Symptom Severity as a Predictor of Reported Differences of Prehospital Delay between Medical Records and Structured Interviews among Patients with AMI

Association of pre‐hospital time intervals and clinical outcomes in ST‐elevation myocardial infarction patients

Study Objectives

Timely coronary reperfusion is critical for favorable outcomes after ST‐elevation myocardial infarction (STEMI). A substantial proportion of the total ischemic time is patient related, occurring before first medical contact (FMC). We aimed to expand the limited current understanding of the associations between prehospital intervals and clinical outcomes.

Methods

We conducted a retrospective analysis of consecutive STEMI patients who underwent primary percutaneous coronary intervention (pPCI) (January 2009–March 2016) and assessed the associations between prehospital intervals and the incidence of new heart failure, cardiogenic shock, and hospital length of stay (LOS), adjusting for important clinical variables.

Results

A total of 773 patients (77% men, median age 65 years) met eligibility criteria. The median pre‐911 activation interval was 29 minutes (interquartile range: 11, 89); the median 911 call to FMC interval was 12 minutes (interquartile range: 9, 15). In multivariable analysis, there was a V‐shaped relationship between the pre‐911 activation interval and outcomes: a lower likelihood of new heart failure (odds ratio [OR] 0.51; 95% confidence interval [CI]: 0.30, 0.87), cardiogenic shock (OR 0.40; 95% CI: 0.21, 0.75) and prolonged LOS (OR 0.24; 95% CI: 0.14, 0.42) for midrange intervals (11–88 minutes) when compared to the early (< 11‐minute) interval. There was no statistically significant relationship between total pre‐FMC time and FMC to device activation time.

Conclusions

Among ambulance‐transported STEMI patients receiving pPCI, the shortest and longest pre‐911 activation time intervals were associated with poorer outcomes. However, variation in post‐FMC interval alone was not associated with outcomes, suggesting that interventions to reduce pre‐FMC intervals must be prioritized.

Patient delay prior to care-seeking in acute myocardial infarction during the outbreak of the coronavirus SARS-CoV2 pandemic

AIMS

To examine patient delay in seeking medical care when afflicted by an acute myocardial infarction during March-June 2020.

METHODS AND RESULTS

This was a cross-sectional study in a region in Sweden during the first wave of the COVID-19 pandemic examining patients selected from the national registry (SWEDEHEART). Eligible patients were those with acute myocardial infarction, and a total of 602 patients were invited. A self-administered psychometric evaluated questionnaire, 'Patients' appraisal, emotions, and action tendencies preceding care-seeking in acute myocardial infarction' (AMI), was sent to the patients, and questions regarding COVID-19 were added. A total of 326 patients answered the questionnaire. Of these, 19% hesitated to seek medical care because of the pandemic, which was related to a fear that the healthcare services were already overcrowded with patients with COVID-19, followed by a fear of becoming infected with COVID-19 in hospital. Characteristics of this cohort were significantly higher prevalences of women, immigrants, smokers, and patients with type 2 diabetes.

CONCLUSIONS

During the outbreak and first wave of the COVID-19 pandemic, women and immigrants delayed seeking medical care for AMI because of fears about overcrowded hospitals and about becoming infected themselves. Therefore, during the COVID-19 pandemic, it is especially important to convey information about how and when to seek medical care. A collaboration involving the healthcare professionals, patient organizations, and the media would be desirable.

Determining Time of Symptom Onset in Patients With Acute Coronary Syndromes: Agreement Between Medical Record and Interview Data

BACKGROUND

Prehospital delay, the time of symptom onset until the time of hospital arrival, for patients with symptoms of acute coronary syndrome (ACS) is frequently used to determine the course of care. Total ischemic time (time for symptom onset until the time of first coronary artery balloon inflation) is another criterion for quality of care for patients experiencing ST-segment elevation myocardial infarction. However, obtaining the exact time of symptom onset, the starting point of both time intervals, is challenging. Currently 2 methods are used to obtain the time of symptom onset: abstraction of data from the medical record and structured interviews done after the acute event. It is not clear whether these methods are equally accurate.

PURPOSE

Using identified search terms, PubMed and the Cumulative Index to Nursing and Allied Health Literature were searched for articles published from 1990 to 2014 to identify studies that examined agreement between the 2 data sources to determine prehospital delay in patients with ACS.

CONCLUSIONS

Five studies examined the accuracy and/or agreement of prehospital delay by medical record review and structured patient interviews. In these studies, the percentage of missing/incomplete data in the medical record was higher compared with interviews (14%-40% vs 12%-13%). Three of the 4 studies that compared the 2 data sources reported more than 50% disagreement, with the time of symptom onset starting sooner when obtained by interview compared with the time recorded in their medical record at hospital presentation.

