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Symptoms awareness, emergency medical service utilization and hospital transfer delay in myocardial infarction.

ABSTRACT: BACKGROUND:The length of time between symptom onset and reperfusion therapy in patients with ST-segment elevation acute myocardial infarction (STEMI) is a key determinant of mortality. Information on this delay is scarce, particularly for developing countries. The objective of the study is to prospectively evaluate the individual components of reperfusion time (RT) in patients with STEMI treated at a University Hospital in 2012. METHODS:Medical records were reviewed to determine RT, its main (patient delay time [PDT] and system delay time [SDT]) and secondary components and hospital access variables. Cognitive responses were evaluated using a semi-structured questionnaire. RESULTS:A total of 50 patients with a mean age of 59 years (SD?=?10.5) were included, 64% of whom were male. The median RT was 430 min, with an interquartile range of 315-750 min. Regarding the composition of RT in the sample, PDT corresponded to 18.9% and SDT to 81.1%. Emergency medical services were used in 23.5% of cases. Patients treated in intermediate care units showed a significant increase in SDT (p?=?0.008). Regarding cognitive variables, PDT was approximately 40 min longer among those who answered "I didn't think it was serious" (p?=?0.024). CONCLUSIONS:In a Brazilian tertiary public hospital, RT was higher than that recommended by international guidelines, mainly because of long SDT, which was negatively affected by time spent in intermediate care units. Emergency Medical Services underutilization was noted. A patient's low perception of severity increased PDT.

SUBMITTER: Mesas CE

PROVIDER: S-EPMC6020233 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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Symptoms awareness, emergency medical service utilization and hospital transfer delay in myocardial infarction.

Mesas Cézar E CE Rodrigues Ricardo J RJ Mesas Arthur E AE Feijó Vivian B R VBR Paraiso Lucas M C LMC Bragatto Gabriela F G A GFGA Moron Viviane V Bergonso Marcos H MH Uemura Laercio L Grion Cintia Magalhães Carvalho CMC

BMC health services research 20180625 1

<h4>Background</h4>The length of time between symptom onset and reperfusion therapy in patients with ST-segment elevation acute myocardial infarction (STEMI) is a key determinant of mortality. Information on this delay is scarce, particularly for developing countries. The objective of the study is to prospectively evaluate the individual components of reperfusion time (RT) in patients with STEMI treated at a University Hospital in 2012.<h4>Methods</h4>Medical records were reviewed to determine R ...[more]

PMID: 29940942

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Project description:BackgroundTransfer delay provokes prolongation of prehospital time, which contributes to treatment delay that endangers patients with ST-segment elevation myocardial infarction (STEMI). A key constraint in reducing transfer delay is the shortage of emergency healthcare workers. This study was to explore the influence of the quality and quantity of healthcare professionals at emergency medical stations on transfer delay and in-hospital mortality among STEMI patients.MethodsA cross-sectional study using mixed methods was conducted at 89 emergency stations in 9 districts in China's Shenzhen province. Based on a sample of 31 hospitals, 1,255 healthcare professionals, and 3,131 patients with STEMI, a generalized linear model was used to explore the associations between the quality and quantity of healthcare professionals and transfer delay and in-hospital mortality among STEMI patients. Qualitative data were collected and analyzed to explore the reasons for the lack of qualified healthcare professionals at emergency medical stations.ResultsThe analysis of the quantity of healthcare professionals showed that an increase of one physician per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 5.087 min (95% CI -6.722, -3.452; P < 0.001). An increase of one nurse per 100,000 individuals was associated with decreased transfer delay by 1.471 min (95% CI -2.943, 0.002; P=0.050). Analysis of the quality of healthcare professionals showed that an increase of one physician with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 8.508 min (95% CI -10.457, -6.558; P < 0.001). An increase of one nurse with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay by 6.645 min (95% CI -8.218, -5.072; P < 0.001). Qualitative analysis illustrated that the main reasons for low satisfaction of healthcare professionals at emergency medical stations included low income, limited promotion opportunities, and poor working environment.ConclusionsThe quantity and quality of emergency healthcare professionals are key factors influencing transfer delay in STEMI patients. The government should increase the quantity of healthcare professionals at emergency medical stations, strengthen the training, and improve their performance by linking with clinical pathways to enhance job enthusiasm among emergency healthcare professionals.

