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Yiadom MYAB, Gong W, Patterson BW, Baugh CW, Mills AM, Gavin N, Podolsky SR, Mumma BE, Tanski M, Salazar G, Azzo C, Dorner SC, Hadley K, Bloos SM, Bunney G, Vogus TJ, Liu D. Influence of time-to-diagnosis on time-to-percutaneous coronary intervention for emergency department ST-elevation myocardial infarction patients: Time-to-electrocardiogram matters. J Am Coll Emerg Physicians Open 2024; 5:e13174. [PMID: 38726468 PMCID: PMC11079543 DOI: 10.1002/emp2.13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 02/28/2024] [Accepted: 03/15/2024] [Indexed: 05/12/2024] Open
Abstract
Objectives Earlier electrocardiogram (ECG) acquisition for ST-elevation myocardial infarction (STEMI) is associated with earlier percutaneous coronary intervention (PCI) and better patient outcomes. However, the exact relationship between timely ECG and timely PCI is unclear. Methods We quantified the influence of door-to-ECG (D2E) time on ECG-to-PCI balloon (E2B) intervention in this three-year retrospective cohort study, including patients from 10 geographically diverse emergency departments (EDs) co-located with a PCI center. The study included 576 STEMI patients excluding those with a screening ECG before ED arrival or non-diagnostic initial ED ECG. We used a linear mixed-effects model to evaluate D2E's influence on E2B with piecewise linear terms for D2E times associated with time intervals designated as ED intake (0-10 min), triage (11-30 min), and main ED (>30 min). We adjusted for demographic and visit characteristics, past medical history, and included ED location as a random effect. Results The median E2B interval was longer (76 vs 68 min, p < 0.001) in patients with D2E >10 min than in those with timely D2E. The proportion of patients identified at the intake, triage, and main ED intervals was 65.8%, 24.9%, and 9.7%, respectively. The D2E and E2B association was statistically significant in the triage phase, where a 1-minute change in D2E was associated with a 1.24-minute change in E2B (95% confidence interval [CI]: 0.44-2.05, p = 0.003). Conclusion Reducing D2E is associated with a shorter E2B. Targeting D2E reduction in patients currently diagnosed during triage (11-30 min) may be the greatest opportunity to improve D2B and could enable 24.9% more ED STEMI patients to achieve timely D2E.
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Affiliation(s)
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Brian W. Patterson
- Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Christopher W. Baugh
- Department of Emergency MedicineBrigham and Women's Hospital–Harvard UniversityBostonMassachusettsUSA
| | - Angela M. Mills
- Department of Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Nicholas Gavin
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Seth R. Podolsky
- Legacy HealthPortlandOregonUSA
- Oregon Health & Science UniversityCollege of MedicinePortlandOregonUSA
- Elson S. Floyd College of MedicineWashington State UniversitySpokaneWashingtonUSA
| | - Bryn E. Mumma
- Department of Emergency MedicineUniversity of California–DavisDavisCaliforniaUSA
| | - Mary Tanski
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Gilberto Salazar
- Department of Emergency MedicineUniversity of Texas SouthwesternDallasTexasUSA
| | - Caitlin Azzo
- Department of Emergency MedicineMassachusetts General Hospital, Harvard School of MedicineBostonMassachusettsUSA
| | - Stephen C. Dorner
- Department of Emergency MedicineMassachusetts General Hospital, Harvard School of MedicineBostonMassachusettsUSA
| | - Kelsea Hadley
- School of MedicineAmerican University of AntiguaOsbournAntigua and Barbuda
| | - Sean M. Bloos
- Department of Emergency MedicineStanford UniversityStanfordCaliforniaUSA
- Tulane University, School of MedicineNew OrleansLouisianaUSA
| | - Gabrielle Bunney
- Department of Emergency MedicineStanford UniversityStanfordCaliforniaUSA
| | - Timothy J. Vogus
- Owen Graduate School of ManagementVanderbilt UniversityNashvilleTennesseeUSA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical CenterNashvilleTennesseeUSA
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Yiadom MYAB, Gong W, Bloos SM, Bunney G, Kabeer R, Pasao MA, Rodriguez F, Baugh CW, Mills AM, Gavin N, Podolsky SR, Salazar GA, Patterson B, Mumma BE, Tanski ME, Liu D. Shorter Door-to-ECG Time Is Associated with Improved Mortality in STEMI Patients. J Clin Med 2024; 13:2650. [PMID: 38731180 PMCID: PMC11084706 DOI: 10.3390/jcm13092650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/09/2024] [Accepted: 04/16/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Delayed intervention for ST-segment elevation myocardial infarction (STEMI) is associated with higher mortality. The association of door-to-ECG (D2E) with clinical outcomes has not been directly explored in a contemporary US-based population. Methods: This was a three-year, 10-center, retrospective cohort study of ED-diagnosed patients with STEMI comparing mortality between those who received timely (<10 min) vs. untimely (>10 min) diagnostic ECG. Among survivors, we explored left ventricular ejection fraction (LVEF) dysfunction during the STEMI encounter and recovery upon post-discharge follow-up. Results: Mortality was lower among those who received a timely ECG where one-week mortality was 5% (21/420) vs. 10.2% (26/256) among those with untimely ECGs (p = 0.016), and in-hospital mortality was 6.0% (25/420) vs. 10.9% (28/256) (p = 0.028). Data to compare change in LVEF metrics were available in only 24% of patients during the STEMI encounter and 46.5% on discharge follow-up. Conclusions: D2E within 10 min may be associated with a 50% reduction in mortality among ED STEMI patients. LVEF dysfunction is the primary resultant morbidity among STEMI survivors but was infrequently assessed despite low LVEF being an indication for survival-improving therapy. It will be difficult to assess the impact of STEMI care interventions without more consistent LVEF assessment.
