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Qureshi MN, Ahmed EN, Ahmed KA, Bashtawi E. Retrospective review of non-ST segment elevation acute coronary syndrome presenting to the emergency department of a major tertiary center in Saudi Arabia. Ann Saudi Med 2024; 44:1-10. [PMID: 38433430 PMCID: PMC10910079 DOI: 10.5144/0256-4947.2024.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/03/2023] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Acute coronary syndrome (ACS) comprises a spectrum of diseases ranging from unstable angina (UA), non-ST elevation myocardial infarction (non-STEMI) and ST elevation myocardial infarction (STEMI). Treatment of ACS without STEMI (NSTEMI-ACS) can vary, depending on the severity of presentation and multiple other factors. OBJECTIVE Analyze the NSTEMI-ACS patients in our institution. DESIGN Retrospective observational. SETTING A tertiary care institution with accredited chest pain center. PATIENTS AND METHODS The travel time from ED booking to the final disposition for patients presenting with chest pain was retrieved over a period of 6 months. The duration of each phase of management was measured with a view to identify the factors that influence their management and time from the ED to their final destination. The data was analyzed using descriptive statistics. MAIN OUTCOME MEASURES Travel time from ED to final destination. SAMPLE SIZE 300 patients. RESULTS The majority of patients were males (64%) between 61 and 80 years of age (45%). The median disposition time (from ED booking to admission order by the cardiology team) was 5 hours and 19 minutes. Cardiology admissions took 10 hours and 20 minutes from ED booking to the inpatient bed. UA was diagnosed in 153 (51%) patients and non-STEMI in 52 (17%). Coronary catheterization was required in 79 (26%) patients, 24 (8%) had coronary artery bypass grafting (CABG) and 8 (3%) had both catheterization and CABG. CONCLUSION The time from ED booking to final destination for NSTEMI-ACS patients is delayed due to multiple factors, which caused significant delays in overall management. Additional interventional steps can help improve the travel times, diagnosis, management and disposition of these patients. LIMITATIONS Single center study done in a tertiary care center so the results from this study may not be extrapolated to other centers.
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Affiliation(s)
- Muhammad Nauman Qureshi
- From the Department of Emergency Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Eman Nayaz Ahmed
- From the College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | - Eyad Bashtawi
- From the Department of Emergency Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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2
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Kim J, Jeong J, Jo YH, Lee JH, Kim YJ, Park SM, Kim J. Impact of an Emergency Department Isolation Policy for Patients With Suspected COVID-19 on Door-to-Electrocardiography Time and Clinical Outcomes in Patients With Acute Myocardial Infarction. J Korean Med Sci 2023; 38:e388. [PMID: 38147837 PMCID: PMC10752746 DOI: 10.3346/jkms.2023.38.e388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/11/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND Rapid electrocardiography diagnosis within 10 minutes of presentation is critical for acute myocardial infarction (AMI) patients in the emergency department (ED). However, the coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the emergency care system. Screening for COVID-19 symptoms and implementing isolation policies in EDs may delay the door-to-electrocardiography (DTE) time. METHODS We conducted a cross-sectional study of 1,458 AMI patients who presented to a single ED in South Korea from January 2019 to December 2021. We used multivariate logistic regression analysis to assess the impact of COVID-19 pandemic and ED isolation policies on DTE time and clinical outcomes. RESULTS We found that the mean DTE time increased significantly from 5.5 to 11.9 minutes (P < 0.01) in ST segment elevation myocardial infarction (STEMI) patients and 22.3 to 26.7 minutes (P < 0.01) in non-ST segment elevation myocardial infarction (NSTEMI) patients. Isolated patients had a longer mean DTE time compared to non-isolated patients in both STEMI (9.2 vs. 24.4 minutes) and NSTEMI (22.4 vs. 61.7 minutes) groups (P < 0.01). The adjusted odds ratio (aOR) for the effect of COVID-19 duration on DTE ≥ 10 minutes was 1.93 (95% confidence interval [CI], 1.51-2.47), and the aOR for isolation status was 5.62 (95% CI, 3.54-8.93) in all patients. We did not find a significant association between in-hospital mortality and the duration of COVID-19 (aOR, 0.9; 95% CI, 0.52-1.56) or isolation status (aOR, 1.62; 95% CI, 0.71-3.68). CONCLUSION Our study showed that ED screening or isolation policies in response to the COVID-19 pandemic could lead to delays in DTE time. Timely evaluation and treatment of emergency patients during pandemics are essential to prevent potential delays that may impact their clinical outcomes.
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Affiliation(s)
- Jinhee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joo Jeong
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, Korea.
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, Korea
| | - Jin Hee Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, Korea
| | - Yu Jin Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, Korea
| | - Seung Min Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, Korea
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3
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Jawade P, Khillare KM, Mangudkar S, Palange A, Dhadwad J, Deshmukh M. A Comparative Study of Ischemia-Modified Albumin: A Promising Biomarker for Early Detection of Acute Coronary Syndrome (ACS). Cureus 2023; 15:e44357. [PMID: 37779796 PMCID: PMC10539834 DOI: 10.7759/cureus.44357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction The second most common cause of emergency department (ED) visits is chest pain and discomfort. Timely identification or threat stratification is crucial for identifying high-risk individuals who benefit from sophisticated diagnostic investigations (including cardiac biomarkers) and early relevant therapies. We aimed to assess the levels of ischemia-modified albumin (IMA) and also to study its sensitivity and specificity in comparison with cardiac troponin T/troponin I and electrocardiogram (ECG) (alone and in combination) in the diagnosis of acute myocardial infarction. Methods Adults (either gender) presented at the ED of a tertiary care centre with classical chest pain suggestive of angina pectoris or angina-like chest pain and ECG changes suggestive of ACS, ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial MI (NSTEMI), and unstable angina, within three hours of onset were enrolled. Demographic and clinical information was recorded. ECG, haematological investigations like complete blood count, blood sugar level, lipid profile, IMA, troponin I, and creatinine kinase-MB (CK-MB), and radiological investigations like 2D-echocardiography (2D-ECHO) and coronary angiography were performed. Results A total of 100 subjects were enrolled in the study out of which 50 were cases and 50 were controls. Cases were older as compared to controls (mean age 60.5 versus 46.0 years). Of the 50 cases, 33 (66%) were males. There were equal numbers of males (33 each) and females (17 each) subjects in both the groups. Typical chest pain, risk factors, and history of coronary artery disease (CAD) were higher in cases. ECG diagnosis revealed the presence of STEMI (52%) and coronary angiography revealed the presence of double vessel CAD (60%) in cases. Among controls, gastroesophageal reflux disorder was the most common cause of chest pain followed by costochondritis and pneumonia. Glucose (fasting and postprandial), all lipid profile parameters (except high-density lipoprotein) and IMA values were significantly higher in cases as compared to controls. A combination of ECG+IMA has the highest sensitivity (90%) with 79% PPV in the diagnosis of ACS within three hours of the onset of chest pain, and ECG+IMA+2D-ECHO had similar results. However, ECG is equally sensitive. IMA alone has 64% sensitivity with 82% diagnostic accuracy which was higher than other biomarkers (CK-MB, cardiac troponin I). Conclusions As found in our study, among the biomarkers used, the diagnostic accuracy of IMA was the highest and better than that of cardiac troponin I and CK-MB. Although ECG is the preferred diagnostic tool for diagnosing ACS (STEMI, NSTEMI, and unstable angina) in patients presenting within three hours of the onset of chest pain, a confirmation can be done with the help of other diagnostic tests and investigations like serum IMA levels and further treatment can be initiated.
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Affiliation(s)
- Pranav Jawade
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Kishor M Khillare
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Sangram Mangudkar
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Amit Palange
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Jagannath Dhadwad
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Madhura Deshmukh
- Central Research Facility, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
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4
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Turner D, Yu J, Murphy D, Chiew A. Triage to electrocardiogram sign-off time in patients with acute coronary syndrome at a metropolitan Sydney hospital. Emerg Med Australas 2023. [PMID: 36796425 DOI: 10.1111/1742-6723.14181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To compare the time from triage to ECG sign-off in patients with acute coronary syndrome, before and after the introduction of an electronic medical record-integrated ECG workflow system (Epiphany). Additionally, to assess for any correlation between patient characteristics and ECG sign-off times. METHODS A retrospective, single-centre cohort study was performed at Prince of Wales Hospital, Sydney. Patients were included if they were over 18 years, presented to Prince of Wales Hospital ED during 2021, had an ED diagnosis code of 'ACS', 'UA', 'NSTEMI' or 'STEMI' and were subsequently admitted under the cardiology team. ECG sign-off times and demographic data were compared between patients presenting prior to 29 June (pre-Epiphany group) and those presenting after (post-Epiphany group). Those without ECGs signed-off were excluded. RESULTS There were 200 patients (100 each group) included in the statistical analysis. There was a significant decrease in the median triage to ECG sign-off time, from 35 min (IQR 18-69) pre-Epiphany, to 21 min (IQR 13-37) post-Epiphany. There were only 10 (5%) patients in the pre-Epiphany group and 16 (8%) in the post-Epiphany group, who had ECG sign-off times less than the 10-min. There was no correlation between gender, triage category, age or time of shift with triage to ECG sign-off time. CONCLUSIONS The introduction of the Epiphany system has significantly reduced the triage to ECG sign-off time in the ED. Despite this, there remains a large proportion of patients with acute coronary syndrome who do not have an ECG signed-off within the guideline-recommended 10 min.
