Study objective Emergency department (ED) patients with atrial fibrillation or flutter are at risk of stroke, and guidelines recommend anticoagulation for patients with increased cardiovascular risk. ...Emergency physicians have a unique opportunity to provide appropriate anticoagulation for such patients, and we wished to investigate whether this was accomplished. Methods This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation or flutter from April 1, 2006, to March 31, 2010, who were managed solely by the emergency physician. Comorbidities, rhythms, and management were obtained by chart review, and complicated patients (those with an acute underlying medical condition) were excluded by predefined criteria. Patient medications on ED presentations were obtained through the provincial Pharmanet database. Patients were stratified into CHADS 2 (congestive heart failure, hypertension, age > 75, diabetes, stroke/transient ischemic attack) scores, and the primary outcome was the proportion of higher-risk (CHADS 2 score >0) patients who were discharged home with the incorrect anticoagulation by the emergency physician. The secondary outcome was the number of lower-risk (CHADS 2=0) patients who began receiving warfarin by the emergency physician orders. The regional ED database was interrogated to ascertain the number of patients who had a stroke at 30 days. Results Consecutive patients (1,090) were enrolled and 732 were discharged home with no cardiology consultation (657 fibrillation and 75 flutter). Of 151 higher-risk (CHADS 2 score >0) patients who should have been anticoagulated, 80 (53.0%; 95% confidence interval 44.7% to 61.0%) were discharged home from the ED without appropriate anticoagulation. In this group, 1 patient had an ischemic stroke at 24 days. Among 300 lower-risk patients (CHADS 2 score=0), 25 (8.3%; 95% confidence interval 5.6% to 12.2%) had warfarin initiated. Conclusion In this cohort of ED patients with uncomplicated atrial fibrillation or flutter who were discharged without cardiology involvement, many were not appropriately anticoagulated before ED arrival, and more than half of such patients did not appear to have corrective measures initiated by the emergency physician. This may represent a potential opportunity to improve patient care and outcomes.
Abstract Background Symptoms of acute coronary syndromes (ACS) account for a large proportion of emergency department (ED) visits and hospitalizations. High-sensitivity troponin can rapidly rule-out ...or rule-in acute myocardial infarction (AMI) within a short time of ED arrival. We sought to validate test characteristics and classification performance of two-hour high-sensitivity troponin T (hsTnT) algorithms for the rapid diagnosis of AMI. Methods We included consecutive patients from four academic EDs with suspected cardiac chest pain who had hsTnT assays performed two hours apart (+/- 30 minutes) as part of routine care. The primary outcome was AMI at 7 days. Secondary outcomes included major adverse cardiac events (MACE: mortality, AMI and revascularization). Test characteristics and classification performance for multiple 2-hour algorithms were quantified. Results 722 patients met inclusion criteria. 7-day AMI incidence was 10.9% and MACE incidence was 13.7%. A two-hour rule-out algorithm proposed by Reichlin and colleagues ruled out AMI in 59.4% of patients with 98.7% sensitivity and 99.8% NPV. The two-hour rule-out algorithm proposed by the UK National Institute for Health and Care Excellence ruled out AMI in 50.3% of patients with similar sensitivity and NPV. Other exploratory algorithms had similar sensitivity but marginally better classification performance. Reichlin et al’s two-hour rule-in algorithm ruled in AMI in 16.5% of patients with 92.4% specificity and 58.5% PPV. Conclusion 2-hour hsTnT algorithms can rule-out AMI with very high sensitivity and NPV. The algorithm developed by Reichlin et al. had superior classification performance. Reichlin and colleagues' 2-hour rule-in algorithm had poor PPV and may not be suitable for early rule-in decision-making.
