémostase prescrits en 2005, en 2006 et en 2007, avant et après l’instauration en mai 2006 de la seniorisation des demandes de bilans d’hémostase avec une feuille de rappel des bonnes indications de prescription. Le nombre de passages aux urgences a été également colligé.

Résultats

Entre 2005 et 2007, alors que le nombre de passages aux urgences a crû de 5 %, le nombre d’examens d’hémostase prescrits a baissé de 53 %. Le ratio du nombre d’examens d’hémostase sur le nombre de passages est passé de 0,43 à 0,19, le nombre mensuel moyen d’examens est passé de 1 675 ± 186 à 787 ± 101 (p < 0,001). Cette baisse correspond à une économie de 75 000 euros en année pleine.

Conclusion

Les conditions plus strictes de prescription du bilan d’hémostase aux urgences (seniorisation et rappel des bonnes indications) ont permis d’obtenir une diminution de moitié du nombre d’examens demandés, correspondant à une économie substantielle.

Abstract

Objectives

Many biological measurements are not necessary in adult emergency departments. We tested the hypothesis that seniorization of prescription and recall of good indications could reduce the prescription of blood coagulation tests in a medical and surgical adult emergency department (ED).

Methods

We performed a before-after monocentric study. The number of prescribed blood coagulation tests in 2005, 2006 and 2007 were compared before and after new procedures set up in May 2006: control of the prescriptions by the attending physicians and reminder notes of good indications of prescription in the ED. The number of patients admitted into the ED was also collected.

Results

Between 2005 and 2007, while the number of patients consulting the ED grew by 5%, the number of prescribed blood coagulation tests decreased by 53%. The ratio of the number of blood coagulation tests to the number of admitted patients decreased from 0.43 to 0.19 and the mean number of tests per month decreased from 1,675 ± 186 to 787 ± 101 (P < 0.001). This decrease corresponded to a saving of 75,000 Euro full year.

Conclusion

Stringent conditions for prescribing blood coagulation tests in the adult ED (control by the attending physician and recall of good indications) reduced by half the prescriptions, resulting in a substantial saving.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Références

  1. Caisse nationale de l’assurance maladie (2010) Nomenclature des actes de biologie médicale. http://www.codage.ext.cnamts.fr/f_mediam/fo/nabm/DOC.pdf (accès 1er décembre 2010)

  2. Gouault-Heilmann M, Ajzenberg N, Alhenc-Gelas M, et al (2006) Recommandations pour une juste prescription des examens d’hémostase en pratique médicale courante. STV 18:29–42

    Google Scholar 

  3. Agence nationale d’accréditation et d’évaluation en santé, ANAES (1998) Les examens préopératoires systématiques. ANAES - service des recommandations et références professionnelles, pp 40–48

  4. Haute Autorité de santé, HAS (2007) Surveillance des malades atteints de cirrhose non compliquée et prévention primaire des complications, pp 1–153. http://www.has-sante.fr/portail/jcms/c_606530/surveillance-des-malades-atteints-de-cirrhose-non-compliquee-et-prevention-primaire-des-complications (accès 1er décembre 2010)

  5. National Institute for Clinical Excellence (2003) Clinical guideline 3. Preoperative tests: the use of preoperative tests for elective surgery, pp 1–30 (http://www.nice.org.uk/nicemedia/pdf/CG3NICEguideline.pdf) (accès 1er décembre 2010)

  6. Recommandations du groupe d’étude sur l’hémostase et la thrombose (GEHT) (1999) consultables sur: www.geht.org.fr (accès 1er décembre 2010)

  7. Riou B (1998) Bilan préopératoire. Encycl Med Chir, AKOS Encyclopédie Pratique de Médecine 2-0570

  8. Klok FA, Kruisman E, Spaan J, et al (2008) Comparison of the revised Geneva score with the Wells rule for assessing clinical probability of pulmonary embolism. J Thromb Haemost 6:40–44