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Affiliation(s)
- Dane Turner
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Jennifer Yu
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Cardiology Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - David Murphy
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Angela Chiew
- Prince of Wales Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
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5
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Bunney G, Sundaram V, Graber-Naidich A, Miller K, Brown I, McCoy AB, Freeze B, Berger D, Wright A, Yiadom MYAB. Beyond chest pain: Incremental value of other variables to identify patients for an early ECG. Am J Emerg Med 2023; 67:70-78. [PMID: 36806978 DOI: 10.1016/j.ajem.2023.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Chest pain (CP) is the hallmark symptom for acute coronary syndrome (ACS) but is not reported in 20-30% of patients, especially women, elderly, non-white patients, presenting to the emergency department (ED) with an ST-segment elevation myocardial infarction (STEMI). METHODS We used a retrospective 5-year adult ED sample of 279,132 patients to explore using CP alone to predict ACS, then we incrementally added other ACS chief complaints, age, and sex in a series of multivariable logistic regression models. We evaluated each model's identification of ACS and STEMI. RESULTS Using CP alone would recommend ECGs for 8% of patients (sensitivity, 61%; specificity, 92%) but missed 28.4% of STEMIs. The model with all variables identified ECGs for 22% of patients (sensitivity, 82%; specificity, 78%) but missed 14.7% of STEMIs. The model with CP and other ACS chief complaints had the highest sensitivity (93%) and specificity (55%), identified 45.1% of patients for ECG, and only missed 4.4% of STEMIs. CONCLUSION CP alone had highest specificity but lacked sensitivity. Adding other ACS chief complaints increased sensitivity but identified 2.2-fold more patients for ECGs. Achieving an ECG in 10 min for patients with ACS to identify all STEMIs will be challenging without introducing more complex risk calculation into clinical care.
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Affiliation(s)
- Gabrielle Bunney
- Department of Emergency Medicine, Stanford University, Palo Alto, CA, United States of America
| | - Vandana Sundaram
- Quantitative Sciences Unit, Stanford University, Palo Alto, CA, United States of America
| | - Anna Graber-Naidich
- Quantitative Sciences Unit, Stanford University, Palo Alto, CA, United States of America
| | - Katharine Miller
- Quantitative Sciences Unit, Stanford University, Palo Alto, CA, United States of America
| | - Ian Brown
- Department of Emergency Medicine, Stanford University, Palo Alto, CA, United States of America
| | - Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Brian Freeze
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ, United States of America
| | - David Berger
- Department of Emergency Medicine, Beaumont Royal Oak Hospital, Royal Oak, MI, United States of America
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Maame Yaa A B Yiadom
- Department of Emergency Medicine, Stanford University, Palo Alto, CA, United States of America.
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6
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Yoo S, Chang H, Kim T, Yoon H, Hwang SY, Shin TG, Sim MS, Jo IJ, Choi JH, Cha WC. Intervention in the timeliness of two ECG types for emergency department patients with chest pain: randomized controlled trial (Preprint). Interact J Med Res 2022; 11:e36335. [PMID: 36099010 PMCID: PMC9516380 DOI: 10.2196/36335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/07/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background In the emergency department (ED), the result obtained using the 12-lead electrocardiography (ECG) is the basis for diagnosing and treating patients with chest pain. It was found that performing ECG at the appropriate time could improve treatment outcomes. Hence, a wearable ECG device with a timer can ensure that the findings are continuously recorded. Objective We aimed to compare the time accuracy of a single-patch 12-lead ECG (SP-ECG) with that of conventional ECG (C-ECG). We hypothesized that SP-ECG would result in better time accuracy. Methods Adult patients who visited the emergency room with chest pain but were not in shock were randomly assigned to one of the following 2 groups: the SP-ECG group or the C-ECG group. The final analysis included 33 (92%) of the 36 patients recruited. The primary outcome was the comparison of the time taken by the 2 groups to record the ECG. The average ages of the participants in the SP-ECG and C-ECG groups were 63.7 (SD 18.4) and 58.1 (SD 12.4) years, respectively. Results With a power of 0.95 and effect sizes of 0.05 and 1.36, the minimum number of samples was calculated. The minimum sample size for each SP-ECG and C-ECG group is 15.36 participants, assuming a 20% dropout rate. As a result, 36 patients with chest pain participated, and 33 of them were analyzed. The timeliness of SP-ECG and C-ECG for the first follow-up ECG was 87.5% and 47.0%, respectively (P=.74). It was 75.0% and 35.2% at the second follow-up, respectively (P=.71). Conclusions Continuous ECG monitoring with minimal interference from other examinations is feasible and essential in complex ED situations. However, the precision of SP-ECG has not yet been proved. Nevertheless, the application of SP-ECG is expected to improve overcrowding and human resource shortages in EDs, though more research is needed. Trial Registration ClinicalTrials.gov NCT04114760; https://clinicaltrials.gov/ct2/show/NCT04114760
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Affiliation(s)
- Suyoung Yoo
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology, Sungkyunkwan University, Seoul, Republic of Korea
| | - Hansol Chang
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute for Health Science & Technology, Sungkyunkwan University, Seoul, Republic of Korea
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Health Information and Strategy Center, Samsung Medical Center, Seoul, Republic of Korea
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7
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Villarroel NA, Houghton CJ, Mader SC, Poronsky KE, Deutsch AL, Mader TJ. A prospective analysis of time to screen protocol ECGs in adult Emergency Department triage patients. Am J Emerg Med 2021; 46:23-26. [PMID: 33706253 DOI: 10.1016/j.ajem.2020.03.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/28/2020] [Accepted: 03/15/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Early identification of ST elevation MI (STEMI) in emergency departments (ED) via electrocardiogram (ECG) expedites intervention. While screening of all ED chest pain ECGs should be obtained within 10 minutes per the American Heart Association, 40% of all ECGs are software-analyzed as "Normal" or "Otherwise Normal." However, the reliability of this analysis and the time for confirmation read are uncertain. This study investigates the time necessary for Patient Care Technicians (PCTs) to deliver ECGs to ED attendings to confirm automated interpretation. METHODS A prospective cohort study was conducted at a single academic ED. All patients ≥18 years who had a triage ECG were included. ECGs were obtained within 10 min of arrival, time-stamped, delivered for ED attending review and time-stamped upon PCT return to triage. Data were entered into REDCap and analyzed using StatPlus. RESULTS During the 4-month study, 1768 ECGs were collected. Distribution of automated readings was: "Normal ECG" 33.7%; "Otherwise Normal ECG" 11.2%; and "borderline/abnormal" 55.1%. The median time necessary for PCTs to confirm a screening ECG was 2.8 min (IQR 2,4) with attending physicians interrupted an average of 14.6 times per day. CONCLUSION Screening of triage ECGs is time-intensive and compounds the frequency of physician interruptions. Although findings are not generalizable, the impact of these interruptions on patient care and safety is paramount and universal. Future directions include validating the reliability of "Normal" and "Otherwise Normal" ECG automated readings to obviate the need to interrupt ED physician for expedited screening confirmation.
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Affiliation(s)
- Nadia A Villarroel
- University of Massachusetts Medical School-Baystate Medical Center, Department of Emergency Medicine, 759 Chestnut Street, Springfield, MA 01199, USA.
| | - Connor J Houghton
- University of Massachusetts Medical School-Baystate Medical Center, Department of Emergency Medicine, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Shelby C Mader
- University of Massachusetts Medical School-Baystate Medical Center, Department of Emergency Medicine, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Kye E Poronsky
- University of Massachusetts Medical School-Baystate Medical Center, Department of Emergency Medicine, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Ashley L Deutsch
- University of Massachusetts Medical School-Baystate Medical Center, Department of Emergency Medicine, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Timothy J Mader
- University of Massachusetts Medical School-Baystate Medical Center, Department of Emergency Medicine, 759 Chestnut Street, Springfield, MA 01199, USA
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8
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McLaren JT, Kapoor M, Yi SL, Chartier LB. Using ECG-To-Activation Time to Assess Emergency Physicians’ Diagnostic Time for Acute Coronary Occlusion. J Emerg Med 2021; 60:25-34. [DOI: 10.1016/j.jemermed.2020.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/24/2020] [Accepted: 09/12/2020] [Indexed: 12/27/2022]
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9
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Bahbah EI, Noehammer C, Pulverer W, Jung M, Weinhaeusel A. Salivary biomarkers in cardiovascular disease: An insight into the current evidence. FEBS J 2020; 288:6392-6405. [PMID: 33370493 DOI: 10.1111/febs.15689] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/28/2020] [Accepted: 12/23/2020] [Indexed: 01/08/2023]
Abstract
Cardiovascular diseases (CVDs) are the most common cause of mortality worldwide. In acute cardiovascular conditions, time is a crucial player in the outcomes of disease management. Given the ease and noninvasiveness of obtaining saliva, salivary biomarkers may provide a rapid and efficient diagnosis of CVD. Here, we reviewed the published data on the value of salivary molecules for diagnosis of CVD, especially in acute care settings. In this review, we show that some biomarkers such as salivary creatinine kinase myocardial band, C-reactive protein, troponin-1, and myoglobin exhibited promising diagnostic values that were comparable to their serum counterparts. Other molecules were also investigated and showed controversial results, including myeloperoxidase, brain natriuretic peptide, and some oxidative stress markers. Based on our review, we concluded that the clinical use of salivary biomarkers to diagnose CVD is promising; however, it is still in the early stage of development. Further studies are needed to validate these findings, determine cutoff values for diagnosis, and compare them to other established biomarkers currently in clinical use.
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Affiliation(s)
- Eshak I Bahbah
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria.,Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | - Christa Noehammer
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Walter Pulverer
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Martin Jung
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria
| | - Andreas Weinhaeusel
- AIT Molecular Diagnostics, Center for Health & Bioresources, AIT Austrian Institute of Technology GmbH, Vienna, Austria
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10
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France DJ, Levin S, Ding R, Hemphill R, Han J, Russ S, Aronsky D, Weinger M. Factors Influencing Time-Dependent Quality Indicators for Patients With Suspected Acute Coronary Syndrome. J Patient Saf 2020; 16:e1-e10. [PMID: 26756723 PMCID: PMC4940339 DOI: 10.1097/pts.0000000000000242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Rapid risk stratification and timely treatment are critical to favorable outcomes for patients with acute coronary syndrome (ACS). Our objective was to identify patient and system factors that influence time-dependent quality indicators (QIs) for patients with unstable angina/non-ST elevation myocardial infarction (NSTEMI) in the emergency department (ED). METHODS A retrospective, cohort study was conducted during a 42-month period of all patients 24 years or older suspected of having ACS as defined by receiving an electrocardiogram and at least 1 cardiac biomarker test. Cox regression was used to model the effects of patient characteristics, ancillary service use, staffing provisions, equipment availability, and ED and hospital crowding on ACS QIs. RESULTS Emergency department adherence rates to national standards for electrocardiogram readout time and biomarker turnaround time were 42% and 37%, respectively. Cox regression models revealed that chief complaints without chest pain and the timing of stress testing and medication administration were associated with the most significant delays. CONCLUSIONS Patient and system factors both significantly influenced QI times in this cohort with unstable angina/NSTEMI. These results illustrate both the complexity of diagnosing patients with NSTEMI and the competing effects of clinical and system factors on patient flow through the ED.