Study objective Chest pain units have been used to monitor and investigate emergency department (ED) patients with potential ischemic chest pain to reduce the possibility of missed acute coronary ...syndrome. We seek to optimize the use of hospital resources by implementing a chest pain diagnostic algorithm. Methods This was a prospective cohort study of ED patients with potential ischemic chest pain. High-risk patients were referred to cardiology, and patients without ECG or biomarker evidence of ischemia were discharged home after 2 to 6 hours of observation. Emergency physicians scheduled discharged patients for outpatient stress ECGs or radionuclide scans at the hospital within 48 hours. Patients with positive provocative test results were immediately referred back to the ED. The primary outcome was the rate of missed diagnosis of acute coronary syndrome at 30 days. Results We prospectively followed 1,116 consecutive patients who went through the chest pain diagnostic algorithm, of whom 197 (17.7%) were admitted at the index visit and 254 (22.8%) received outpatient testing on discharge. The 30-day acute coronary syndrome event rate was 10.8%, and the 30-day missed acute coronary syndrome rate was 0% (95% confidence interval 0% to 2.4%). Of the 120 acute coronary syndrome cases, 99 (82.5%) were diagnosed at the index ED visit, and 21 patients (17.5%) received the diagnosis during outpatient stress testing. Conclusion In ED patients with chest pain, a structured diagnostic approach with time-focused ED decision points, brief observation, and selective application of early outpatient provocative testing appears both safe and diagnostically efficient, even though some patients with acute coronary syndrome may be discharged for outpatient stress testing on the index ED visit.
Study objective Atrial fibrillation is the most common dysrhythmia observed in the emergency department (ED), yet there is little research describing long-term outcomes after ED management. Our ...objective is to describe ED treatment approach, conversion success rates, ED adverse events, and 30-day and 1-year outcomes for a cohort of ED patients with atrial fibrillation and no acute underlying medical cause. Methods This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with an acute underlying medical condition were excluded by predefined criteria. Patients were stratified into 5 groups according to ED management: electrocardioversion, chemical cardioversion, spontaneous cardioversion, rate control only, and no arrhythmia-specific treatment. To identify deaths, strokes, and ED revisits within 1 year, each patient's unique provincial health number was linked to the provincial vital statistics registry and the regional ED database. Primary outcome was the number of patients having either stroke or death of any cause at 30 days, stratified by treatment group. Results Of 927 consecutive eligible patients, 121 (13.1%) converted to sinus rhythm before ED intervention, 357 (38.5%) received ED rhythm control, and 449 (48.4%) did not receive rhythm control. Overall, 142 of 927 patients (15.3%) were admitted to the hospital at the index ED visit. At 30 days, 2 patients had a stroke and 5 died (combined outcome rate 0.8%; 95% confidence interval 0.3% to 1.6%). All 7 of these patients were admitted at the index ED visit. Conclusion In this large cohort of ED patients with atrial fibrillation and no acute underlying medical cause, the 30-day rate for stroke or death was less than 1%. Nearly 85% of patients—regardless of treatment approach or conversion to sinus rhythm—were discharged at the index ED visit, and none of these patients had a stroke or died at 30 days.
Study objective Atrial flutter is a common arrhythmia seen in the emergency department (ED), yet there is little research describing its management and outcomes. We analyze the success and safety of ...treatment of ED patients with atrial flutter. Methods This was a retrospective cohort study obtained by searching the ED administrative database of 2 urban hospitals to identify consecutive patients with a primary discharge diagnosis of atrial flutter from April 1, 2006, to January 31, 2009. We linked each patient's unique provincial health number to the provincial vital statistics registry and the regional ED database to identify subsequent deaths and strokes within 1 year. Manual chart review was conducted to confirm rhythms and outcomes and to identify patient comorbidities. Patients were stratified into 5 groups based on initial ED presentation and management approach: electrocardioversion, chemical cardioversion, spontaneous cardioversion, rate control only, and no acute ED arrhythmia-specific treatment. Primary outcome was the combined 1-year rate of stroke or death, and secondary outcomes included the proportion of eligible patients with conversion to normal sinus rhythm in each group and discharged to home. Results Data from 122 consecutive patients with a primary ED diagnosis of atrial flutter were collected; there were 3 deaths and no strokes (2.5%; 95% confidence interval 0% to 5.1%) in the following year. Patients undergoing electrocardioversion achieved normal sinus rhythm 91% of the time, with 93% discharged home; patients undergoing oral or intravenous antiarrhythmic treatment achieved sinus rhythm 27% of the time, with 60% discharged home. Discharge rates of patients with spontaneous cardioversion, rate control, and no ED treatment were 93%, 58%, and 96%, respectively. Conclusion In this 2-center cohort of ED patients with atrial flutter, patients eligible for rhythm control had a higher success and lower admission rate with electrocardioversion than patients treated with antiarrhythmic medications. Overall, the majority of patients were discharged home. Deaths were typically related to concurrent medical illness rather than atrial flutter.