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Affiliation(s)
- Maame Yaa A. B. Yiadom
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Ste 350, Palo Alto, CA 94304, USA; (G.B.); (R.K.); (M.A.P.)
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1100, Nashville, TN 37203, USA; (W.G.); (D.L.)
| | - Sean M. Bloos
- Tulane University School of Medicine, 1430 Tulane Ave., New Orleans, LA 70112, USA;
| | - Gabrielle Bunney
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Ste 350, Palo Alto, CA 94304, USA; (G.B.); (R.K.); (M.A.P.)
| | - Rana Kabeer
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Ste 350, Palo Alto, CA 94304, USA; (G.B.); (R.K.); (M.A.P.)
| | - Melissa A. Pasao
- Department of Emergency Medicine, Stanford University, 900 Welch Road, Ste 350, Palo Alto, CA 94304, USA; (G.B.); (R.K.); (M.A.P.)
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, 6453 Quarry Rd., Palo Alto, CA 94304, USA;
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard University, 75 Francis Street, Boston, MA 02115, USA;
| | - Angela M. Mills
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, 622 W 168th St., New York, NY 10032, USA;
| | - Nicholas Gavin
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1468 Madison Ave., New York, NY 10029, USA;
| | - Seth R. Podolsky
- Department of Dean Administration, Oregon Health & Sciences University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA;
| | - Gilberto A. Salazar
- Department of Emergency Medicine Parkland Hospital, University of Texas Southwestern Medical Center—Dallas, 5323 Harry Hines Boulevard E4.300, Dallas, TX 75390, USA;
| | - Brian Patterson
- Department of Emergency Medicine, University of Wisconsin—Madison, 800 University Bay Dr Suite 310, Madison, WI 53705, USA;
| | - Bryn E. Mumma
- Department of Emergency Medicine, University of California at Davis, 2245 45th St., Sacramento, CA 95817, USA
| | - Mary E. Tanski
- Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, USA;
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1100, Nashville, TN 37203, USA; (W.G.); (D.L.)
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Ulintz AJ, Podolsky SR, Lapin B, Wyllie RR. Addition of community paramedics to a physician home-visit program: A prospective cohort study. J Am Geriatr Soc 2023; 71:3896-3905. [PMID: 37800363 DOI: 10.1111/jgs.18625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/17/2023] [Accepted: 09/11/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Home-based primary care promotes aging in place but is not immediately responsive to urgent needs. Community paramedicine leverages emergency medical services clinicians to expedite in-home care, though limited evidence supports this model. We evaluated the primary care and acute care use of older adults evaluated urgently by a community paramedic with telemedicine physician compared to a physician home visit model. METHODS This prospective cohort study enrolled older adults in home-based primary care who requested an urgent evaluation. We allocated participants to the physician home visit model or physician home visit plus community paramedic model by ZIP code. We observed primary care and acute care use for 6 months following enrollment. The primary outcome was the median number of primary care and acute care visits per participant. Secondary outcomes included 30-day readmission rates, median wait times, and physician productivity. Data analysis included descriptive statistics, comparison of means and proportions, and negative binomial regression modeling reported as incidence rate ratios (IRR). RESULTS We screened 255 participants, determined 203 eligible, allocated 199, and completed observation for 167 (84 community paramedicine, 83 physician home visit). Participants were mostly female, age 76-86 years, with 3-5 comorbidities, living in a home/apartment. Community paramedic participants had 29% more primary care visits (IRR 1.29, 95% confidence interval [CI] 1.06-1.57) and shorter wait times for urgent evaluations (1 vs. 5 days, p < 0.001) without increasing acute care use (IRR 0.75, 95% CI 0.48-1.18) or 30-day readmissions (IRR 1.32, 95% CI 0.49-3.55). Physician productivity increased 81% (40 vs. 22 visits/week, p < 0.001). CONCLUSION Older adults evaluated by a community paramedic for urgent needs were seen sooner, used acute care similarly to patients evaluated by a physician home visit, and nearly doubled physician efficiency. This suggests that older adults may benefit from combining emergency medical services and primary care resources for urgent evaluations.