    Article  PubMed  CAS  Google Scholar 

  9. Perrier A (2006) The Wells clinical prediction guide and D-dimer testing predict deep vein thrombosis. Evid Based Med 11:119

    Article  PubMed  Google Scholar 

  10. Perrier A, Roy PM, Aujesky D, et al (2004) Diagnosing pulmonary embolism in outpatients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: a multicenter management study. Am J Med 116:291–299

    Article  PubMed  Google Scholar 

  11. Wells PS, Anderson DR, Rodger M, et al (2000) Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost 83:416–420

    PubMed  CAS  Google Scholar 

  12. Wicki J, Perneger TV, Junod A, et al (2001) Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 161:92–97

    Article  PubMed  CAS  Google Scholar 

  13. Le Gal G, Righini M, Roy PM, et al (2006) Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 144:165–171

    PubMed  Google Scholar 

  14. Righini M, Le Gal G, Aujesky D, et al (2008) Diagnosis of pulmonary embolism by multidetector computed tomography alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial. Lancet 371:1343–1352

    Article  PubMed  Google Scholar 

  15. Christopher Study Investigators (2006) Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 295:172–179

    Article  Google Scholar 

  16. Righini M, Perrier A, de Moerloose P, et al (2008) D-dimer for venous thromboembolism diagnosis: twenty years later. J Thromb Haemost 6:1059–1071

    Article  PubMed  CAS  Google Scholar 

  17. Kruip MJ, Slob MJ, Schijen JH, et al (2002) Use of a clinical decision rule in combination with D-dimer concentration in diagnostic work-up of patients with suspected pulmonary embolism: a prospective management study. Arch Intern Med 162:1631–1635

    Article  PubMed  Google Scholar 

  18. Perrier A, Roy PM, Sanchez O, et al (2005) Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med 352:1760–1768

    Article  PubMed  CAS  Google Scholar 

  19. Righini M, Aujesky D, Roy PM, et al (2004) Clinical usefulness of D-dimer depending on clinical probability and cut off value in outpatients with suspected pulmonary embolism. Arch Intern Med 164:2483–2487

    Article  PubMed  Google Scholar 

  20. Stein PD, Hull RD, Patel KC, et al (2004) D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med 140:589–602

    PubMed  Google Scholar 

  21. Carrier M, Righini M, Djurabi RK, et al (2009) VIDAS D-dimer in combination with clinical pretest probability to rule out pulmonary embolism. A systematic review of management outcome studies. Thromb Haemost 101:886–892

    PubMed  CAS  Google Scholar 

  22. Rhigini M, Goehring C, Bounameaux H, Perrier A (2000) Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med 109:357–361

    Article  Google Scholar 

  23. Bombeli T, Raddatz-Mueller P, Fehr J (2001) Coagulation activation markers do not correlate with the clinical risk of thrombosis in pregnant women. Am J Obstet Gynecol 184:382–389

    Article  PubMed  CAS  Google Scholar 

  24. Epiney M, Boehlen F, Boulvain M, et al (2005) D-dimer levels during delivery and the postpartum. J Thromb Haemost 3:268–271

    Article  PubMed  CAS  Google Scholar 

  25. Bruinstroop E, van de Ree MA, Huisman MV (2009) The use of D-dimer in specific clinical conditions: a narrative review. Eur J Intern Med 20(5):441–446. Epub 2009 Jan 24

    Article  PubMed  CAS  Google Scholar 

  26. Bounameaux H, Perrier A, Righini M (2010) Diagnosis of venous thromboembolism: an update. Vasc Med 15(5):399–406

    Article  PubMed  Google Scholar 

  27. Tardy B, Tardy-Poncet B, Viallon A, et al (2002) D-dimer levels in patients with suspected acute cerebral venous thrombosis. Am J Med 113:238–241