Abstract Objective High-sensitivity troponin T (hs-TnT) assays detect myocardial injury sooner, possibly improving throughput times for emergency department (ED) assessment of suspected acute ...myocardial infarction (AMI). This study evaluates the influence of hs-TnT implementation on ED length of stay (LOS), consultations and admissions, as well as ED revisits with cardiology admissions for patients undergoing testing for suspected AMI. Methods This control pre-post design analysis included patients evaluated using hs-TnT or conventional troponin T. Data were collected from 3 ED databases for patients who had a troponin assay for suspected AMI for the periods February 12, 2011-April 22, 2011 (Ctrl); November 20, 2011-January 28, 2012 (Pre); and February 12, 2012-April 21, 2012 (Post). The primary outcome was ED LOS; secondary outcomes included the proportions of patients who received ED cardiology consultations, patients who were admitted to hospital, and discharged patients who revisited the ED within 30 days. Results Data were analyzed from 6650 (Ctrl), 6866 (Pre), and 5754 (Post) patients. Median ED LOS decreased following hs-TnT implementation (6.60 hours in Ctrl and Pre vs 6.10 hours in Post, P < .001). There was no change in cardiology consultations or admissions following hs-TnT implementation. Fewer ED revisits occurred within 30 days in Post (16.0% Ctrl, 16.5% Pre vs 14.9% Post; P < .01). These results were preserved after adjusting for age and Canadian Triage Acuity Score. Conclusions This hs-TnT implementation strategy, using an equivalent cutoff for the conventional troponin T and hs-TnT assays, decreased ED LOS for patients with suspected AMI and did not increase cardiology resource utilization or ED revisits.
Abstract Objective Overcrowding is an important issue facing many emergency departments (EDs). Access block (admitted patients occupying ED stretchers) is a leading contributor, and expeditious ...placement of admitted patients is an area of research interest. This review examined the effectiveness of full capacity protocols (FCPs) on mitigating ED overcrowding. Methods A comprehensive literature search was undertaken to identify potentially relevant studies between 1966 and 2009. Intervention studies in which an FCP was used to influence ED/hospital length of stay and ED/hospital access block were included as a single program or part of a systemwide intervention. Two reviewers independently assessed citation relevance, inclusion, study quality, and extracted data; because of limited data, pooling was not undertaken. Results From 14 446 potentially relevant studies, 2 abstracts from the same comparative study were included. From 29 studies on systemwide intervention, 4 contained an FCP component. The included study was a single-center ED study using a before-after design; its methodological quality was rated as weak. One of the abstracts reported that an FCP was associated with less ED length of stay (5-hour reduction) when compared with the comparison period; the other reported that an FCP decreased ED and hospital access block (28% and 37% reduction, respectively). The ED triggers, format, and implementation of FCP protocols varied widely. Conclusion Although FCPs may be a promising alternative for overcrowded EDs, the available evidence upon which to support implementation of an FCP is limited. Additional efforts are required to improve the outcome reporting of FCP research using high-quality research methods.