CLINICAL IMPLICATIONS

There is a need for a consistent, reliable method to assess the time of symptom onset in patients with ACS. To ensure the accuracy of data collected for the medical record, training of emergency and critical care clinicians should (1) emphasize the importance of assessing symptoms broadly, (2) provide tips on interviewing techniques to help patients pinpoint the time of symptom onset, and (3) instill the value of complete documentation.

Congruence of the Medical Record and Subject Interview on Time of Symptom Onset in Patients Diagnosed With Acute Coronary Syndrome

BACKGROUND

Past research has shown discrepancies between the time of symptom onset for patients with acute coronary syndrome (ACS) as documented in the medical record (MR) and patients' recall of the time assessed through subject interviews done later by researchers.

PURPOSE

The aim of this study is to determine if there were differences between the time of symptom onset documented in the MR and subject interview taking into consideration sex, age group, and recall period for patients admitted to the emergency department for symptoms suggestive of ACS.

METHODS

A secondary analysis was conducted on data from the PROMOTION (Patient Response to Myocardial Infarction Following a Teaching Intervention Offered by Nurses) trial, a multicenter randomized clinical trial to reduce patient prehospital delay to treatment in ACS.

RESULTS

Of the 3522 subjects with CAD enrolled into the trial, 3087 subjects completed 2-year follow-up. Of these, 331 subjects sought treatment in the emergency department for ACS symptoms and 276 patients (83%) had complete information on the time of symptom onset from both sources. Of the 276 patients, 25 (9%) had differing times more than 48 hours and were thus excluded. The median difference between the 2 sources was 45.0 minutes. When both times were examined, there were no significant differences in time by sex (P = .720) or by age group (P = .188). The median number of days between the interview and the date of symptom onset was 29.5 days. There was a significant correlation between differences in the time of symptom onset and the length of recall period (rs = 0.148, P = .023). In multivariable modeling, a longer recall period was associated with greater median differences in the symptom onset time (b = 13.2, P = .023).

CONCLUSION

These results suggest that the time of symptom onset obtained at the time of the index event and documented in the MR is not interchangeable with data obtained later by research staff, especially if the interview is not conducted near the time of the index event.

A comparison of direct and two-stage transportation of patients to hospital in Poland

BACKGROUND

The rapid international expansion of telemedicine reflects the growth of technological innovations. This technological advancement is transforming the way in which patients can receive health care.

MATERIALS AND METHODS

The study was conducted in Poland, at the Department of Cardiology of the Regional Hospital of Louis Rydygier in Torun. The researchers analyzed the delay in the treatment of patients with acute coronary syndrome. The study was conducted as a survey and examined 67 consecutively admitted patients treated invasively in a two-stage transport system. Data were analyzed statistically.

RESULTS

Two-stage transportation does not meet the timeframe guidelines for the treatment of patients with acute myocardial infarction. Intervals for the analyzed group of patients were statistically significant (p < 0.0001).

CONCLUSIONS

Direct transportation of the patient to a reference center with interventional cardiology laboratory has a significant impact on reducing in-hospital delay in case of patients with acute coronary syndrome.

PERSPECTIVES

This article presents the results of two-stage transportation of the patient with acute coronary syndrome. This measure could help clinicians who seek to assess time needed for intervention. It also shows how time from the beginning of pain in chest is important and may contribute to patient disability, death or well-being.

Inconsistent measurement of acute coronary syndrome patients' pre-hospital delay in research: a review of the literature

BACKGROUND

Patients' treatment-seeking delay remains a significant barrier to timely initiation of reperfusion therapy. Measurement of treatment-seeking delay is central to the large body of research that has focused on pre-hospital delay (PHD), which is primarily patient-related. This research has aimed to quantify PHD and its effects on morbidity and mortality, identify contributing factors, and evaluate interventions to reduce such delay. A definite time of symptom onset in acute coronary syndrome (ACS) is essential for determining delay, but difficult to establish. This literature review aimed to explore the variety of operational definitions of both PHD and symptom onset in published research.

METHODS AND RESULTS

We reviewed the English-language literature from 1998-2013 for operational definitions of PHD and symptom onset. Of 626 papers of possible interest, 175 were deemed relevant. Ninety-seven percent reported a delay time and 84% provided an operational definition of PHD. Three definitions predominated: (a) symptom onset to decision to seek help (18%); (b) symptom onset to hospital arrival (67%), (c) total delay, incorporating two or more intervals (11%). Of those that measured delay, 8% provided a definition of which symptoms triggered the start of timing.

CONCLUSION

We found few and variable operational definitions of PHD, despite American College of Cardiology/American Heart Association recommendations to report specific intervals. Worryingly, definitions of symptom onset, the most elusive component of PHD to establish, are uncommon. We recommend that researchers (a) report two PHD delay intervals (onset to decision to seek care, and decision to seek care to hospital arrival), and (b) develop, validate and use a definition of symptom onset. This will increase clarity and confidence in the conclusions from, and comparisons within and between studies.