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Affiliation(s)
- Daniel J France
- From the Department of Anesthesiology, Vanderbilt Medical Center, Nashville, Tennessee
| | - Scott Levin
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ru Ding
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robin Hemphill
- National Center for Patient Safety, Veterans Affairs, Ann Arbor, Michigan
| | - Jin Han
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Stephan Russ
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Dominik Aronsky
- Department of Emergency Medicine, Vanderbilt Medical Center, Nashville, Tennessee
| | - Matt Weinger
- From the Department of Anesthesiology, Vanderbilt Medical Center, Nashville, Tennessee
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11
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Ratnovsky A, Rozenes S, Halpern P. Establishment of a Unified Quality Indicators System to Increase the Effectiveness of Emergency Departments. ACTA ACUST UNITED AC 2019. [DOI: 10.4018/ijissc.2019100101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The overall quality of an emergency department (ED) can be measured by its ability to provide fast, efficient yet high-quality medical treatments to its patients. The objective of the present study was to derive a common set of key indicators that could be used to assess the quality of the performance of EDs. A modified Delphi process was employed to achieve this. This consisted of a detailed literature review followed by a three-round expert panel interaction, which was used to reduce and refine the list of indicators. The members of the panel comprised ED physicians, ED nurses and hospital and ED administrators drawn from six EDs. This process yielded 47 essential performance indicators and 12 recommended indicators. The performance indicators were classified into 7 main groups according to their characteristics. The chosen indicators comprise a core set that will be used in an ongoing study on a representative sample of EDs.
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Affiliation(s)
- Anat Ratnovsky
- Afeka Tel Aviv Academic College of Engineering, Tel Aviv, Israel
| | - Shai Rozenes
- Engineering and Management of Service Systems, Afeka Tel Aviv Academic College of Engineering, Tel Aviv, Israel
| | - Pinchas Halpern
- Tel Aviv Sourasky Medical Center and Tel Aviv University, Sackler Faculty of Medicine, Tel Aviv, Israel
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12
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Interventions to reduce emergency department door-to- electrocardiogram times: A systematic review. CAN J EMERG MED 2019; 21:607-617. [DOI: 10.1017/cem.2019.342] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjectivesWe sought to identify emergency department interventions that lead to improvement in door-to-electrocardiogram (ECG) times for adults presenting with symptoms suggestive of acute coronary syndrome.MethodsTwo reviewers searched Medline, Embase, CINAHL, and Cochrane CENTRAL from inception to April 2018 for studies in adult emergency departments with an identifiable intervention to reduce median door-to-ECG times when compared with the institution's baseline. Quality was assessed using the Quality Improvement Minimum Quality Criteria Set critical appraisal tool. The primary outcome was the absolute median reduction in door-to-ECG times as calculated by the difference between the post-intervention time and pre-intervention time.ResultsTwo reviewers identified 809 unique articles, yielding 11 before-after quality improvement studies that met eligibility criteria (N = 15,622 patients). The majority of studies (10/11) reported bundled interventions, and most (10/11) showed statistical improvement in door-to-ECG times. The most common interventions were having a dedicated ECG machine and technician in triage (5/11); improved triage education (4/11); improved triage disposition (2/11); and data feedback mechanisms (2/11).ConclusionsThere are multiple interventions that show potential for reducing emergency department door-to-ECG times. Effective bundled interventions include having a dedicated ECG technician, triage education, and better triage disposition. These changes can help institutions attain best practice guidelines. Emergency departments must first understand their local context before adopting any single or group of interventions.
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Abstract
BACKGROUND Adherence to guidelines for the initial treatment of ST-Segment Elevation Myocardial Infarction has been thoroughly studied, whereas the study of emergency department (ED) adherence to guidelines for Non-ST-Segment Elevation Myocardial Infarction-Acute Coronary Syndrome (NSTEMI-ACS) has been much scarcer. The recommended guidelines for the initial prompt workup and treatment of NSTEMI-ACS remains a challenge. AIM We studied adherence to guidelines for NSTEMI in the ED. METHODS A single-center, retrospective study of consecutive patients with NSTEMI admitted to a tertiary hospital and discharged alive between March 2013 and March 2014. ED records were manually reviewed for adherence to prespecified parameters. Cases with sudden death, shock, or type-II NSTEMI were excluded. Canadian Triage and Acuity Scale score system was used for triage in the ED. RESULTS Adherence rates were 33.3%/24.6% of 240 patients for ECG/troponin obtained within 10/60 minutes receptively and 31.3% for anticoagulation within 15 minutes from diagnosis of ACS. Females were less likely to undergo electrocardiography (P = 0.009) or troponin-level tests within the specified timeframe (P = 0.043). Many cardiovascular risk markers were missed. Global Registry of Acute Coronary Events score was not used to risk stratify patients. CONCLUSIONS Prompt identification and early medical treatment of NSTEMI in the ED is lacking. Better computerized medical history assembly, attention to typical and atypical clinical presentation, and the employment of an appropriate cardiologic risk stratification method may unblind the treating teams at the point of care and improve adherence to NSTEMI guidelines.
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Stanfield L. Improvement of Door-to-Electrocardiogram Time Using the First-Nurse Role in the ED Setting. J Emerg Nurs 2018; 44:466-471. [DOI: 10.1016/j.jen.2017.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/29/2017] [Accepted: 12/23/2017] [Indexed: 01/07/2023]
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Yiadom MYAB, Mumma BE, Baugh CW, Patterson BW, Mills AM, Salazar G, Tanski M, Jenkins CA, Vogus TJ, Miller KF, Jackson BE, Lehmann CU, Dorner SC, West JL, Wang TJ, Collins SP, Dittus RS, Bernard GR, Storrow AB, Liu D. Measuring outcome differences associated with STEMI screening and diagnostic performance: a multicentred retrospective cohort study protocol. BMJ Open 2018; 8:e022453. [PMID: 29724744 PMCID: PMC5942471 DOI: 10.1136/bmjopen-2018-022453] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Advances in ST-segment elevation myocardial infarction (STEMI) management have involved improving the clinical processes connecting patients with timely emergency cardiovascular care. Screening upon emergency department (ED) arrival for an early ECG to diagnose STEMI, however, is not optimal for all patients. In addition, the degree to which timely screening and diagnosis are associated with improved time to intervention and postpercutaneous coronary intervention outcomes, under more contemporary practice conditions, is not known. METHODS We present the methods for a retrospective multicentre cohort study anticipated to include 1220 patients across seven EDs to (1) evaluate the relationship between timely screening and diagnosis with treatment and postintervention clinical outcomes; (2) introduce novel measures for cross-facility performance comparisons of screening and diagnostic care team performance including: door-to-screening, door-to-diagnosis and door-to-catheterisation laboratory arrival times and (3) describe the use of electronic health record data in tandem with an existing disease registry. ETHICS AND DISSEMINATION The completion of this study will provide critical feedback on the quality of screening and diagnostic performance within the contemporary STEMI care pathway that can be used to (1) improve emergency care delivery for patients with STEMI presenting to the ED, (2) present novel metrics for the comparison of screening and diagnostic care and (3) inform the development of screening and diagnostic support tools that could be translated to other care environments. We will disseminate our results via publication and quality performance data sharing with each site. Institutional ethics review approval was received prior to study initiation.
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Affiliation(s)
- Maame Yaa A B Yiadom
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California at Davis, Sacramento, California, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Brian W Patterson
- Department of Emergency Medicine, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University Medical Center, New York, USA
| | - Gilberto Salazar
- Department of Emergency Medicine, Parkland Hospital, University of Texas Southwestern, Dallas, Texas, USA
| | - Mary Tanski
- Department of Emergency Medicine, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Cathy A Jenkins
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Timothy J Vogus
- Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee, USA
| | - Karen F Miller
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Brittney E Jackson
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Christoph U Lehmann
- Department of Biomedical Informatics, Vanderbilt University, Nashville, Tennessee, USA
| | - Stephen C Dorner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Jennifer L West
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Thomas J Wang
- Division of Cardiology, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Robert S Dittus
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Gordon R Bernard
- Division of Critical Care, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
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Tsai KC, Lin RF, Lee C, Li AH. An alternative tool for triaging patients with possible acute coronary symptoms before admission to a chest pain unit. Am J Emerg Med 2018; 36:1222-1230. [PMID: 29338968 DOI: 10.1016/j.ajem.2017.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 12/08/2017] [Accepted: 12/09/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This study aimed to develop a triage tool to more effectively triage possible ACS patients presenting to the emergency department (ED) before admission to a protocol-driven chest pain unit (CPU). METHODS Seven hundred ninety-three clinical cases, randomly selected from 7962 possible ACS cases, were used to develop and test an ACS triage model using cluster analysis and stepwise logistic regression. RESULTS The ACS triage model, logit (suspected ACS patient)=-5.283+1.894×chest pain+1.612×age+1.222×male+0.958×proximal radiation pain+0.962×shock+0.519×acute heart failure, with a threshold value set at 2.5, was developed to triage patients. Compared to four existing methods, the chest-pain strategy, the Zarich's strategy, the flowchart, and the heart broken index (HBI), the ACS triage model had better performance. CONCLUSION This study developed an ACS triage model for triaging possible ACS patients. The model could be used as a rapid tool in EDs to reduce the workloads of ED nurses and physicians in relation to admissions to the CPU.
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Affiliation(s)
- Kuang-Chau Tsai
- Department of Emergency, Far Eastern Memorial Hospital, 21 Sec. 2, Nanya S. Rd., New Taipei City, Taiwan 220
| | - Ray F Lin
- Department of Industrial Engineering and Management, Yuan Ze University, 135 Yuan-Tung Rd., Chung-Li, Taiwan 32003.
| | - Chieh Lee
- Department of Industrial Engineering and Management, Yuan Ze University, 135 Yuan-Tung Rd., Chung-Li, Taiwan 32003
| | - Ai-Hsien Li
- Department of Cardiology, Far Eastern Memorial Hospital, 21 Sec. 2, Nanya S. Rd., New Taipei City, Taiwan 220
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Hughes JA, Cabilan CJ, Young C, Staib A. Effect of the 4-h target on ‘time-to-ECG’ in patients presenting with chest pain to an emergency department: a pilot retrospective observational study. AUST HEALTH REV 2018; 42:196-202. [DOI: 10.1071/ah16263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 02/01/2017] [Indexed: 12/17/2022]
Abstract
Objectives
The aim of this study was to assess the relationship between compliance with time-based Emergency Department (ED) targets (known as NEAT) and the time taken to collect an electrocardiogram (TTE) in patients presenting with chest pain.