Abstract Background While coronary CT angiography (coronary CTA) may be comparable to standard care in diagnosing acute coronary syndrome (ACS) in emergency department (ED) chest pain patients, it ...has traditionally been obtained prior to ED discharge and a strategy of delayed outpatient coronary CTA following an ED visit has not been evaluated. Objective To investigate the safety of discharging stable ED patients and obtaining outpatient CCTA. Methods At two urban Canadian EDs, patients up to 65 years with chest pain but no findings indicating presence of ACS were further evaluated depending upon time of presentation: (1) ED-based coronary CTA during normal working hours, (2) or outpatient coronary CTA within 72 hours at other times. All data were collected prospectively. The primary outcome was the proportion of patients who had an outpatient coronary CTA ordered and had a predefined major adverse cardiac event (MACE) between ED discharge and outpatient CT; secondary outcome was the ED length of stay in both groups. Results From July 1, 2012 to June 30, 2014, we enrolled 521 consecutive patients: 350 with outpatient CT and 171 with ED-based CT. Demographics and risk factors were similar in both cohorts. No outpatient CT patients had a MACE prior to coronary CTA. (0.0%, 95% CI 0 to 0.9%) The median length of stay for ED-based evaluation was 6.6 hours (interquartile range 5.4 to 8.3 hours) while the outpatient group had a median length of stay of 7.0 hours (IQR 6.0 to 9.8 hours, n.s.). Conclusions In ED chest pain patients with a low risk of ACS, performing coronary CTA as an outpatient may be a safe strategy.
Study objective Emergency department (ED) crowding has been associated with a variety of adverse outcomes. Current guidelines suggest that patients with potentially ischemic chest pain should undergo ...rapid assessment and treatment in a monitored setting to optimize the diagnosis of acute coronary syndrome. These patients may be at high risk of incorrect diagnosis and adverse events when their evaluation is delayed because of crowding. To mitigate crowding-related delays, we developed processes that enabled emergency physicians to evaluate potentially sick patients in the waiting room when all nurse-staffed stretchers are occupied. The objective of this study was to investigate the safety of waiting room chest pain evaluation. Methods This prospective comparative cohort study was conducted in a busy urban, tertiary care ED. Explicit triage and waiting room evaluation processes were introduced. One thousand one hundred seven patients with chest pain of potential cardiac origin were triaged either to a monitored bed or a waiting room chair, depending on bed availability and triage judgment. After diagnostic evaluation, patients were followed for 30 days to identify the proportion of missed cases of acute coronary syndrome (primary outcome) and other prespecified adverse events. Analysis was based on intention to treat. Results Eight hundred four patients were triaged to monitored bed and 303 to waiting room evaluation. Initial vital signs were similar, but the waiting room group was younger and had lower rates of some cardiovascular risk factors. The rate of acute coronary syndrome, defined as acute myocardial infarction or objective unstable angina, was 11.7% in the monitored bed group and 7.6% in waiting room patients. There were no missed acute coronary syndrome cases in either the monitored bed group (0%; 95% confidence interval CI 0% to 0.4%) or the waiting room group (0%; 95% CI 0% to 1.0%). There were 32 adverse events in the monitored bed group (4.0%; 95% CI 2.6% to 5.3%) and 2 in the waiting room group (0.7%; 95% CI 0% to 1.6%). Conclusion Our organized approach to triage and waiting room evaluation for stable chest pain patients was safe and efficient. Although waiting room evaluation is not ideal, it may be a feasible contingency strategy for periods when ED crowding compromises access to monitored, nurse-staffed ED beds.
Very low high-sensitivity cardiac troponin T (hs-cTnT) thresholds on presentation can rule out acute myocardial infarction (AMI), but the ability to identify patients at low risk of 30-day major ...adverse cardiac events (MACE) is less clear. This study examines the sensitivity of low concentrations of hs-cTnT on presentation to rule out 30-day MACE.