Longer pre-hospital delay in first myocardial infarction among patients with diabetes: an analysis of 4266 patients in the northern Sweden MONICA Study

Background

Reperfusion therapy reduces both morbidity and mortality in myocardial infarction, but the effectiveness depends on how fast the patient receives treatment. Despite the time-dependent effectiveness of reperfusion therapy, many patients with myocardial infarction have delays in seeking medical care. The aim of this study was to describe pre-hospital delay in a first myocardial infarction among men and women with and without diabetes and to describe the association between pre-hospital delay time and diabetes, sex, age, symptoms and size of residential area as a proxy for distance to hospital.

Methods

This population based study was based on data from 4266 people aged 25–74 years, with a first myocardial infarction registered in the Northern Sweden MONICA myocardial infarction registry between 2000 and 2008.

Results

The proportion of patients with delay times ≥ 2 h was 64% for patients with diabetes and 58% for patients without diabetes. There was no difference in delay time ≥ 2 h between men and women with diabetes. Diabetes, older age and living in a town or rural areas were factors associated with pre-hospital delay times ≥ 2 h. Atypical symptoms were not a predictor for pre-hospital delay times ≥ 2 h, OR 0.59 (0.47; 0.75).

Conclusions

A higher proportion of patients with diabetes have longer pre-hospital delay in myocardial infarction than patients without diabetes. There are no differences in pre-hospital delay between men and women with diabetes. The largest risk difference for pre-hospital delay ≥ 2 h is between women with and without diabetes. Diabetes, older age and living in a town or rural area are predictors for pre-hospital delay ≥ 2 h.

Agreement between self-report and medical records on signs and symptoms of respiratory illness

BACKGROUND

Information on patient symptoms can be obtained by patient self-report or medical records review. Both methods have limitations.

AIMS

To assess the agreement between self-report and documentation in the medical records of signs/symptoms of respiratory illness (fever, cough, runny nose, sore throat, headache, sinus problems, muscle aches, fatigue, earache, and chills).

METHODS

Respondents were 176 research participants in the Hutterite Influenza Prevention Study during the 2008-2009 influenza season with information about the presence or absence of signs/symptoms from both self-report and primary care medical records.

RESULTS

Compared with medical records, lower proportions of self-reported fever, sore throat, earache, cough, and sinus problems were found. Total agreements between self-report and medical report of symptoms ranged from 61% (for sore throat) to 88% (for muscle aches and earache), with kappa estimates varying from 0.05 (for chills) to 0.41 (for cough) and 0.51 (for earache). Negative agreement was considerably higher (from 68% for sore throat to 93% for muscle aches and earache) than positive agreement (from 13% for chills to 58% for earache) for each symptom except cough where positive agreement (77%) was higher than negative agreement (64%). Agreements varied by age group. We found better agreement for earache (kappa = 0.62) and lower agreements for headache, sinus problems, muscle aches, fatigue, and chills in older children (aged >5 years) and adults.

CONCLUSIONS

Agreements were variable depending on the specific symptom. Contrary to research in other patient populations which suggests that clinicians report fewer symptoms than patients, we found that the medical record captured more symptoms than selfreport. Symptom agreement and disagreement may be affected by the perspectives of the person experiencing them, the observer, the symptoms themselves, measurement error, the setting in which the symptoms were observed and recorded, and the broader community and cultural context of patients.

A review of interventions aimed at reducing pre-hospital delay time in acute coronary syndrome: what has worked and why?

BACKGROUND

Delay in seeking treatment for acute coronary syndrome (ACS) symptoms is a well recognised problem. While the factors that influence pre-hospital delay have been well researched, to date this information alone has been insufficient in altering delay behaviour.

AIM

This paper reports the results of a critical appraisal of previously tested interventions designed to reduce pre-hospital delay in seeking treatment for ACS symptoms.

METHODS

The search was confined to interventions published between 1986 and the present that were written in English and aimed at reducing pre-hospital delay time. The following databases were searched using keywords: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Pubmed, Academic Search Premier, Ovid, Cochrane, British Nursing Index, and Google Scholar. A total of eight intervention studies were identified as relevant. This review was developed following a systematic comparative analysis of those eight studies.

RESULTS

Seven of the eight interventions were based on mass media campaigns. One campaign was targeted at individuals. All were aimed at raising ACS symptom awareness and/or increasing prompt action in the presence of symptoms. Only two studies reported a statistically significant reduction in pre-hospital delay time.

CONCLUSION

In response to concerns about prolonged pre-hospital delay time in ACS, interventions targeting the problem have been developed. The literature indicates that responses to symptoms depend on a variety of factors. In light of this, interventions should include the scope of factors that can potentially influence pre-hospital delay time and ideally target those who are at greatest risk of an ACS event.