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Affiliation(s)
- Alexander J Ulintz
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Seth R Podolsky
- Medical Operations, Legacy Health, Portland, Oregon, USA
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | - Brittany Lapin
- Department of Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert R Wyllie
- Medical Operations, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Pediatrics, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
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Yiadom MYAB, Gong W, Patterson BW, Baugh CW, Mills AM, Gavin N, Podolsky SR, Salazar G, Mumma BE, Tanski M, Hadley K, Azzo C, Dorner SC, Ulintz A, Liu D. Fallacy of Median Door‐to‐ECG Time: Hidden Opportunities for STEMI Screening Improvement. J Am Heart Assoc 2022; 11:e024067. [PMID: 35492001 PMCID: PMC9238601 DOI: 10.1161/jaha.121.024067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background ST‐segment elevation myocardial infarction (STEMI) guidelines recommend screening arriving emergency department (ED) patients for an early ECG in those with symptoms concerning for myocardial ischemia. Process measures target median door‐to‐ECG (D2E) time of 10 minutes. Methods and Results This 3‐year descriptive retrospective cohort study, including 676 ED‐diagnosed patients with STEMI from 10 geographically diverse facilities across the United States, examines an alternative approach to quantifying performance: proportion of patients meeting the goal of D2E≤10 minutes. We also identified characteristics associated with D2E>10 minutes and estimated the proportion of patients with screening ECG occurring during intake, triage, and main ED care periods. We found overall median D2E was 7 minutes (IQR:4–16; range: 0–1407 minutes; range of ED medians: 5–11 minutes). Proportion of patients with D2E>10 minutes was 37.9% (ED range: 21.5%–57.1%). Patients with D2E>10 minutes, compared to those with D2E≤10 minutes, were more likely female (32.8% versus 22.6%, P=0.005), Black (23.4% versus 12.4%, P=0.005), non‐English speaking (24.6% versus 19.5%, P=0.032), diabetic (40.2% versus 30.2%, P=0.010), and less frequently reported chest pain (63.3% versus 87.4%, P<0.001). ECGs were performed during ED intake in 62.1% of visits, ED triage in 25.3%, and main ED care in 12.6%. Conclusions Examining D2E>10 minutes can identify opportunities to improve care for more ED patients with STEMI. Our findings suggest sex, race, language, and diabetes are associated with STEMI diagnostic delays. Moving the acquisition of ECGs completed during triage to intake could achieve the D2E≤10 minutes goal for 87.4% of ED patients with STEMI. Sophisticated screening, accounting for differential risk and diversity in STEMI presentations, may further improve timely detection.