Methods
This was a pilot descriptive retrospective cohort study completed in a large inner city tertiary ED. Patients who presented with active or recent chest pain between July 2014 and June 2015 were eligible for inclusion. Pregnant patients, inter-hospital transfers, and traumatic chest pain were excluded. A random selection of 300 patients from the eligible cohort comprised the final sample. The differences of TTE between categories of NEAT compliance were compared using Kruskal-Wallis test. Also, the factors affecting with the acquisition of ECG within ten minutes of arrival were explored using proportional hazards regression.
Results
There was a significant inverse association between the percentage of admitted patients leaving the ED within four hours (admitted NEAT) and TTE. As admitted NEAT compliance increased TTE decreased (p = 0.004). A number of variables including triage score, arrival time, total NEAT, first location, doctor wait time, and cardiac diagnosis were all significant predictors of TTE. After adjusting for other variables Admitted NEAT remained as an independent predictor of TTE.
Conclusion
There is likely to be a relationship between NEAT and TTE that is reflective of overall hospital and not just ED functioning; however the exact relationship remains uncertain. Further study in a multisite study is warranted to further explore the relationship between NEAT, TTE and other important clinical metrics of ED performance.
What is known about the topic?
The 4-h time target or National Emergency Access Target (NEAT) is implemented in Australia to ease crowding and access block. However, little is known of its effect on important clinical endpoints, particularly ‘time-to-ECG’ (TTE).
What does this paper add?
This paper demonstrates a complex relationship between measures of time-based targets, such as time to ECG. It is likely that increasing compliance with admitted NEAT shortens TTE, demonstrating the effect of hospital functioning on the ability to deliver quality care in the emergency department.
What are the implications for practitioners?
Emergency department flow has an effect on the ability of the department to deliver key assessment. There is a relationship between NEAT compliance and TTE, but the exact relationship requires further exploration in larger multicentre studies.
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Mirhaghi A. Combination of clinical and ECG criteria may increase validity of triage scales. Intern Emerg Med 2017; 12:1331-1332. [PMID: 27987065 DOI: 10.1007/s11739-016-1588-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Amir Mirhaghi
- Evidence-Based Caring Research Center, Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Chahrrahe-Doktorha, Mashhad, Razavi Khorasan, 9137913199, Iran.
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Alnsasra H, Zahger D, Geva D, Matetzky S, Beigel R, Iakobishvili Z, Alcalai R, Atar S, Shimony A. Contemporary Determinants of Delayed Benchmark Timelines in Acute Myocardial Infarction in Men and Women. Am J Cardiol 2017; 120:1715-1719. [PMID: 28864323 DOI: 10.1016/j.amjcard.2017.07.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 07/20/2017] [Accepted: 07/20/2017] [Indexed: 11/29/2022]
Abstract
Treatment delays in patients with acute myocardial infarction (AMI) are related to increased morbidity and mortality. Hence, identifying determinants of delay may help reduce time to treatment. Importantly, limited data suggest that there may be sex-related disparities in benchmark timelines. Although guidelines advocate the use of the first medical contact (FMC) rather than hospital admission as the moment from which delays to treatment should be monitored, the latter is still often used for quality purposes. We aimed to identify factors associated with treatment delays, with an emphasis on sex-related disparities. We reviewed data on 3,658 patients with AMI from 2 contemporary, consecutive multicenter surveys. Measured delays were FMC-to-electrocardiogram >10 minutes in ST-elevation MI (STEMI) and non-STEMI, FMC-to-primary percutaneous coronary intervention >90 minutes in STEMI, and invasive angiography >72 hours after admission in non-STEMI patients. Timely electrocardiogram was performed in 48% of patients with STEMI and in 39.8% of non-STEMI patients without significant sex-related differences. Independent determinants of delay included atypical chest pain (CP) and presentation during daytime. In patients with STEMI, 37.5% had primary percutaneous coronary intervention in less than 90 minutes without significant sex-related disparities. Independent determinants of delay included atypical CP, night presentation, and diabetes. In non-STEMI patients, independent determinants of delayed invasive approach were female sex, age >75 years, atypical CP, and renal failure. In conclusion, significant treatment delays in patients with AMI are still frequent in contemporary practice, highlighting the need for improvement and guidelines implementation. Predictors of delay identified in our study may facilitate targeting of interventions to improve adherence to guidelines.
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Affiliation(s)
- Hilmi Alnsasra
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Diklah Geva
- Department of Cardiology, Sheba Medical Center, Tel-Hashomer, Sackler school of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shlomi Matetzky
- Department of Cardiology, Sheba Medical Center, Tel-Hashomer, Sackler school of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Beigel
- Department of Cardiology, Sheba Medical Center, Tel-Hashomer, Sackler school of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zaza Iakobishvili
- Department of Cardiology, Rabin Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ronny Alcalai
- Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Bar-Ilan University, Naharya, Israel
| | - Avi Shimony
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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Gutiérrez-Corrales A, Campano-Cuevas E, Castillo-Dalí G, Torres-Lagares D, Gutiérrez-Pérez JL. Ability of salivary biomarkers in the prognostic of systemic and buccal inflammation. J Clin Exp Dent 2017; 9:e716-e722. [PMID: 28512552 PMCID: PMC5429487 DOI: 10.4317/jced.53776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 03/08/2017] [Indexed: 12/18/2022] Open
Abstract
Nowadays, there is a growing interest in using saliva as an alternative sample for the diagnosis, prediction and progression of several diseases. It has been established that some molecules found in saliva are related to oral inflammatory processes and systemic health status. Furthermore, it is known that saliva is crucial for the carrying out of different functions in the oral cavity and its role in the local modulation of inflammatory and immune response is being thoroughly studied by the health research community. The aim of this review is to analyze the most important biomarkers which have been utilized in biomedicine during the last two decades in order to establish a correlation between certain specific salivary biomarkers and systemic inflammation. Then, we discuss the utility of total proteins, immunoglobulin A and alpha-amylase as biomarkers for the prognostic of local inflammation after oral surgery.
Key words:Inflammation, salivary biomarkers, systemic disease, buccal surgery, total proteins, inmunoglobulin A, Alpha-amylase.
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Kang J, Kim J, Jo YH, Kim K, Lee JH, Kim T, Lee J, Hwang JE, Jung E. ED crowding and the outcomes of out-of-hospital cardiac arrest. Am J Emerg Med 2015; 33:1659-64. [PMID: 26324002 DOI: 10.1016/j.ajem.2015.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 07/27/2015] [Accepted: 08/02/2015] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Emergency department (ED) overcrowding is a worldwide problem associated with adverse outcomes. This study was performed to investigate the association between ED overcrowding and the outcomes and quality of cardiopulmonary resuscitation for out-of-hospital cardiac arrest (OHCA). METHODS Prospectively collected data including patients' demographics, Utstein factors, and outcomes on 608 consecutive OHCA patients at a single ED from January 2008 to December 2012 were retrospectively analyzed. The patients were categorized into 4 groups according to ED occupancy rate. The primary outcome was resuscitation outcome, a composite of rates of return of spontaneous circulation (ROSC), survival at discharge, and neurologic outcome at 6months. The secondary outcome was resuscitation quality assessed by time to advanced airway, time to first drug administration, resuscitation duration in refractory cases, and rate of initiation of therapeutic hypothermia after ROSC in the ED. RESULTS There was no significant difference in rates of ROSC, survival at discharge, and good neurologic outcome according to ED occupancy rate in the univariate and multivariate analyses (P>.05). In addition, ED overcrowding was not associated with resuscitation quality (P>.05). CONCLUSION Emergency department overcrowding was not associated with the outcomes of OHCA or resuscitation quality.
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Affiliation(s)
- Jiwon Kang
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gyeonggi-do 463-707, Republic of Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gyeonggi-do 463-707, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gyeonggi-do 463-707, Republic of Korea.
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gyeonggi-do 463-707, Republic of Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gyeonggi-do 463-707, Republic of Korea
| | - Taeyun Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gyeonggi-do 463-707, Republic of Korea
| | - Jungyoup Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gyeonggi-do 463-707, Republic of Korea
| | - Ji Eun Hwang
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gyeonggi-do 463-707, Republic of Korea
| | - Euigi Jung
- Department of Emergency Medicine, Seoul National University Bundang Hospital 82, Gyeonggi-do 463-707, Republic of Korea
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Sprockel JJ, Tovar Diaz LP, Omaña Orduz OP, Saavedra MA, Chaves Santiago WG, Diaztagle Fernández JJ. Optimization of door-to-electrocardiogram time within a critical pathway for the management of acute coronary syndromes at a teaching hospital in Colombia. Crit Pathw Cardiol 2015; 14:25-30. [PMID: 25679084 DOI: 10.1097/hpc.0000000000000034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Door-to-electrocardiogram (D2E) time is recognized as one of the quality parameters in the attention of acute coronary syndromes. Electrocardiogram realization within periods below 10 minutes increases the possibility to achieve quick and effective reperfusion, which has an impact on outcomes. OBJECTIVE To describe the results of a strategy whose goal is to improve the fulfillment of the D2E deadline below 10 minutes in adults who attend the emergency service due to chest pain with clinical suspicion of acute coronary syndromes. METHODS Before-and-after study that assesses D2E time upon the implementation of actions for the reorganization of the process of attention of the patients with chest pain within the context of the implementation of a critical pathway. RESULTS A total of 373 patients were assessed, 204 in the before stage and 169 in the after stage. The median D2E time was 16 minutes in the before stage, in 41% of the cases it was below 10 minutes; upon the implementation of the change in the process of attention of chest pain the median was 5 minutes, with 63% of the cases below 10 minutes, exhibiting a statistically significant difference. CONCLUSIONS The actions taken led to a lower median of D2E time and a higher percentage of patients with times below 10 minutes. However, further interventions are required to assure a higher number of patients with D2E times below 10 minutes.