Time of admission, quality of PCI care, and outcome of patients with ST-elevation myocardial infarction

OBJECTIVE

Our study aimed to analyse the hospital mortality of patients admitted in- and off-regular working hours with ST-elevation myocardial infarction (STEMI) within the special logistical setting of the urban area of the city of Berlin.

BACKGROUND

There is a debate whether patients with acute myocardial infarction admitted to hospital outside regular working hours experience higher mortality rates than those admitted within regular working hours.

METHODS

This study analyses data from the Berlin Myocardial Infarction Registry and comprises 2,131 patients with STEMI and treated with percutaneous coronary intervention (PCI) in 2004-2007. Data of patients admitted during in- and off-regular working hours were compared.

RESULTS

There was significant difference in door-to-balloon time (median in-hours: 79 min; median off-hours: 90 min, p < 0.001) and in hospital mortality (in-hours: 4.3%; off-hours: 6.8%, p = 0.020) between STEMI patients admitted in- and off-hours for treatment with PCI. After adjustment, admission off-hours remained an independent predictor for in-hospital death for patients (OR = 2.50; 95% CI 1.38-4.56). In patients with primary care from physician-escorted Emergency Medical Services (EMS), door-to-balloon time was reduced by 10 min for in-hours as well as off-hours patients. The difference in hospital mortality between off-hour and in-hour admission was reduced to a non-significant OR = 1.61 (95% CI 0.79-3.27).

CONCLUSIONS

In conclusion, patients admitted off-hours experienced longer door-to-balloon times and higher hospital mortality than did those admitted in-hours. The differences observed between patients admitted in-hours and off-hours were reduced through physician-escorted EMS reflecting the influence of optimized STEMI care.

The causes of prehospital delay in myocardial infarction

INTRODUCTION

The elapsed time between the onset of symptoms and reperfusion is a critical determinant of the clinical course of patients with myocardial infarction. The patients' own decision time is the most important component of prehospital delay.

METHODS

Selective literature review based on the references in a meta-analysis, complemented by a PubMed search on the expression "prehospital delay" in combination with "myocardial infarction," "acute coronary syndrome," "psychological factors," "gender," and "public campaign." A total of 73 papers addressing factors that influence prehospital delay were selected.

RESULTS

The reasons for delays of more than 120 minutes in a patient with symptoms of myocardial infarction reaching the hospital are still not sufficiently elucidated. Patients' uncertainty about their symptoms, advanced age, and female sex are three factors that appear to be associated with longer delays.

DISCUSSION

Factors influencing prehospital delay operate at the following levels: the perception of acute symptoms, the recognition of the importance of these symptoms, and the decision to call for help. Intervention trials should consider these levels in meeting the needs of clinically relevant subpopulations.

Time trends in symptoms and prehospital delay time in women vs. men with myocardial infarction over a 15-year period. The Northern Sweden MONICA Study

BACKGROUND

Few studies have examined the time between onset of myocardial infarction (MI) symptoms and arrival at hospital (prehospital delay time) and symptoms in men vs. women.

AIMS

To describe prehospital delay time and symptoms in men vs. women with MI and to analyse trends over time and according to age.

METHODS

The Northern Sweden MONICA myocardial infarction registry, 1989-2003, included 5,072 men and 1,470 women with a confirmed MI.

RESULTS

Typical pain was present in 86% of the men and 81% of the women. The proportion with typical symptoms decreased over time for men and increased for women. Typical symptoms were more common among younger persons than older persons. Insufficiently reported symptoms was unchanged in men over time and decreased among women. Up to the age of 65, no gender differences were seen in the prehospital delay. In the oldest age group (65-74 years) time to hospital was longer than among the younger groups, especially among women.

CONCLUSION

There were no major gender differences in prehospital delay or type of symptoms. However, over time the proportion with typical symptoms decreased in men and increased in women. Older patients had longer prehospital delay and less typical symptoms.

Somatic awareness, uncertainty, and delay in care-seeking in acute heart failure

Symptom monitoring is difficult for heart failure (HF) patients. Difficulties physically sensing and determining symptom meaning may lead to uncertainty and delay treatment. Somatic awareness may provide insight into symptom monitoring ability. A model combining physical and cognitive aspects of the symptom experience was developed to examine factors affecting care-seeking among HF patients. Adults hospitalized with acute HF were interviewed and completed questionnaires measuring somatic awareness and uncertainty. HF symptom duration prior to admission measured delay. HF specific somatic awareness and symptom pattern predicted delay. Uncertainty correlated with somatic awareness, but did not predict delay. Few responded to early HF symptoms delaying until acutely ill. Development of interventions to improve symptom monitoring is needed.