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Affiliation(s)
| | - Wu Gong
- Department of Biostatistics Vanderbilt University Medical Center Nashville TN
| | - Brian W. Patterson
- Department of Emergency Medicine University of Wisconsin School of Medicine and Public Health Madison WI
| | - Christopher W. Baugh
- Department of Emergency Medicine Brigham and Women’s Hospital, Harvard Medical School Boston MA
| | - Angela M. Mills
- Department of Emergency Medicine Columbia University College of Physicians and Surgeons New York NY
| | - Nicholas Gavin
- Department of Emergency Medicine Columbia University College of Physicians and Surgeons New York NY
| | - Seth R. Podolsky
- Legacy Health Portland OR
- Elson S. Floyd College of Medicine at Washington State University Spokane WA
| | - Gilberto Salazar
- Department of Emergency Medicine Parkland HospitalUniversity of Texas Southwestern Medical Center Dallas TX
| | - Bryn E. Mumma
- Department of Emergency Medicine University of CaliforniaDavis, School of Medicine Sacramento CA
| | - Mary Tanski
- Department of Emergency Medicine Oregon Health & Sciences University Portland OR
| | - Kelsea Hadley
- School of Medicine American University of the Caribbean Cupecoy Sint Maarten
| | - Caitlin Azzo
- Department of Emergency Medicine University of Pennsylvania Philadelphia PA
| | - Stephen C. Dorner
- Department of Emergency Medicine Massachusetts General HospitalHarvard Medical School Boston MA
| | - Alexander Ulintz
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
| | - Dandan Liu
- Department of Biostatistics Vanderbilt University Medical Center Nashville TN
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Chan DK, Alegria BD, Chadaga SR, Goren LJ, Mikasa TJ, Pearson AM, Podolsky SR, Won RS, LeTourneau JL. Rapid Deployment of Multiple-Tactics to Address SARS-CoV-2 Vaccine Uptake in Healthcare Employees with a focus on Those Who Identify as Black, Indigenous, and People of Color (BIPOC). Open Forum Infect Dis 2022; 9:ofac012. [PMID: 35198643 PMCID: PMC8860151 DOI: 10.1093/ofid/ofac012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/10/2022] [Indexed: 11/12/2022] Open
Abstract
Background In the third quarter of 2021, government entities enacted vaccine requirements across multiple employment sectors, including healthcare. Experience from previous vaccination campaigns within healthcare emphasize the need to translate community modalities of vaccine outreach and education that partner with Black communities, Indigenous communities, and communities of Color stakeholders to increase vaccine confidence broadly. Methods This was an observational feasibility study conducted from August through October 2021 that deployed and measured the effect of a multimodal approach to increasing vaccine uptake in healthcare employees. Vaccine data were acquired through the Center for Disease Control Immunization Information Systems across Oregon and Washington. Rates of complete vaccination before the intervention were compared with rates after as a measure of feasibility of this intervention. These data were subdivided by race/ethnicity, age, gender, and job class. Complete vaccination was defined as completion of a 2-dose mRNA SARS-CoV-2 vaccine series or a 1-dose adenoviral vector SARS-CoV-2 vaccine. Results Overall preintervention and postintervention complete vaccination rates were 83.7% and 93.5%, respectively. Of those employees who identified as a certain race, black employees demonstrated the greatest percentage difference increase, 18.5% (preintervention, 72.1%; postintervention, 90.6%), followed by Hispanic employees, 14.1% (preintervention, 79.4%; postintervention, 93.5%), and employees who identify as 2 or more races, 13.9% (preintervention, 78.7%; postintervention, 92.6%) Conclusions We found that a multimodal approach to improving vaccination uptake in employees was feasible. For organizations addressing vaccine requirements for their workforce, we recommend a multimodal strategy to increase vaccine confidence and uptake.
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Affiliation(s)
- Dominic K Chan
- Department of Pharmacy, Legacy Health, Portland, OR, United States
| | - Brittany D Alegria
- Department of Human Resources, Legacy Health, Portland, OR, United States
| | - Smitha R Chadaga
- Department of Internal Medicine Service, Legacy Health, Portland, OR, United States
| | - Lisa J Goren
- Department of Human Resources, Legacy Health, Portland, OR, United States
| | - Traci J Mikasa
- Department of Emanuel Internal Medicine Residency, Legacy Health, Portland, OR, United States
| | - Anna M Pearson
- Department of Strategy & Business Development, Legacy Health, Portland, OR, United States
| | - Seth R Podolsky
- Department of Office of Clinical Transformation, Legacy Health, Portland, OR, United States
| | - Regina S Won
- Department of Infectious Disease, Legacy Health, Portland, OR, United States
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Engineer RS, Podolsky SR, Fertel BS, Grover P, Jimenez H, Simon EL, Smalley CM. A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department Using a Clinical Decision Support Tool and a Structured Parent Discussion Tool. Pediatr Emerg Care 2021; 37:e1670-e1674. [PMID: 29768294 DOI: 10.1097/pec.0000000000001501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool. METHODS A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013. RESULTS The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group. CONCLUSION A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.
