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Quality of care for acute myocardial infarction in 58 U.S. emergency departments.

ABSTRACT: The objectives of this study were to determine concordance of emergency department (ED) management of acute myocardial infarction (AMI) with guideline recommendations and to identify ED and patient characteristics predictive of higher guideline concordance.The authors conducted a chart review study of ED AMI care as part of the National Emergency Department Safety Study (NEDSS). Using a primary hospital discharge diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 410.XX), a random sample of ED visits for AMI in 58 urban EDs across 20 U.S. states between 2003 and 2006 were identified. Concordance with American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations was evaluated using five individual quality measures and a composite concordance score. Concordance scores were calculated as the percentage of eligible patients who received guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance.The cohort consisted of 3,819 subjects; their median age was 65 years, and 62% were men. The mean (± standard deviation [SD]) ED composite concordance score was 61?±?8), with a broad range of values (42 to 84). Except for aspirin use (mean concordance, 82), ED concordance scores were low (beta-blocker use, 56; timely electrocardiogram [ECG], 41; timely fibrinolytic therapy, 26; timely ED disposition for primary percutaneous coronary intervention [PCI] candidates, 43). In multivariable analyses, older age (beta-coefficient per 10-year increase, -1.5; 95% confidence interval [CI]?=?-2.4 to -0.5) and southern EDs (beta-coefficient, -5.2; 95% CI?=?-9.6 to -0.9) were associated with lower guideline concordance, whereas ST-segment elevation on initial ED ECG was associated with higher guideline concordance (beta-coefficient, 3.6; 95% CI?= 1.5 to 5.7).Overall ED concordance with guideline-recommended processes of care was low to moderate. Emergency physicians should continue to work with other stakeholders in AMI care, such as emergency medical services (EMS) and cardiologists, to develop strategies to improve care processes.

SUBMITTER: Tsai CL

PROVIDER: S-EPMC3547596 | biostudies-literature | 2010 Sep

REPOSITORIES: biostudies-literature

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Quality of care for acute myocardial infarction in 58 U.S. emergency departments.

Tsai Chu-Lin CL Magid David J DJ Sullivan Ashley F AF Gordon James A JA Kaushal Rainu R Michael Ho P P Peterson Pamela N PN Blumenthal David D Camargo Carlos A CA

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 20100901 9

<h4>Objectives</h4>The objectives of this study were to determine concordance of emergency department (ED) management of acute myocardial infarction (AMI) with guideline recommendations and to identify ED and patient characteristics predictive of higher guideline concordance.<h4>Methods</h4>The authors conducted a chart review study of ED AMI care as part of the National Emergency Department Safety Study (NEDSS). Using a primary hospital discharge diagnosis of AMI (International Classification o ...[more]

PMID: 20836774

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Project description:BackgroundPre-hospital delay is currently a major factor limiting early reperfusion among ST-elevation myocardial infarction (STEMI) patients worldwide. This study aims to determine pre-hospital factors affecting symptom-to-door time among STEMI patients in Malaysia.MethodsThis cross-sectional study included 222 STEMI patients admitted to two tertiary hospitals in Malaysia. By determining symptom-to-door time, the study population was categorised into two definitive treatment seeking groups: early (≤ 3 h) and delayed (> 3 h). Data was collected focusing on socio-demographical data, risk factors and comorbidities, clinical presentation, situational factors and action taken by patients.ResultsThe mean age of our patients was 58.0 (SD = 11.9) years old, and the population consisted of 186 (83.8%) males and 36 (16.2%) females. Our study found that the median symptom-to-door time was 130.5 (IQR 240) min, with 64% of subjects arriving early and 36% arriving late. Pre-hospital delays were found to be significant among females (adj OR = 2.42; 95% CI: 1.02, 5.76; P = 0.046), patients with recurrence of similar clinical presentations (adj OR = 2.74; 95% CI: 1.37, 5.46; P = 0.004), patients experiencing atypical symptoms (adj OR = 2.64; 95% CI: 1.11, 6.31; P = 0.029) and patients who chose to have their first medical contact (FMC) for their symptoms with a general practitioner (adj OR = 2.80; 95% CI: 1.20, 6.56; P = 0.018). However, patients with hyperlipidaemia (adj OR = 0.46; 95% CI: 0.23, 0.93; P = 0.030), self-perceived cardiac symptoms (adj OR = 0.36; 95% CI: 0.17, 0.73; P = 0.005) and symptoms that began in public places (adj OR = 0.21; 95% CI: 0.06, 0.69; P = 0.010) tended to seek treatment earlier.ConclusionThe symptom-to-door time among the Malaysian population is shorter in comparison to other developing countries. Nevertheless, identified, modifiable pre-hospital factors can be addressed to further shorten symptom-to-door time among STEMI patients.

Project description:BACKGROUND:People living in rural areas usually suffer comparatively disadvantaged emergency health care than those living in urban areas, reasons including long transit time due to geographic factors. As for many time critical diseases, it is necessary to obtain treatment as quickly as possible. METHODS:Screening of eligible studies were conducted based on inclusion an exclusion criteria. A comprehensive search was conducted by using following database: EMBASE, Medline, Cochrane library and Scopus. Quality assessment tool for observational cohort and cross-sectional study is used for assessing the risk of bias. The time group were defined based on the median or mean transit time among patients. In symptom onset-balloon time, we take 120?min transit time as the standard so patients in included studies are divided into two groups:less than 120?min (group A) and more than 120?min (group B). The collected data were used for quantitative analysis, they were inputted into Review Manager Software (v5.3) to produce summary results. RESULTS:Ten studies representing 71,099 patients were included in the meta-analysis. All studies were retrospective and prospective observational studies and RCTs in which patients experienced ST-elevation myocardial infarction (STEMI) and were treated with percutaneous coronary intervention (PCI). Random effects meta-analysis of the point estimate was 0.69 (CI 0.60, 0.79). Heterogeneity between study results was evaluated via examination of the forest plots and quantified by using I2 statistic. Heterogeneity in two stage time was moderate among studies (I2 =?29%, P =?0.23). CONCLUSION:The meta-analysis for included studies report less mortality in less than 120?min symptom onset-balloon and door-balloon time than that in more than 120?min. It is necessary to optimize the prehospital system for rapid decision making and logical destination and mode of transport with prehospital notification of the cath lab so that the hospital is ready to optimize door to balloon time.

Dataset Information

Quality of care for acute myocardial infarction in 58 U.S. emergency departments.

Publications

Quality of care for acute myocardial infarction in 58 U.S. emergency departments.

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