This prospective cohort study enrolled patients with chest pain presenting to the emergency department with nonischemic electrocardiograms who underwent AMI rule-out with an hs-cTnT assay. The primary outcome was 30-day MACE; secondary outcomes were individual MACE components. Because guidelines recommend using a single hs-cTnT strategy only for patients with more than 3 hours since symptom onset, a subgroup analysis was performed for this population. Outcomes were adjudicated on the basis of review of medical records and telephone follow-up.
Of 1167 patients enrolled, 125 (10.7%) experienced 30-day MACE and 97 (8.3%) had AMI on the index visit. More than one-third of patients (35.6%) had presenting hs-cTnT concentrations below the limit of detection (5 ng/L), which was 94.4% (95% confidence interval CI, 88.8-97.7) sensitive for 30-day MACE and 99.0% (95% CI, 94.5-100) sensitive for index AMI. Of 292 patients (25.0%) with hs-cTnT < 5 ng/L and at least 3 hours since symptom onset, only 3 experienced 30-day MACE (sensitivity 97.6%; 95% CI, 93.2-100) and none had AMI within 30 days (sensitivity 100%; 95% CI, 96.3-100).
Among patients with nonischemic electrocardiograms and > 3 hours since symptom onset, low hs-cTnT thresholds on presentation confer a very low risk of 30-day MACE. In the absence of a high-risk clinical presentation, further risk stratification is likely to be low yield.
Un seuil de troponine T cardiaque hypersensible (TnTc-hs) très bas au moment de la consultation permet d’écarter le diagnostic d’infarctus aigu du myocarde (IAM), mais l’utilité de ce paramètre pour reconnaître les patients exposés à un faible risque d’événement cardiaque indésirable majeur (ECIM) à 30 jours est moins bien établie. Les auteurs examinent la sensibilité de la présence d’une faible concentration de TnTc-hs à la consultation comme critère pour écarter la possibilité d’un ECIM à 30 jours.
Ont été admis dans cette étude de cohorte prospective les patients qui se sont présentés à l’urgence en raison d’une douleur à la poitrine, dont l’électrocardiogramme n’a pas révélé d’ischémie et chez qui le diagnostic d’IAM a été écarté au moyen d’un dosage de la TnTc-hs. Le critère d’évaluation principal était la survenue d’un ECIM à 30 jours; les critères d’évaluation secondaires étaient les composantes individuelles de l’ECIM. Comme les lignes directrices recommandent le recours à un simple dosage de la TnTc-hs seulement pour les patients présentant des symptômes depuis plus de 3 heures, une analyse a été réalisée dans ce sous-groupe de la population à l’étude. Les critères d’évaluation ont été confirmés par un examen des dossiers médicaux et par un suivi téléphonique.
Des 1167 patients retenus, 125 (10,7 %) ont présenté un ECIM à 30 jours et 97 (8,3 %) avaient reçu un diagnostic d’IAM à la visite de référence. Au moment de la consultation, plus du tiers des patients (35,6 %) présentaient une concentration de TnTc-hs sous le seuil de détection (5 ng/l), ce qui représente une sensibilité de 94,4 % (intervalle de confiance IC à 95 % : de 88,8 à 97,7) dans le cas de l’ECIM à 30 jours et de 99,0 % (IC à 95 % : de 94,5 à 100) dans le cas de l’IAM de référence. Des 292 patients (25,0 %) présentant un taux de TnTc-hs < 5 ng/l et des symptômes apparus depuis au moins 3 heures, seulement 3 ont subi un ECIM à 30 jours (sensibilité de 97,6 %; IC à 95 % : de 93,2 à 100) et aucun n’a subi d’IAM dans les 30 jours (sensibilité de 100 %; IC à 95 % : de 96,3 à 100).
Chez les patients dont l’électrocardiogramme ne révèle pas d’ischémie et qui présentent des symptômes depuis au moins 3 heures, un seuil de TnTc-hs faible au moment de la consultation est associé à un très faible risque d’ECIM à 30 jours. En l’absence d’un tableau clinique associé à un risque élevé, il est peu probable qu’une stratification du risque plus poussée soit utile.
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