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Affiliation(s)
- Rakesh S Engineer
- From the Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH
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Bloos SM, Kaur K, Lang K, Gavin N, Mills AM, Baugh CW, Patterson BW, Podolsky SR, Salazar G, Mumma BE, Tanski M, Hadley K, Roumie C, McNaughton CD, Yiadom MYAB. Comparing the Timeliness of Treatment in Younger vs. Older Patients with ST-Segment Elevation Myocardial Infarction: A Multi-Center Cohort Study. J Emerg Med 2021; 60:716-728. [PMID: 33676790 DOI: 10.1016/j.jemermed.2021.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/06/2021] [Accepted: 01/23/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND ST-segment elevation myocardial infarction (STEMI) predominantly affects older adults. Lower incidence among younger patients may challenge diagnosis. OBJECTIVES We hypothesize that among patients ≤ 50 years old, emergent percutaneous coronary intervention (PCI) for STEMI is delayed when compared with patients aged > 50 years. METHODS This 3-year, 10-center retrospective cohort study included emergency department (ED) STEMI patients ≥ 18 years of age treated with emergent PCI. We excluded patients with an electrocardiogram (ECG) completed prior to ED arrival or a nondiagnostic initial ECG. Our primary outcome was door-to-balloon (D2B) time. We compared characteristics and outcomes among younger vs. older STEMI patients, and among age subgroups. RESULTS There were 576 ED STEMI PCI patients, of whom 100 were ≤ 50 years old and 476 were > 50 years old. Median age was 44 years in the younger cohort (interquartile range [IQR] 41-47) vs. 62 years (IQR 57-70) among older patients. Median D2B time for the younger cohort was 76.5 min (IQR 67.5-102.5) vs. 81.0 min (IQR 65.0-105.5) in the older cohort (p = 0.91). This outcome did not change when ages 40 or 45 years were used to demarcate younger vs. older. The younger cohort had a higher prevalence of nonwhite races (38% vs. 21%; p < 0.001) and those currently smoking (36% vs. 23%; p = 0.005). The very young (≤30 years; 6/576) and very old (>80 years; 45/576) had 5.51 and 2.2 greater odds of delays. CONCLUSION We found no statistically significant difference in D2B times between patients ≤ 50 years old and those > 50 years old. Nonwhite patients and those who smoke were disproportionately represented within the younger population. The very young and very old had higher odds of D2B times > 90 min.
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Affiliation(s)
- Sean M Bloos
- Master of Public Health Program, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karampreet Kaur
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kendrick Lang
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Nicholas Gavin
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Christopher W Baugh
- Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian W Patterson
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Seth R Podolsky
- Emergency Services Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gilberto Salazar
- Department of Emergency Medicine, University of Texas Southwestern, Parkland Hospital, Dallas, Texas
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis, Sacramento, California
| | - Mary Tanski
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kelsea Hadley
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christianne Roumie
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee; Veterans Health Administration, Tennessee Valley Healthcare System, Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Veterans Health Administration, Tennessee Valley Healthcare System, Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee
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8
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Simon EL, Shakya S, Smalley CM, Muir M, Podolsky SR, Fertel BS. Same provider, different location: Variation in patient satisfaction scores between freestanding and hospital-based emergency departments. Am J Emerg Med 2020; 38:968-974. [PMID: 31956050 DOI: 10.1016/j.ajem.2020.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/27/2019] [Accepted: 01/01/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Patient satisfaction scores have become quality benchmarks for hospitals, are publicly reported, and are often tied to financial incentives. We determined whether patient satisfaction scores for individual emergency medicine providers varied according to the clinical setting. METHODS We obtained patient satisfaction survey results from January 1, 2018 to December 31, 2018 for patients treated at 6 freestanding (FED) and 11 hospital-based emergency departments (HBED). Differences in mean score by ED facility were tested for significance. Mean score differences with 95% confidence intervals are presented. Univariate and multivariable logistic regression analysis was conducted to predict the odds of receiving different scores by type of ED facility and adjusted for patient and provider demographics and ED length of stay. RESULTS Sixty-six providers with 3743 total surveys were analyzed: FED (n = 1974) and HBED (n = 1769). Overall satisfaction scores were higher for FED compared to HBED surveys 1.13 [95% CI, 1.0-1.3]. In multivariable logistic regression, we found patients seen at the FEDs were 42% more likely to rate providers courtesy as "very good" compared to patients seen at a HBED [OR: 1.42, 95% CI (0.94-2.15)]. Similarly, patients from FEDs showed increased likelihood to rate providers as "very good" for keeping patients informed about treatment [OR: 1.70, 95% CI (1.21-2.39)], took time to listen to patients [OR: 1.66, 95% CI (0.72-1.60)] and concerned for patient's comfort [OR: 1.54, 95% CI (1.12-2.12)]. CONCLUSION Individual providers, who practice at both types of facilities, consistently received higher satisfaction ratings from patients at FEDs compared to HBEDs.