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Affiliation(s)
- John Jaime Sprockel
- From the *Division of Research, Department of Internal Medicine, Fundación Universitaria de Ciencias de la Salud, Hospital de San José, Bogotá, Colombia and †Department of Physiological Sciences, Universidad Nacional de Colombia, Bogotá, Colombia
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Coyne CJ, Testa N, Desai S, Lagrone J, Chang R, Zheng L, Kim H. Improving door-to-balloon time by decreasing door-to-ECG time for walk-in STEMI patients. West J Emerg Med 2014; 16:184-9. [PMID: 25671039 PMCID: PMC4307715 DOI: 10.5811/westjem.2014.10.23277] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 10/01/2014] [Accepted: 10/13/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction The American Heart Association/American College of Cardiology guidelines recommend rapid door-to-electrocardiography (ECG) times for patients with ST-segment elevation myocardial infarction (STEMI). Previous quality improvement research at our institution revealed that we were not meeting this benchmark for walk-in STEMI patients. The objective is to investigate whether simple, directed changes in the emergency department (ED) triage process for potential cardiac patients could decrease door-to-ECG times and secondarily door-to-balloon times. Methods We conducted an interventional study at a large, urban, public teaching hospital from April 2010 to June 2012. All patients who walked into the ED with a confirmed STEMI were enrolled in the study. The primary intervention involved creating a chief complaint-based “cardiac triage” designation that streamlined the evaluation of potential cardiac patients. A secondary intervention involved moving our ECG technician and ECG station to our initial triage area. The primary outcome measure was door-to-ECG time and the secondary outcome measure was door-to-balloon time. Results We enrolled 91 walk-in STEMI patients prior to the intervention period and 141 patients after the invention. We observed statistically significant reductions in door-to-ECG time (43±93 to 30±72 minutes, median 23 to 14 minutes p<0.01), ECG-to-activation time (87±134 to 52±82 minutes, median 43 to 31 minutes p<0.01), and door-to-balloon time (134±146 to 84±40 minutes, median 85 -75 minutes p=0.03). Conclusion By creating a chief complaint-based cardiac triage protocol and by streamlining ECG completion, walk-in STEMI patients are systematically processed through the ED. This is not only associated with a decrease in door-to-balloon time, but also a decrease in the variability of the time sensitive intervals of door-to-ECG and ECG-to-balloon time.
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Affiliation(s)
- Christopher J Coyne
- Los Angeles County/University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Nicholas Testa
- Los Angeles County/University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Shoma Desai
- Los Angeles County/University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Joy Lagrone
- Los Angeles County/University of Southern California, Los Angeles, California
| | - Roger Chang
- Los Angeles County/University of Southern California, Los Angeles, California
| | - Ling Zheng
- Los Angeles County/University of Southern California, Los Angeles, California
| | - Hyung Kim
- Los Angeles County/University of Southern California, Department of Emergency Medicine, Los Angeles, California
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Delay and inequality in treatment of the elderly with suspected acute coronary syndrome. Int J Cardiol 2014; 176:946-50. [PMID: 25189499 DOI: 10.1016/j.ijcard.2014.08.109] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 08/06/2014] [Accepted: 08/17/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND/OBJECTIVES The aim of this study is to determine differences between elderly patients (≥80 years) and younger patients with suspected acute coronary syndrome (ACS) regarding delay times before diagnostic tests and treatments. METHODS All patients with chest pain who were admitted to a hospital in the Gothenburg area were included consecutively over a 3-month period. They were divided into an elderly group (≥80 years) and a reference group (<80 years). Previous medical history, ECG findings, treatments, diagnostic tests, and delay times were registered. RESULTS Altogether, 2588 patients were included (478 elderly and 2110 reference). There were no significant differences in delay time to hospital ward admission, to first medical therapy with aspirin, or to investigation with coronary angiography (CA) between the two groups. The elderly patients had a significantly shorter median time from first medical contact to first ECG (12 vs. 14 min, p=0.002) but after adjustment for confounding factors, especially mode of transport, the opposite was found to be the case (p=0.002). Elderly hospitalized patients with ACS were less often investigated with CA (44% vs. 89%, p<0.0001) and received less medical treatment with P2Y12 antagonists and lipid lowering drugs. CONCLUSIONS Elderly individuals with chest pain could not be shown to have a delay to hospital admission compared to their younger counterparts. Nevertheless, higher age was associated with a longer time to first ECG. The elderly patients received less active therapy, and fear of age-related side effects might explain this difference.
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Miller CS, Foley JD, Floriano PN, Christodoulides N, Ebersole JL, Campbell CL, Bailey AL, Rose BG, Kinane DF, Novak MJ, McDevitt JT, Ding X, Kryscio RJ. Utility of salivary biomarkers for demonstrating acute myocardial infarction. J Dent Res 2014; 93:72S-79S. [PMID: 24879575 DOI: 10.1177/0022034514537522] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The comparative utility of serum and saliva as diagnostic fluids for identifying biomarkers of acute myocardial infarction (AMI) was investigated. The goal was to determine if salivary biomarkers could facilitate a screening diagnosis of AMI, especially in cases of non-ST elevation MI (NSTEMI), since these cases are not readily identified by electrocardiogram (ECG). Serum and unstimulated whole saliva (UWS) collected from 92 AMI patients within 48 hours of chest pain onset and 105 asymptomatic healthy control individuals were assayed for 13 proteins relevant to cardiovascular disease, by Beadlyte technology (Luminex(®)) and enzyme immunoassays. Data were analyzed with concentration cut-points, ECG findings, logistic regression (LR) (adjusted for matching for age, gender, race, smoking, number of teeth, and oral health status), and classification and regression tree (CART) analysis. A sensitivity analysis was conducted by repetition of the CART analysis in 58 cases and 58 controls, each matched by age and gender. Serum biomarkers demonstrated AMI sensitivity and specificity superior to that of saliva, as determined by LR and CART. The predominant discriminators in serum by LR were troponin I (TnI), B-type natriuretic peptide (BNP), and creatine kinase-MB (CK-MB), and TnI and BNP by CART. In saliva, LR identified C-reactive protein (CRP) as the biomarker most predictive of AMI. A combination of smoking tobacco, UWS CRP, CK-MB, sCD40 ligand, gender, and number of teeth identified AMI in the CART decision trees. When ECG findings, salivary biomarkers, and confounders were included, AMI was predicted with 80.0% sensitivity and 100% specificity. These analyses support the potential utility of salivary biomarker measurements used with ECG for the identification of AMI. Thus, saliva-based tests may provide additional diagnostic screening information in the clinical course for patients suspected of having an AMI.
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Affiliation(s)
- C S Miller
- Department of Oral Health Practice, Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - J D Foley
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - P N Floriano
- Department of Bioengineering and Chemistry, Rice University, Houston, TX, USA
| | - N Christodoulides
- Department of Bioengineering and Chemistry, Rice University, Houston, TX, USA
| | - J L Ebersole
- Department of Oral Health Practice, Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - C L Campbell
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - A L Bailey
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - B G Rose
- School of Dentistry, University of Louisville, Louisville, KY, USA
| | - D F Kinane
- School of Dentistry, University of Louisville, Louisville, KY, USA
| | - M J Novak
- Department of Oral Health Practice, Center for Oral Health Research, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - J T McDevitt
- Department of Bioengineering and Chemistry, Rice University, Houston, TX, USA
| | - X Ding
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - R J Kryscio
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA Department of Statistics, College of Arts & Science, University of Kentucky, Lexington, KY, USA
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Na JP, Shin KC, Kim S, Park YS, Chung SP, Park IC, Park JM, Kim MJ. Performance of reperfusion therapy and hospital mortality in ST-elevation myocardial infarction patients with non-chest pain complaints. Yonsei Med J 2014; 55:617-24. [PMID: 24719127 PMCID: PMC3990061 DOI: 10.3349/ymj.2014.55.3.617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 08/26/2013] [Accepted: 09/02/2013] [Indexed: 11/27/2022] Open
Abstract
PURPOSE ST-elevation myocardial infarction (STEMI) patients may visit the emergency department (ED) complaining of sensations of pain other than the chest. We investigated our performance of reperfusion therapy for STEMI patients presenting with non-chest pains. MATERIALS AND METHODS This was a retrospective observational cohort study. STEMI patients who underwent primary percutaneous coronary intervention (PCI) were divided into a chest pain group and a non-chest pain group. Clinical differences between the two groups and the influence of presenting with non-chest pains on door-to-electrocardiograms (ECG) time, door-to-balloon time, and hospital mortality were evaluated. RESULTS Of the 513 patients diagnosed with STEMI, 93 patients presented with non-chest pains. Patients in the non-chest pain group were older, more often female, and had a longer symptom onset to ED arrival time and higher Killip class than patients in the chest pain group. There was a statistically significant delay in door-to-ECG time (median, 2.0 min vs. 5.0 min; p<0.001) and door-to-balloon time (median, 57.5 min vs. 65.0 min; p<0.001) in patients without chest pain. In multivariate analysis, presenting with non-chest pains was an independent predictor for hospital mortality (odds ratio, 2.3; 95% confidence interval, 1.1-4.7). However, door-to-ECG time and door-to-balloon time were not factors related to hospital mortality. CONCLUSION STEMI patients presenting without chest pain showed higher baseline risk and hospital mortality than patients presenting with chest pain. ECG acquisition and primary PCI was delayed for patients presenting with non-chest pains, but not influencing hospital mortality. Efforts to reduce pre-hospital time delay for these patients are necessary.
