Critical pathways in cardiology
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For patients presenting to emergency departments (ED) with a suspected acute coronary syndrome, time of arrival until an electrocardiogram is performed is an important quality metric. In our ED routine quality monitoring found that mean door-to-electrocardiogram (D2ECG) time did not meet our goal and national benchmark of 10 minutes. We describe the use of quality improvement tools to assess and decrease our D2ECG time. ⋯ Mean time to ECG before intervention was 21.28 +/- 5.49 minutes. After the intervention period, the mean D2ECG for STEMI decreased to 9.47 +/- 2.48 minutes representing a 55% improvement. A D2ECG time of less than 10 minutes time can be achieved by the implementation of patient prioritization triage process changes, assigning specific personnel to obtain the ECG, continuous feedback by reviewing cases that fall outside the 10-minute goal and by ED staff education regarding STEMI symptoms other than chest pain.
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We describe the case of a 73 year-old woman presenting with symptoms compatible with myocardial ischemia/injury and left bundle branch block in whom the electrocardiogram fulfilled Sgarbossa criteria for ST-elevation myocardial infarction. Coronary angiography revealed an acute coronary occlusion and she was successfully revascularized. The value and limitations of the Sgarbossa criteria are discussed and the importance of considering ST-elevation myocardial infarction in patients presenting with chest discomfort and new left bundle branch block is emphasized.
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Evidence-based guidelines call for advanced and definitive therapy for patients with non-ST-elevation myocardial infarction (NSTEMI). It is not known whether these guidelines are follow more diligently when patients arrive in the ED during regular hours, during which hospital resources including cardiology consultation may be more readily available. To determine whether patients with NSTEMI who present to the ED outside of usual hours have prolonged times to advanced and definitive therapy and poorer short-term outcomes. ⋯ Despite these differences, in-hospital outcomes were similar. Time of patient presentation has a modest impact on the timeliness of intervention in NSTEMI but was not associated with lower mortality. Although intensity of medical management was similar between groups, it was generally lower than current guidelines recommend, indicating potential for improvement in NSTEMI outcomes, regardless of time of presentation.
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Comparative Study
Improvements in time to reperfusion: do women have an advantage?
Several studies demonstrate that women have greater delays in primary percutaneous coronary intervention (PCI). To improve care for women, the Women's Heart Advantage at Yale-New Haven Hospital (YNHH) developed patient- and physician-level interventions to improve knowledge about chest pain syndromes to promote early presentation, diagnosis, and timely management of ST-elevation myocardial infarction (STEMI) in women presenting to the emergency department. Specifically, we analyzed chart-abstracted data from all patients undergoing PCI for STEMI at YNHH from January 2004 to July 2007 and assessed quality of care for STEMI and trends in time to reperfusion. ⋯ In this single-site study of men and women undergoing primary PCI at a large, urban teaching hospital, where ongoing interventions to increase both patient and physician awareness regarding heart disease in women were initiated, time to reperfusion for women improved to a greater degree than in men. These results are encouraging, showing that significant improvements can be made over a relatively short time frame. It is hoped these reductions in time to reperfusion are associated with improved outcomes; however, further studies are needed to verify this potential benefit.
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Comparative Study
Physician documentation of nonspecific EKG changes predicts hospital admission among observation unit chest pain patients.
Our emergency department (ED) observation unit specifically excludes patients with "significant" electrocardiogram (EKG) findings, but patients may be admitted with "nonspecific" EKG findings. We evaluated whether physician documentation of nonspecific findings predicted eventual admission to an inpatient unit from the observation unit. We reviewed the charts of all chest pain patients admitted to our ED observation unit over a 14-month period. ⋯ Patients with documented nonspecific EKG changes also had higher rates of positive stress testing (17.5% vs. 10.5%, P = 0.103) and stent placement (5.1% vs. 3.3%, P = 0.309), although these were not statistically significant. Patients with documented nonspecific EKG findings were admitted to an inpatient unit from the observation unit at higher rates than those without these findings. Physicians may wish to use the ED EKG more effectively in screening patients for admission to the ED observation unit.