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Affiliation(s)
- Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, Akron, OH, United States of America; Northeast Ohio Medical University, Rootstown, OH, United States of America.
| | - Sunita Shakya
- Cleveland Clinic Akron General, Akron, OH, United States of America; Kent State University, Kent, OH, United States of America
| | - Courtney M Smalley
- Cleveland Clinic Emergency Services Institute, Cleveland, OH, United States of America
| | - McKinsey Muir
- Cleveland Clinic Emergency Services Institute, Cleveland, OH, United States of America
| | - Seth R Podolsky
- Cleveland Clinic Emergency Services Institute, Cleveland, OH, United States of America
| | - Baruch S Fertel
- Cleveland Clinic Emergency Services Institute, Cleveland, OH, United States of America
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Huded CP, Kumar A, Johnson M, Abdallah M, Ballout JA, Kravitz K, Menon V, Gullett TC, Hantz S, Ellis SG, Podolsky SR, Meldon SW, Kralovic DM, Brosovich D, Smith E, Kapadia SR, Khot UN. Incremental Prognostic Value of Guideline-Directed Medical Therapy, Transradial Access, and Door-to-Balloon Time on Outcomes in ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2019; 12:e007101. [PMID: 30871354 DOI: 10.1161/circinterventions.118.007101] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Systems to improve ST-segment-elevation myocardial infarction (STEMI) care have traditionally focused on improving door-to-balloon time. However, prompt guideline-directed medical therapy and transradial primary percutaneous coronary intervention (PCI) are also associated with reduced STEMI mortality. The incremental prognostic value of each facet of STEMI care on clinical outcomes within a STEMI system of care is unknown. METHODS AND RESULTS We implemented systems-based strategies at our hospital to improve 3 STEMI care metrics: (1) prompt guideline-directed medical therapy before sheath insertion for PCI, (2) use of transradial primary PCI, and (3) door-to-balloon time. We assessed the incremental association of metrics achieved with in-hospital adverse events and 30-day mortality. Of 1272 consecutive patients with STEMI treated with PCI at our hospital (January 1, 2011, to December 31, 2016), the percentage with achievement of zero, 1, 2, or 3 STEMI care metrics was 7.1%, 24.1%, 43.8%, and 25.1%; and 30-day mortality was 15.6%, 8.6%, 3.6%, and 3.2%, respectively (log-rank P<0.001). After adjusting for known clinical predictors of STEMI in-hospital mortality, achievement of at least 2 STEMI care metrics was associated with significantly reduced in-hospital mortality (odds ratio, 0.39; 95% CI, 0.16-0.96; P=0.041). Each metric provided incremental prognostic value when modeled in stepwise order of their occurrence in clinical practice (final model C statistic, 0.677; P<0.001). CONCLUSIONS Prompt guideline-directed medical therapy before sheath insertion for PCI, transradial primary PCI, and door-to-balloon time add incremental prognostic value in STEMI care. Expanding STEMI systems of care from a singular focus on door-to-balloon time to a comprehensive focus on multifaceted STEMI care offers an opportunity to further improve STEMI outcomes.