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Affiliation(s)
- Jae Phil Na
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Chul Shin
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seunghwan Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Kangwon National University, Chuncheon, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - In Cheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Min Park
- Department of Emergency Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Kangwon National University, Chuncheon, Korea
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Pelletier R, Humphries KH, Shimony A, Bacon SL, Lavoie KL, Rabi D, Karp I, Tsadok MA, Pilote L. Sex-related differences in access to care among patients with premature acute coronary syndrome. CMAJ 2014; 186:497-504. [PMID: 24638026 DOI: 10.1503/cmaj.131450] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Access to care may be implicated in disparities between men and women in death after acute coronary syndrome, especially among younger adults. We aimed to assess sex-related differences in access to care among patients with premature acute coronary syndrome and to identify clinical and gender-related determinants of access to care. METHODS We studied 1123 patients (18-55 yr) admitted to hospital for acute coronary syndrome and enrolled in the GENESIS-PRAXY cohort study. Outcome measures were door-to-electrocardiography, door-to-needle and door-to-balloon times, as well as proportions of patients undergoing cardiac catheterization, reperfusion or nonprimary percutaneous coronary intervention. We performed univariable and multivariable logistic regression analyses to identify clinical and gender-related determinants of timely procedures and use of invasive procedures. RESULTS Women were less likely than men to receive care within benchmark times for electrocardiography (≤ 10 min: 29% v. 38%, p = 0.02) or fibrinolysis (≤ 30 min: 32% v. 57%, p = 0.01). Women with ST-segment elevation myocardial infarction (MI) were less likely than men to undergo reperfusion therapy (primary percutaneous coronary intervention or fibrinolysis) (83% v. 91%, p = 0.01), and women with non-ST-segment elevation MI or unstable angina were less likely to undergo nonprimary percutaneous coronary intervention (48% v. 66%, p < 0.001). Clinical determinants of poorer access to care included anxiety, increased number of risk factors and absence of chest pain. Gender-related determinants included feminine traits of personality and responsibility for housework. INTERPRETATION Among younger adults with acute coronary syndrome, women and men had different access to care. Moreover, fewer than half of men and women with ST-segment elevation MI received timely primary coronary intervention. Our results also highlight that men and women with no chest pain and those with anxiety, several traditional risk factors and feminine personality traits were at particularly increased risk of poorer access to care.
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Grosmaitre P, Le Vavasseur O, Yachouh E, Courtial Y, Jacob X, Meyran S, Lantelme P. Significance of atypical symptoms for the diagnosis and management of myocardial infarction in elderly patients admitted to emergency departments. Arch Cardiovasc Dis 2013; 106:586-92. [DOI: 10.1016/j.acvd.2013.04.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 04/17/2013] [Accepted: 04/25/2013] [Indexed: 10/26/2022]
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Efficacy and limitations of a STEMI network: 3 years of experience within the myocardial infarction network of the region of Augsburg - HERA. Clin Res Cardiol 2013; 102:905-14. [PMID: 24061282 DOI: 10.1007/s00392-013-0608-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 08/14/2013] [Indexed: 01/20/2023]
Abstract
AIMS The HERA Registry investigates logistics, adherence to standards, time intervals, and mortality in a regional network for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) in a mixed urban and rural area. METHODS AND RESULTS We included 826 consecutive patients (pts) within the HERA network with its dedicated PPCI strategy (female n = 243, mean age 64 years, range 25-98 years) with acute STEMI (May 2007 until January 2010). 680 pts (82 %) received PPCI and 45 (5.4 %) acute bypass surgery. Of 512 pts seen by an emergency physician (EP) as first medical contact (FMC) 87 % received on-scene 12-lead ECG. ECG transmission rate to the PPCI center was 29 %. Median FMC-to-balloon time (CBT) was 135 min and door-to-balloon time (DBT) 70 min. With EP FMC DBT was 38 min with direct transfer to cath lab (n = 70), 69 min via ICU (n = 240), and 132 min via ER (n = 91, p < 0.01). Out of 826 pts, 143(17.3 %) presented in cardiogenic shock. In-hospital mortality was 8.8 % (n = 73), 35.7 % for shock pts versus 3.2 % for non-shock pts (p < 0.01). For pts receiving PPCI, in-hospital mortality was 6.2 %, for shock pts (n = 107) 28.0 %, and for non-shock pts (n = 573) 2.1 % (p < 0.01). CONCLUSION Prehospital management, CBT and DBT compare favourably to data from studies and registries, but do not yet fulfill strict guideline requirements. Real world mortality in non-shock pts is very low. Direct transfer to cath lab reduces DBTs by 49 %. For this crucial improvement, transmission of a 12-lead ECG to the PPCI center is mandatory.
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Chain of care in chest pain — Differences between three hospitals in an urban area. Int J Cardiol 2013; 166:440-7. [DOI: 10.1016/j.ijcard.2011.10.139] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 10/10/2011] [Accepted: 10/30/2011] [Indexed: 11/23/2022]
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McHugh M. The Consequences of Emergency Department Crowding and Delays for Patients. INTERNATIONAL SERIES IN OPERATIONS RESEARCH & MANAGEMENT SCIENCE 2013. [DOI: 10.1007/978-1-4614-9512-3_5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Ravn-Fischer A, Karlsson T, Santos M, Bergman B, Herlitz J, Johanson P. Inequalities in the early treatment of women and men with acute chest pain? Am J Emerg Med 2012; 30:1515-21. [DOI: 10.1016/j.ajem.2011.12.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 12/20/2011] [Accepted: 12/20/2011] [Indexed: 10/28/2022] Open
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O'Donnell S, McKee G, O'Brien F, Mooney M, Moser DK. Gendered symptom presentation in acute coronary syndrome: a cross sectional analysis. Int J Nurs Stud 2012; 49:1325-32. [PMID: 22763336 DOI: 10.1016/j.ijnurstu.2012.06.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 05/10/2012] [Accepted: 06/04/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND The international literature suggests that the symptom presentation of acute coronary syndrome may be different for men and women, yet no definitive conclusion about the existence of gendered presentation in ACS has been provided. OBJECTIVE This study examines whether gendered symptom presentation exists in a well-defined sample of men and women with ACS. DESIGN AND SETTING A cross-sectional analysis of baseline data pertaining to symptom experience and medical profiles were recorded for all ACS patients who participated in a multi-centered randomized control trial, in 5 hospitals, in Dublin, Ireland. PARTICIPANTS : Patients were deemed eligible if they were admitted through the Emergency Department (ED) with a diagnosis of ACS, if they were at least 21 years of age and able to read and converse in English. Patients were excluded if they had serious co-morbidities, cognitive, hearing or vision impairment. METHODS Patients were interviewed 2-4 days following their ACS event and data was gathered using the ACS response to symptom index. RESULTS The study included 1947 patients of whom 28% (n=545) were women. Chest pain was the most commonly experienced symptom in men and women, reported by 71% of patients. Using logistic regression and adjusting for clinical and demographic variables, women had greater odds of experiencing shortness of breath (50% vs 43%; odds ratio [OR]=1.32; 95% CI=1.08-1.62; p=.006) palpitations (5.5% vs 2.8%; OR=2.17; CI=1.31-3.62; p=.003) left arm pain (34% vs 30.5%; OR=1.27; CI=1.02-1.58; p=.03) back pain (7.5% vs 4.8%; OR=1.56; CI=1.03-2.37; p=.034) neck or jaw pain (21.5% vs 13.8%; OR=1.84; CI=1.41-2.40; p=.001) nausea (28% vs 24%; OR=1.30; CI=1.03-1.65; p=.024) a sense of dread (13.4% vs 10.5%; OR=1.47; CI=1.08-2.00; p=.014) and fatigue (29% vs 21.5%; OR=1.64; CI=1.29-2.07; p=.001) than their male counterparts. CONCLUSIONS Although chest pain is the most commonly experienced symptom by men and women, other ACS symptomology may differ significantly between genders.
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Affiliation(s)
- Sharon O'Donnell
- School of Nursing & Midwifery, University of Dublin Trinity College, Dublin, Ireland.
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van Tulder R, Roth D, Weiser C, Heidinger B, Herkner H, Schreiber W, Havel C. An electrocardiogram technician improves in-hospital first medical contact-to-electrocardiogram times: a cluster randomized controlled interventional trial. Am J Emerg Med 2012; 30:1729-36. [PMID: 22463965 DOI: 10.1016/j.ajem.2012.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 01/24/2012] [Accepted: 01/25/2012] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND In the case of chest pain, the current guidelines require electrocardiogram (ECG) recording and patient assessment within 10 minutes upon arrival in the emergency department. METHODS We investigated the effect of an ECG technician (ECG-T) on in-hospital first medical contact-to-ECG times (iFMC-to-ECG) investigated in a cluster randomized, controlled trial. Allocation of intervention was concealed. Staff satisfaction and feasibility was defined as a secondary outcome. Delays between ECG and the availability of an emergency physician and the assessment of ECG were additionally evaluated. RESULTS A total of 163 (44 clusters) and 191 (47 clusters) patients were allocated to control and intervention, respectively. Twenty-seven (17%) of 163 patients in the control group vs 110 (58%) of 191 patients in the intervention group received ECG registration within 10 minutes (risk ratio, 3.40 [2.24-5.15]; P < .001). The iFMC-to-ECG time was 23 (95% confidence interval [CI], 20-27) minutes for the control group vs 9 (95% CI, 8-11) minutes for the intervention group (P < .001). Nursing staff judged the feasibility of intervention with a median of 1 (interquartile range [IQR], 1-1 (on a scale of 1 [best] to 5 [worst]), perceived workload alleviation with a median of 1 (IQR, 1-1), and improvement of quality of care with a median of 1 (IQR, 1-2). The ECG-to-EP time was 78 (95% CI, 64-92) seconds, and diagnosis was made within 17 (95% CI, 16-18) seconds. CONCLUSIONS Delays of iFMC-to-ECG can be effectively addressed by implementation of an ECG-T. The service of an ECG-T is feasible and improves staff satisfaction. Both ECG-to-EP time and ECG assessment constitute no relevant delay.
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Affiliation(s)
- Raphael van Tulder
- Department of Emergency Medicine, Medical University of Vienna, Waehringerguertel 18-20/6D, A-1090 Vienna, Austria
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Wu YF, Wang PC, Hsiao CT, Hsiao KY, Chen IC. Risk Factors of Acute ST Segment Elevation Myocardial Infarction Patients without Chest Pain. HONG KONG J EMERG ME 2012. [DOI: 10.1177/102490791201900204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction To identify factors associated with ST-segment myocardial infarction (STEMI) patients who had no chest pain, and to improve recognition of STEMI patients without presentation of chest pain in the emergency department (ED). Method Clinical characteristics and presentations were recorded in patients diagnosed with STEMI in the ED in a retrospective study of patients treated from 2006 to 2009. Patients with and without chest pain were compared according to clinical features. Results Among 260 STEMI patients, 12.7% of patients had no chest pain presentation in the ED. Syncope, epigastric pain, and dyspnea accounted for more than 60% of symptoms in STEMI patients without chest pain. Diabetes mellitus (DM), cerebrovascular accident (CVA), and old age were risk factors for STEMI patients without chest pain. Conclusions DM, CVA, and elderly patients are more likely to be without chest pain when STEMI occurred.