    Article  PubMed  Google Scholar 

  28. Kosinski CM, Mull M, Schwarz M, et al (2004) Do normal D-dimer levels reliably exclude cerebral sinus thrombosis? Stroke 35:2820–2825

    Article  PubMed  Google Scholar 

  29. Crassard I, Soria C, Tzourio C, et al (2005) A negative D-dimer assay does not rule out cerebral venous thrombosis: a series of seventy-three patients. Stroke 36(8):1716–1719

    Article  PubMed  Google Scholar 

  30. Hassel K (2005) The management of patients with heparininduced thrombocytopenia who require anticoagulant therapy. Chest 127(Suppl 2):1S–8S

    Article  Google Scholar 

  31. Vinceneux P, Deybach C (2010) Évaluation de la prescription des examens complémentaires. Hôpital Louis-Mourier, Colombes. http://portail-cms.aphp.fr/jpbio/IMG/pdf/jpb_lmourier.pdf; http://portail-cms.aphp.fr/jpbio/IMG/ppt/louismourier2.ppt (accès 1er décembre 2010)

    Google Scholar 

  32. Gerbeaux P, Ledoray V, Torro D, et al (2000) Impact de la « seniorisation » sur les prescriptions d’examens de biologie dans un service d’accueil des urgences. Ann Fr Anesth Reanim 19:62–66

    PubMed  CAS  Google Scholar 

  33. Holliman CJ, Wuerz RC, Kimak MJ, et al (1995) Attending supervision of nonemergency medicine residents in a university hospital ED. Am J Emerg Med 13:259–261

    Article  PubMed  CAS  Google Scholar 

  34. Hausfater P, Garric S, Ayed SB, et al (2002) Usefulness of procalcitonin as a marker of systemic infection in emergency department patients: a prospective study. Clin Infect Dis 34:895–901

    Article  PubMed  CAS  Google Scholar 

  35. Hausfater P, Juillien G, Madonna-Py B, et al (2007) Serum procalcitonin measurement as diagnostic and prognostic marker in febrile adult patients presenting to the emergency department. Crit Care 11:R60

    Article  PubMed  Google Scholar 

  36. Trinquart L, Ray P, Riou B, et al (2010) Natriuretic peptide testing in EDs for managing acute dyspnea: a meta-analysis. Am J Emerg Med, Epub ahead May 1, 2010

  37. Ray P, Arthaud M, Lefort Y, et al (2004) EPIDASA Study Group. Usefulness of B-type natriuretic peptide in elderly patients with acute dyspnea. Intensive Care Med 30:2230–2236

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Service d’accueil des urgences, groupe hospitalier Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris (AP-HP), université Pierre-et-Marie-Curie-Paris-VI, 47-83, boulevard de l’Hôpital, F-75651, Paris cedex 13, France

    P. Bonnet, K. Saidi, P. Hausfater, P. Ray & B. Riou

  2. Laboratoire de biologie des urgences, groupe hospitalier Pitié-Salpêtrière (AP-HP), 47-83, boulevard de l’Hôpital, F-75651, Paris cedex 13, France

    C. Devilliers

  3. Service de neurologie, centre hospitalier René-Dubos, 6, avenue de l’Île-de-France, BP 79, F-95303, Cergy-Pontoise cedex, France

    P. Niclot

Authors
  1. P. Bonnet
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. C. Devilliers
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. K. Saidi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. P. Hausfater
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. P. Niclot
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. P. Ray
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. B. Riou
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to P. Bonnet.

Additional information

Travail présenté au congrès de la Société française de médecine d’urgence, Paris, 2007 et 2008.

About this article

Cite this article

Bonnet, P., Devilliers, C., Saidi, K. et al. Impact de la seniorisation et du rappel des bonnes indications sur la prescription d’examens d’hémostase aux urgences pour adultes. Ann. Fr. Med. Urgence 1, 163–169 (2011). https://doi.org/10.1007/s13341-011-0045-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13341-011-0045-4

Mots clés

Keywords

Search

Navigation