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Affiliation(s)
- Chetan P Huded
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Anirudh Kumar
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Michael Johnson
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Mouin Abdallah
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | | | - Kathleen Kravitz
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Venu Menon
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Travis C Gullett
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Scott Hantz
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Stephen G Ellis
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Seth R Podolsky
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Stephen W Meldon
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Damon M Kralovic
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Deborah Brosovich
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Elizabeth Smith
- Emergency Services Institute (T.C.G., S.R.P., S.W.M., D.M.K., E.S.), Cleveland Clinic, OH
| | - Samir R Kapadia
- Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
| | - Umesh N Khot
- Heart and Vascular Institute Center for Healthcare Delivery Innovation (C.P.H., A.K., M.J., M.A., U.N.K.), Cleveland Clinic, OH.,Heart and Vascular Institute (C.P.H., A.K., M.J., M.A., K.K., V.M., S.H., S.G.E., D.B., S.R.K., U.N.K.), Cleveland Clinic, OH
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10
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Fertel BS, Podolsky SR, Mark J, Muir MR, Ladd ME, Smalley CM. Impact of an individual plan of care for frequent and high utilizers in a large healthcare system. Am J Emerg Med 2019; 37:2039-2042. [PMID: 30824276 DOI: 10.1016/j.ajem.2019.02.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION "Frequent or High Utilizers" are significant stressors to Emergency Departments (EDs) and Inpatient Units across the United States (US). These patients incur higher healthcare costs with ED visits and inpatient admissions. Our aims were to determine whether implementation of individualized care plans (ICPs) could 1) reduce costs, 2) reduce inpatient length of stay (LOS), and 3) reduce ED encounters throughout a large healthcare system. METHODS 13 EDs were included including academic, community, Free-standing and pediatric EDs. Data was collected from January 1, 2014 through December 31, 2017. ICPs were created for high ED utilizers, as recommended by staff input through multidisciplinary care committees at each site. The ICP consisted of 1) specific symptom-related information with approaches in management, 2) recent assessment from specialists, 3) social work summary, and 4) psychiatry summary. A Best Practice Alert was placed in the electronic medical record that could be seen at all hospitals within the system. ICP's were updated annually. RESULTS 626 ICPs were written; 452 initial ICPs and 174 updates. The 452 ICP patients accounted for 23,705 encounters during the four-year period; on average, an ICP patient visited the ED 52 times (14.75 encounters/year). Overall indirect and direct costs decreased 42% over first 6 months, inpatient LOS improved from 1.9 to 0.97 days/month, and ED encounters decreased from 1.96 to 1.14. All cost and LOS data significantly improved at 24 months post-ICP inception. CONCLUSION Implementation of individualized care plan can reduce cost, inpatient LOS, and ED encounters for high utilizers.
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Affiliation(s)
- Baruch S Fertel
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, United States of America
| | - Seth R Podolsky
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, United States of America
| | - James Mark
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America
| | - McKinsey R Muir
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America
| | - Mark E Ladd
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America
| | - Courtney M Smalley
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States of America; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, United States of America.
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11
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Huded CP, Johnson M, Kravitz K, Menon V, Abdallah M, Gullett TC, Hantz S, Ellis SG, Podolsky SR, Meldon SW, Kralovic DM, Brosovich D, Smith E, Kapadia SR, Khot UN. 4-Step Protocol for Disparities in STEMI Care and Outcomes in Women. J Am Coll Cardiol 2018. [PMID: 29535061 DOI: 10.1016/j.jacc.2018.02.039] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Women with ST-segment elevation myocardial infarction (STEMI) receive suboptimal care and have worse outcomes than men. Whether strategies to reduce STEMI care variability impact disparities in the care and outcomes of women with STEMI is unknown. OBJECTIVES The study assessed the care and outcomes of men versus women with STEMI before and after implementation of a comprehensive STEMI protocol. METHODS On July 15, 2014, the authors implemented: 1) emergency department catheterization lab activation; 2) STEMI Safe Handoff Checklist; 3) immediate transfer to an immediately available catheterization lab; and 4) radial first approach to percutaneous coronary intervention (PCI). The authors prospectively studied consecutive patients with STEMI and assessed guideline-directed medical therapy (GDMT) before PCI, median door-to-balloon time (D2BT), in-hospital adverse events, and 30-day mortality stratified by sex before (January 1, 2011 to July 14, 2014; control group) and after (July 15, 2014 to December 31, 2016) implementation of the STEMI protocol. RESULTS Of 1,272 participants (68% men, 32% women), women were older with more comorbidities than men. In the control group, women had less GDMT (77% vs. 69%; p = 0.019) and longer D2BT (median 104 min; [interquartile range (IQR): 79 to 133] min vs. 112 [IQR: 85 to 147] min; p = 0.023). Women had more in-hospital stroke, vascular complications, bleeding, transfusion, and death. In the comprehensive 4-step STEMI protocol, sex disparities in GDMT (84% vs. 80%; p = 0.32), D2BT (89 [IQR: 68 to 106] min vs. 91 [IQR: 68 to 114] min; p = 0.15), and in-hospital adverse events resolved. The absolute sex difference in 30-day mortality decreased from the control group (6.1% higher in women; p = 0.002) to the comprehensive 4-step STEMI protocol (3.2% higher in women; p = 0.090). CONCLUSIONS A systems-based approach to STEMI care reduces sex disparities and improves STEMI care and outcomes in women.