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Affiliation(s)
| | - PC Wang
- Chang Gung Memorial Hospital, Department of Cardiology, Puzih City, Chiayi, Taiwan, ROC
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Atzema CL, Schull MJ, Austin PC, Tu JV. Temporal changes in emergency department triage of patients with acute myocardial infarction and the effect on outcomes. Am Heart J 2011; 162:451-9. [PMID: 21884860 DOI: 10.1016/j.ahj.2011.05.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 05/17/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND All patients who present to an emergency department (ED) are triaged. The ED triage score may determine when patients are seen by a physician. Half of patients with acute myocardial infarction (AMI) were given a low priority score in Ontario in 2000/2001. We assessed the appropriateness of ED triage and its association with quality indicators and outcomes in a more recent AMI cohort and compared this with previous findings. METHODS We conducted a retrospective cohort study of a population-based cohort of patients with AMI admitted to 96 hospitals in Ontario, Canada, in 2004/2005. Outcome measures included rate of low-priority ED triage (score of 3, 4, or 5), compared with an earlier cohort (fiscal year 2000) at the same sites, and the adjusted effect of low-priority ED triage on door-to-electrocardiogram, door-to-needle, and door-to-balloon time; hospital length of stay (LOS); and mortality. RESULTS Among 6,605 patients with AMI, low-priority triage was less frequent than in the earlier cohort, at 33.3% versus 50.3%. In patients with ST-segment elevation myocardial infarction (STEMI), it was 25.9%, versus 43.8% previously. Between cohorts, the greatest improvement in triage occurred in patients with chest pain, in those seen at higher AMI volume EDs, and in ambulatory patients; patients seen at low AMI volume EDs, those with diabetes, and the elderly showed the least improvement. Being assigned a low-priority triage score was associated with an adjusted increase in median door-to-electrocardiogram and door-to-needle time of 12.2 (P < .001) and 20.7 minutes (P < .001), respectively, longer than in the earlier cohort (4.4 and 15.1 minutes). It was associated with hospital LOS >75th percentile (odds ratio [OR] 1.25, P < .001), and higher 90-day (OR 1.50, P = .02) and 1-year mortality (OR 1.37, P = .05) in patients with STEMI. CONCLUSION Emergency department triage of patients with AMI improved substantially over 5 years. For the third of patients with AMI who continue to receive a low priority score, including 25% of patients with STEMI, the associated delays in diagnosis and therapy were greater than previously and were associated with increased hospital LOS and mortality. Given the impact of this initial, cursory assessment, hospital systems should consider monitoring the quality of their ED triage.
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Affiliation(s)
- Clare L Atzema
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
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von Scheidt W, Thilo C. As time goes by?: the fallacy of thrombolysis in STEMI networks. Clin Res Cardiol 2011; 100:867-77. [PMID: 21717207 DOI: 10.1007/s00392-011-0332-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 06/08/2011] [Indexed: 11/25/2022]
Abstract
Primary percutaneous coronary intervention (PPCI) is superior to thrombolysis (TL) as reperfusion therapy in ST-elevation myocardial infarction (STEMI). TL is a rapidly available, but semi-effective therapy (effective reperfusion in 50% of patients only), whereas PPCI is a potentially delayed, but highly effective therapy (effective reperfusion in >90%). Since TL loses its efficacy beyond 2-3 h after symptom onset, it is a significant reperfusion alternative to PPCI in early presenters only. The individual decision to treat an early presenter with PPCI or TL requires the evaluation of the time delay between potential start of TL or PPCI, the PCI-related delay (PRD). PRD is greatest, if TL is given in the prehospital setting. Until now, prehospital TL as the most rapidly available reperfusion strategy has failed to demonstrate any prognostic or even any other relevant benefit compared to PPCI in any subgroup of patients, even with time delays for PPCI of up to several hours. On average, a median PRD of at least 90-120 min can be considered a time corridor of prognostic superiority of PPCI over TL. This is already achieved in contemporary registries and myocardial infarction networks.Therefore, the efforts should not focus on the implementation of a dual reperfusion strategy (PPCI, and prehospital TL in selected cases) in established or upcoming myocardial infarction networks, but concentrate on the availability of PPCI in less than 2 h. TL, as rapid as possible, i.e. prehospital, is a vital treatment option in case of non-existing PPCI facilities within a median time limit of 2 h or even more, a scenario not existing or easily to eliminate in European countries by implementing well organized myocardial infarction networks. This is the mission to be accomplished.
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Affiliation(s)
- Wolfgang von Scheidt
- Department of Internal Medicine I, Klinikum Augsburg, Heart Center Augsburg-Swabia, Germany.
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Atzema CL, Austin PC, Tu JV, Schull MJ. Effect of time to electrocardiogram on time from electrocardiogram to fibrinolysis in acute myocardial infarction patients. CAN J EMERG MED 2011; 13:79-89. [PMID: 21435313 DOI: 10.2310/8000.2011.110261] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The American Heart Association (AHA) recommends a benchmark door-to-electrocardiogram (ECG) time of 10 minutes for acute myocardial infarction patients, but this is based on expert opinion (level of evidence C). We sought to establish an evidence-based benchmark door-to-ECG time. METHODS This retrospective cohort study used a population-based sample of patients who suffered an ST elevation myocardial infarction (STEMI) in Ontario between 1999 and 2001. Using cubic smoothing splines, we described (1) the relationship between door-to-ECG time and ECG-to-needle time and (2) the proportion of STEMI patients who met the benchmark door-to-needle time of 30 minutes based on their door-to-ECG time. We hypothesized nonlinear relationships and sought to identify an inflection point in the latter curve that would define the most efficient (benefit the greatest number of patients) door-to-ECG time. RESULTS In 2,961 STEMI patients, the median door-to-ECG and ECG-to-needle times were 8.0 and 27.0 minutes, respectively. There was a linear increase in ECG-to-needle time as the door-to-ECG time increased, up to approximately 30 minutes, after which the ECG-to-needle time remained constant at 53 minutes. The inflection point in the probability of achieving the benchmark door-to-needle time occurred at 4 minutes, after which it decreased linearly, with every minute of door-to-ECG time decreasing the average probability of achievement by 2.2%. CONCLUSIONS Hospitals that are not meeting benchmark reperfusion times may improve performance by decreasing door-to-ECG times, even if they are meeting the current AHA benchmark door-to-ECG time. The highest probability of meeting the reperfusion target time for fibrinolytic administration is associated with a door-to-ECG time of 4 minutes or less.
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Affiliation(s)
- Clare L Atzema
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Room G147, Toronto, ON M4N 3M5.
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Niles NW, Conley SM, Yang RC, Vanichakarn P, Anderson TA, Butterly JR, Robb JF, Jayne JE, Yanofsky NN, Proehl JA, Guadagni DF, Brown JR. Primary Percutaneous Coronary Intervention for Patients Presenting With ST-Segment Elevation Myocardial Infarction: Process Improvement in a Rural ST-Segment Elevation Myocardial Infarction Receiving Center. Prog Cardiovasc Dis 2010; 53:202-9. [PMID: 21130917 DOI: 10.1016/j.pcad.2010.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Nathaniel W Niles
- Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756,
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Herlitz J, Wireklintsundström B, Bång A, Berglund A, Svensson L, Blomstrand C. Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities. Scand J Trauma Resusc Emerg Med 2010; 18:48. [PMID: 20815939 PMCID: PMC2944143 DOI: 10.1186/1757-7241-18-48] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 09/06/2010] [Indexed: 12/20/2022] Open
Abstract
Background The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably. In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count. This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase. Method A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. Results In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women). With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably. In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke. Conclusion Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.
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Affiliation(s)
- Johan Herlitz
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden.
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López L, Wilper AP, Cervantes MC, Betancourt JR, Green AR. Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006. Acad Emerg Med 2010; 17:801-8. [PMID: 20670316 DOI: 10.1111/j.1553-2712.2010.00823.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain. METHODS A nationally representative ED data sample for all adults (>or=18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997-2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics. RESULTS Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51 to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered. CONCLUSIONS Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes.
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Affiliation(s)
- Lenny López
- Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, USA.
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Farwell AL. Saving muscle: evidence-based strategies for reducing door-to-balloon times for st-segment elevation myocardial infarction patients. J Emerg Nurs 2010; 36:231-7. [PMID: 20457318 DOI: 10.1016/j.jen.2009.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Revised: 07/22/2009] [Accepted: 07/31/2009] [Indexed: 10/20/2022]
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Turnipseed SD, Amsterdam EA, Laurin EG, Lichty LL, Miles PH, Diercks DB. Frequency of non-ST-segment elevation injury patterns on prehospital electrocardiograms. PREHOSP EMERG CARE 2010; 14:1-5. [PMID: 19947860 DOI: 10.3109/10903120903144924] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Prehospital electrocardiograms (ECGs) have been recommended to facilitate early diagnosis of ST-segment elevation myocardial infarction (STEMI). However, prehospital ECGs can also be used to triage patients with non-ST-segment elevation acute coronary syndromes, who comprise a majority of patients with ischemic events presenting by ambulance to overcrowded emergency departments. OBJECTIVE We assessed the frequency of non-ST-segment elevation injury patterns on prehospital ECGs in patients with a chief complaint of chest pain evaluated by the emergency medical services (EMS) system. METHODS We analyzed prehospital ECGs of patients with the chief complaint of chest pain during a nine-month period. The ECGs were divided into three categories: injury pattern; no injury pattern; and technically uninterpretable. Injury pattern criteria were as follows: 1) regional ST depression >or=1.0 mm; 2) regional T-wave inversion (TWI) >or=3 mm; 3) left bundle branch block (LBBB); and 4) regional ST-segment elevation >or=1.0 mm. Descriptive statistics with 95% confidence intervals (CIs) are presented. RESULTS Prehospital ECGs were obtained for 322 of 340 chest pain patients: 72% were men; the average age was 60 years (range 18-96 years). Seventy-seven ECGs (24%, 95% CI 19.3-28.9%) met the criteria for injury pattern, 230 (71%) did not show injury, and 15 (5%) were uninterpretable. Of the 77 ECGs that exhibited an injury pattern, 39 (51%) showed ST depression, seven (9%) TWI, seven (9%) LBBB, and 24 (31%) ST-segment elevation. Thus, non-ST-segment elevation injury patterns (ST depression/TWI/LBBB) accounted for 53 (17%, 95% CI 12.6-20.9) of the total 322 prehospital ECGs. CONCLUSION Our findings demonstrate a relatively high frequency (17%) of non-ST-segment elevation injury patterns on prehospital ECGs of patients who summon EMS because of chest pain. These results suggest the potential of prehospital ECGs to facilitate early triage in these high-risk chest pain patients who present to overcrowded emergency departments.