Project description:BackgroundA challenge for emergency medical service (EMS) is accurate identification of acute coronary syndromes (ACS) and ST-segment elevation myocardial infarction (STEMI) for immediate treatment and transport. The electrocardiograph-based acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) and the thrombolytic predictive instrument (TPI) have been shown to improve diagnosis and treatment in emergency departments (EDs), but their use by paramedics in the community has been less studied.ObjectiveTo identify candidates for participation in the Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care (IMMEDIATE) Trial, we implemented EMS use of the ACI-TIPI and the TPI in out-of-hospital electrocardiographs and evaluated its impact on paramedic on-site identification of ACS and STEMI as a community-based approach to improving emergency cardiac care.MethodsAmbulances in the study municipalities were outfitted with electrocardiographs with ACI-TIPI and TPI software. Using a before-after quasi-experimental design, in Phase 1, for seven months, paramedics were provided with the ACI-TIPI/TPI continuous 0-100% predictions automatically printed on electrocardiogram (ECG) text headers to supplement their identification of ACS; in Phase 2, for 11 months, paramedics were told to identify ACS based on an ACI-TIPI cutoff probability of ACS ≥ 75% and/or TPI detection of STEMI. In Phase 3, this cutoff approach was used in seven additional municipalities. Confirmed diagnoses of ACS, acute myocardial infarction (AMI), and STEMI were made by blinded physician review for 100% of patients.ResultsIn Phase 1, paramedics identified 107 patients as having ACS; in Phase 2, 104. In Phase 1, 45.8% (49) of patients so identified had ACS confirmed, which increased to 76.0% (79) in Phase 2 (p < 0.001). Of those with ACS, 59.2% (29) had AMI in Phase 1 versus 84.8% (67) with AMI in Phase 2 (p < 0.01), and STEMI was confirmed in 40.8% (20) versus 68.4% (54), respectively (p < 0.01). In Phase 3, of 226 patients identified by paramedics as having ACS, 74.3% (168) had ACS confirmed, of whom 81.0% (136) had AMI and 65.5% (110) had STEMI. Among patients with ACS, the proportion who received percutaneous coronary intervention (PCI) was 30.6% (15) in Phase 1, increasing to 57.0% (45) in Phase 2 (p < 0.004) and 50.6% (85) in Phase 3, and the proportions of patients with STEMI receiving PCI rose from 75.0% (15) to 83.3% (45) (p < 0.4) and 82.7% (91).ConclusionsIn a wide range of EMS systems, use of electrocardiographs with ACI-TIPI and TPI decision support using a 75% ACI-TIPI cutoff improves paramedic diagnostic performance for ACS, AMI, and STEMI and increases the proportions of patients who receive PCI.

Project description:ImportancePrompt recognition of myocardial infarction symptoms is critical for timely access to lifesaving emergency cardiac care. However, patients with myocardial infarction continue to have a delayed presentation to the hospital.ObjectiveTo understand the variation and disparities in awareness of myocardial infarction symptoms among adults in the United States.Design, setting, and participantsThis cross-sectional study used data from the 2017 National Health Interview Survey among adult residents of the United States, assessing awareness of the 5 following common myocardial infarction symptoms among different sociodemographic subgroups: (1) chest pain or discomfort, (2) shortness of breath, (3) pain or discomfort in arms or shoulders, (4) feeling weak, lightheaded, or faint, and (5) jaw, neck, or back pain. The response to a perceived myocardial infarction (ie, calling emergency medical services vs other) was also assessed.Main outcomes and measuresPrevalence and characteristics of individuals who were unaware of myocardial infarction symptoms and/or chose not to call emergency medical services in response to these symptoms.ResultsAmong 25?271 individuals (13?820 women [51.6%; 95% CI, 50.8%-52.4%]; 17?910 non-Hispanic white individuals [69.9%; 95% CI, 68.2%-71.6%]; and 21?826 individuals [82.7%; 95% CI, 81.5%-83.8%] born in the United States), 23?383 (91.8%; 95% CI, 91.0%-92.6%) considered chest pain or discomfort a symptom of myocardial infarction; 22?158 (87.0%; 95% CI, 86.1%-87.8%) considered shortness of breath a symptom; 22?064 (85.7%; 95% CI, 84.8%-86.5%) considered pain or discomfort in arm a symptom; 19?760 (77.0%; 95% CI, 76.1%-77.9%) considered feeling weak, lightheaded, or faint a symptom; and 16?567 (62.6%; 95% CI, 61.6%-63.7%) considered jaw, neck, or back pain a symptom. Overall, 14?075 adults (53.0%; 95% CI, 51.9%-54.1%) were aware of all 5 symptoms, whereas 4698 (20.3%; 95% CI, 19.4%-21.3%) were not aware of the 3 most common symptoms and 1295 (5.8%; 95% CI, 5.2%-6.4%) were not aware of any symptoms. Not being aware of any symptoms was associated with male sex (odds ratio [OR], 1.23; 95% CI, 1.05-1.44; P?=?.01), Hispanic ethnicity (OR, 1.89; 95% CI, 1.47-2.43; P?<?.001), not having been born in the United States (OR, 1.85; 95% CI, 1.47-2.33; P?<?.001), and having a lower education level (OR, 1.31; 95% CI, 1.09-1.58; P?=?.004). Among 294 non-Hispanic black or Hispanic individuals who were not born in the United States, belonged to the low-income or lowest-income subgroup, were uninsured, and had a lower education level, 61 (17.9%; 95% CI, 13.3%-23.6%) were not aware of any symptoms. This group had 6-fold higher odds of not being aware of any symptoms (OR, 6.34; 95% CI, 3.92-10.26; P?<?.001) compared with individuals without these characteristics. Overall, 1130 individuals (4.5%; 95% CI, 4.0%-5.0%) chose a different response than calling emergency medical services in response to a myocardial infarction.Conclusions and relevanceMany adults in the United States remain unaware of the symptoms of and appropriate response to a myocardial infarction. In this study, several sociodemographic subgroups were associated with a higher risk of not being aware. They may benefit the most from targeted public health initiatives.

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Symptoms awareness, emergency medical service utilization and hospital transfer delay in myocardial infarction.

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Symptoms awareness, emergency medical service utilization and hospital transfer delay in myocardial infarction.

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