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Affiliation(s)
- Chetan P Huded
- Heart and Vascular Institute Center for Healthcare Delivery Innovation, Cleveland, Ohio; Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Johnson
- Heart and Vascular Institute Center for Healthcare Delivery Innovation, Cleveland, Ohio; Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mouin Abdallah
- Heart and Vascular Institute Center for Healthcare Delivery Innovation, Cleveland, Ohio; Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Travis C Gullett
- Emergency Services Institute of the Cleveland Clinic, Cleveland, Ohio
| | - Scott Hantz
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Stephen G Ellis
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Seth R Podolsky
- Emergency Services Institute of the Cleveland Clinic, Cleveland, Ohio
| | - Stephen W Meldon
- Emergency Services Institute of the Cleveland Clinic, Cleveland, Ohio
| | - Damon M Kralovic
- Emergency Services Institute of the Cleveland Clinic, Cleveland, Ohio
| | | | - Elizabeth Smith
- Emergency Services Institute of the Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Umesh N Khot
- Heart and Vascular Institute Center for Healthcare Delivery Innovation, Cleveland, Ohio; Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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12
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Smalley CM, O'Neil M, Engineer RS, Simon EL, Snow GM, Podolsky SR. Dangerous weapons confiscated after implementation of routine screening across a healthcare system. Am J Emerg Med 2018; 36:1505-1507. [PMID: 29306648 DOI: 10.1016/j.ajem.2017.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- Courtney M Smalley
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States.
| | - Michael O'Neil
- University of Pennsylvania, Philadelphia, PA, United States
| | - Rakesh S Engineer
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States
| | - Erin L Simon
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States
| | - Gordon M Snow
- Cleveland Clinic Protective Services, Cleveland, OH, United States
| | - Seth R Podolsky
- Emergency Services Institute, Cleveland Clinic Health System, Cleveland, OH, United States
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13
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Phelan MP, Reineks EZ, Hustey FM, Berriochoa JP, Podolsky SR, Meldon S, Schold JD, Chamberlin J, Procop GW. Does Pneumatic Tube System Transport Contribute to Hemolysis in ED Blood Samples? West J Emerg Med 2016; 17:557-60. [PMID: 27625719 PMCID: PMC5017839 DOI: 10.5811/westjem.2016.6.29948] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Our goal was to determine if the hemolysis among blood samples obtained in an emergency department and then sent to the laboratory in a pneumatic tube system was different from those in samples that were hand-carried. METHODS The hemolysis index is measured on all samples submitted for potassium analysis. We queried our hospital laboratory database system (SunQuest(®)) for potassium results for specimens obtained between January 2014 and July 2014. From facility maintenance records, we identified periods of system downtime, during which specimens were hand-carried to the laboratory. RESULTS During the study period, 15,851 blood specimens were transported via our pneumatic tube system and 92 samples were hand delivered. The proportions of hemolyzed specimens in the two groups were not significantly different (13.6% vs. 13.1% [p=0.90]). Results were consistent when the criterion was limited to gross (3.3% vs 3.3% [p=0.99]) or mild (10.3% vs 9.8% [p=0.88]) hemolysis. The hemolysis rate showed minimal variation during the study period (12.6%-14.6%). CONCLUSION We found no statistical difference in the percentages of hemolyzed specimens transported by a pneumatic tube system or hand delivered to the laboratory. Certain features of pneumatic tube systems might contribute to hemolysis (e.g., speed, distance, packing material). Since each system is unique in design, we encourage medical facilities to consider whether their method of transport might contribute to hemolysis in samples obtained in the emergency department.
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Affiliation(s)
- Michael P Phelan
- Cleveland Clinic Health Systems, Emergency Services Institute, Cleveland, Ohio
| | - Edmunds Z Reineks
- Cleveland Clinic Health Systems, Pathology and Laboratory Medicine Institute, Cleveland, Ohio
| | - Fredric M Hustey
- Cleveland Clinic Health Systems, Emergency Services Institute, Cleveland, Ohio
| | - Jacob P Berriochoa
- MetroHealth Medical Center, Emergency Medicine/Emergency Department, Cleveland, Ohio
| | - Seth R Podolsky
- Cleveland Clinic Health Systems, Emergency Services Institute, Cleveland, Ohio
| | - Stephen Meldon
- Cleveland Clinic Health Systems, Emergency Services Institute, Cleveland, Ohio
| | - Jesse D Schold
- Cleveland Clinic Health Systems, Quantitative Health Sciences, Cleveland, Ohio
| | - Janelle Chamberlin
- Cleveland Clinic Health Systems, Emergency Services Institute, Cleveland, Ohio
| | - Gary W Procop
- Cleveland Clinic Health Systems, Pathology and Laboratory Medicine Institute, Cleveland, Ohio
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