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Affiliation(s)
- Samuel D Turnipseed
- Department of Emergency Medicine, UC Davis Medical Center, Sacramento, California 95817, USA.
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Cannon CP, Hoekstra JW, Larson DM, Carter RD, Cornish J, Karcher RB, Mencia WA, Berry CA, Stowell SA. Physician practice patterns in acute coronary syndromes: an initial report of an individual quality improvement program. Crit Pathw Cardiol 2010; 9:23-29. [PMID: 20215907 DOI: 10.1097/hpc.0b013e3181d09d2d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The American College of Cardiology and the American Heart Association guidelines are the nationally accepted standards for the treatment of patients with acute coronary syndromes. Despite this recognition, adherence to guideline recommendations remains suboptimal with 25% of opportunities to provide guideline appropriate care missed. To address performance gaps related to acute coronary syndrome care and improve patient outcomes, a performance improvement (PI) initiative was designed for cardiologists and emergency department physicians. As an American Medical Association-approved, standardized continuing medical education initiative, participating physicians can earn up to 20 American Medical Association-PRA Category 1 Credits by completing 2 phases of self-assessment in addition to developing and implementing a PI plan to address self-identified areas where improvement in patient care is needed. As the second in a series of 3 articles, this article describes the initial data submitted by 101 participating physicians and how their treatment practices compared with American College of Cardiology/American Heart Association guidelines as well as with current national standards. Overall, participating physicians meet guideline expectations with performance and documentation of a 12-lead electrocardiography, measurement of cardiac biomarkers, and administration of aspirin. Identified areas of improvement were the standardization of treatment protocols, use of risk assessment scores, appropriate dosing of anticoagulants, and improvement in patient treatment times. A noted challenge of this PI initiative is the low rate of physician participation, with fewer than 10% of registered physicians actively submitting patient data. This fact may reflect several barriers to PI, such as: (1) lack of time to collect and submit data, (2) the belief that current practices do not need to be improved, and (3) the need for system-based improvements.
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Initial ECG acquisition within 10 minutes of arrival at the emergency department in persons with chest pain: time and gender differences. J Emerg Nurs 2009; 37:109-12. [PMID: 21237383 DOI: 10.1016/j.jen.2009.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 10/08/2009] [Accepted: 11/09/2009] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The American Heart Association recommends all patients presenting to the emergency department with complaints of chest pain/anginal equivalent symptoms receive an initial ECG within 10 minutes of presentation. The Synthesized Twelve-lead ST Monitoring & Real-time Tele-electrocardiography (ST SMART) study is a prospective randomized clinical trial that enrolls all subjects who call 911 for ischemic complaints in Santa Cruz County, California. ST SMART is a 5-year study ending in 2008. The primary aim of the ST SMART study is to determine whether subjects who receive prehospital ECG have more timely hospital intervention and better outcomes. OBJECTIVE The aims of this secondary analysis of a subset of ST SMART study data were to determine (1) the rate of adherence to the American Heart Association goal in smaller community hospitals in less populous areas of receiving initial hospital ECG within the recommended 10 minutes and (2) whether there were gender differences in meeting this goal. METHODS The dataset included patients 30 years of age and older who were transported by ambulance to 1 of 2 rural hospitals in Santa Cruz County. All patients received an initial hospital ECG after arrival at the emergency department. RESULTS In this analysis of 425 patients (mean age, 70.4 years; 53% male), the mean time for all patients from ED arrival to initial ECG was 43 minutes (±145). The mean time to initial ECG was 34 minutes (±125) in male patients versus 53 minutes (±165) in female patients (Mann-Whitney test, P = .001). Forty-one percent of all patients presenting with ischemic symptoms received an initial ECG within 10 minutes of arrival. Forty-nine percent of male patients versus 32% of female patients received an initial ECG in 10 minutes or less (Fisher exact test, P = .000). CONCLUSION In this analysis, the majority of patients with ischemic symptoms did not receive an ECG within 10 minutes of hospital presentation as recommended in evidence-based guidelines. There is a significant delay in door to time-to-ECG for women. ED nurses are in a unique position to initiate efforts to establish processes to decrease time to initial ECG for patients with ischemic symptoms. Attention to timely ECG acquisition in women may improve treatment of acute coronary syndromes in this group.
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Improving emergency department door-to-electrocardiogram time in ST segment elevation myocardial infarction. Crit Pathw Cardiol 2009; 8:119-21. [PMID: 19726931 DOI: 10.1097/hpc.0b013e3181b5a6f3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
For patients presenting to emergency departments (ED) with a suspected acute coronary syndrome, time of arrival until an electrocardiogram is performed is an important quality metric. In our ED routine quality monitoring found that mean door-to-electrocardiogram (D2ECG) time did not meet our goal and national benchmark of 10 minutes. We describe the use of quality improvement tools to assess and decrease our D2ECG time. The ED quality improvement committee identified 2 main causes of D2ECG >10 minutes: (1) priority delay (eg, completing triage and registration data entry tasks before ECG), and (2) failure to recognize patients with nonchest pain ST Elevation Myocardial Infarction (STEMI) symptoms. Interventions included are-designed patient prioritization process for triage, staff assignment to provide immediate ECG testing, continuous feedback and a triage staff educational initiative to identify high risk patients. Mean time to ECG before intervention was 21.28 +/- 5.49 minutes. After the intervention period, the mean D2ECG for STEMI decreased to 9.47 +/- 2.48 minutes representing a 55% improvement. A D2ECG time of less than 10 minutes time can be achieved by the implementation of patient prioritization triage process changes, assigning specific personnel to obtain the ECG, continuous feedback by reviewing cases that fall outside the 10-minute goal and by ED staff education regarding STEMI symptoms other than chest pain.
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Takakuwa KM, Burek GA, Estepa AT, Shofer FS. A method for improving arrival-to-electrocardiogram time in emergency department chest pain patients and the effect on door-to-balloon time for ST-segment elevation myocardial infarction. Acad Emerg Med 2009; 16:921-7. [PMID: 19754862 DOI: 10.1111/j.1553-2712.2009.00493.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objectives were to determine if an emergency department (ED) could improve the adherence to a door-to-electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door-to-balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients. METHODS This was a planned 1-month before-and-after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders. RESULTS A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (+/-standard deviation [SD]) age was 50 (+/-16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty-nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes. CONCLUSIONS The overall percentage of patients with a door-to-ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site.
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Affiliation(s)
- Kevin M Takakuwa
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Robinson MR, Curzen N. Electrocardiographic body surface mapping: potential tool for the detection of transient myocardial ischemia in the 21st century? Ann Noninvasive Electrocardiol 2009; 14:201-10. [PMID: 19419406 DOI: 10.1111/j.1542-474x.2009.00284.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Coronary artery disease (CAD) is one of the leading causes of cardiovascular mortality and morbidity worldwide. CAD presents as a wide spectrum of clinical disease from stable angina to ST segment elevation myocardial infarction. The 12-lead electrocardiogram (ECG) has been the main tool for the diagnosis of these events for almost a century but is limited in its diagnostic ability. For patients with suspected angina, the exercise tolerance test is often used to provoke and detect stress-induced ischemia but does not provide a definitive answer in a substantial proportion of patients. Body surface mapping (BSM) is a technique that samples multiple points around the thorax to provide a more comprehensive electrocardiographic data set than the conventional 12-lead ECG. Moreover, recent preliminary data demonstrate that BSM can detect and display transient regional myocardial ischemia in an intuitive fashion, employing subtraction color mapping, making it potentially valuable for diagnosing CAD causing transient regional ischemia. Research is ongoing to determine the full extent of its utility.
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Affiliation(s)
- Monique R Robinson
- Wessex Cardiothoracic Unit, Southampton General Hospital, Southampton, UK
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Hollander JE, Gibson CM, Pollack CV. Hospitals with and without percutaneous coronary intervention capability: considerations for treating acute coronary syndromes. Am J Emerg Med 2009; 27:595-606. [PMID: 19497467 DOI: 10.1016/j.ajem.2008.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Accepted: 04/14/2008] [Indexed: 10/20/2022] Open
Abstract
The crucial aim in the emergency management of patients presenting with chest pain is the identification of acute coronary syndromes (ACS) and the initiation of appropriate treatment. Institution-specific triage to initial medical or interventional therapies is influenced by the availability of percutaneous coronary intervention (PCI) facilities. Although the use of invasive strategies has increased, most US hospitals do not have PCI facilities. Pharmacological management is an integral part of all treatment strategies, regardless of the availability of interventional capability. Given the growing importance of invasive management strategies, a therapy that is compatible with both medical and invasive therapy options is becoming increasingly important. Aspirin and clopidogrel are recommended for patients with ACS regardless of the conservative or invasive management strategy. With enoxaparin, patients with ACS can seamlessly transition from the medical management phase to the interventional management phase without the need for introducing a second anticoagulant in the cardiac catheterization laboratory. Fondaparinux can be used for patients with ACS treated medically, but should not be used alone during PCI because of the risk of catheter thrombosis. Bivalirudin can be used in non-ST-segment elevation myocardial infarction patients who are managed invasively.
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Affiliation(s)
- Judd E Hollander
- Department of Emergency Medicine, University of Pennsylvania, School of Medicine, Philadelphia, PA 19104-4283, USA.
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