Critical pathways in cardiology
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Observational Study
Impact of a "Team-focused CPR" Protocol on Out-of-hospital Cardiac Arrest Survival in a Rural EMS System.
More than 300,000 persons in the United States experience an out-of-hospital cardiac arrest every year. The American Heart Association emphasizes on the rapid, effective delivery of cardiac arrest interventions by bystanders and emergency medical services (EMS) on scene. In July 2013, the EMS of Randolph County, a rural county in central North Carolina, implemented a team-focused cardiopulmonary resuscitation(CPR) protocol. The protocol emphasized early chest compressions and resuscitation on scene until the return of spontaneous circulation (ROSC) or until efforts were deemed futile. ⋯ The introduction of a team-focused CPR protocol in a single rural county-based EMS system dramatically improved ROSC and hospital admission rates, but not survival to discharge. Continued surveillance, as well as evaluation and optimization of inpatient care, is warranted.
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Randomized Controlled Trial
Chest Pain Risk Stratification: A Comparison of the 2-Hour Accelerated Diagnostic Protocol (ADAPT) and the HEART Pathway.
The 2-hour accelerated diagnostic protocol (ADAPT) and the history electrocardiogram age risk factors troponin (HEART) Pathway are decision aids designed to identify Emergency Department (ED) patients with chest pain who are safe for early discharge. Both have demonstrated high sensitivity (>99%) for major adverse cardiac events (MACE) at 30 days and early discharge rates ≥20%. The objective of this study is to compare the sensitivity and early discharge rates of the ADAPT and HEART Pathway decision aids in a cohort of ED patients with acute chest pain. ⋯ Within a cohort of ED patients with acute chest pain, ADAPT and the HEART pathway had high sensitivity for MACE. The HEART pathway outperformed ADAPT by correctly identifying more patients as low risk and safe for early discharge.
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Observation units are dedicated areas in the hospital to deliver care to patients in observation status-those too risky to be immediately discharged following an emergency department evaluation but also clearly not in need of an inpatient admission. Observation units have been commonplace for several decades but in recent years some hospitals have begun to operate an additional observation unit with a distinct care delivery model and patient population. ⋯ Second level observation units are still relatively uncommon but are emerging as an extension of hospital-based observation services as an additional resource to cohort observation patients into a dedicated unit. These units share some similarities with traditional OUs, such as the nursing ratio of approximately 4:1 and the preponderance of chest pain pathways; however, they also differ in important ways around key metrics, such as length of stay, attending staffing coverage, and rate of subsequent inpatient admission. Additional study is needed both to fully characterize these units and their potential benefits.
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To assess the clinical and electrocardiographic characteristics of patients diagnosed with ST elevation myocardial infarction (STEMI) that are associated with an increased likelihood of not undergoing percutaneous coronary intervention (PCI) after prehospital Cardiac Catheterization Laboratory activation in a regional STEMI system. ⋯ Several of the above variables are expected electrocardiogram mimics; however, the decreased rate of PCI in non-white patients highlights an area for investigation and process improvement. This may guide the development of prehospital STEMI protocols, although avoiding false positive and inappropriate activations.
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Observational Study
Significance of an Indeterminate Troponin I in Patients Evaluated for Chest Pain in an Emergency Department Observation Unit.
Previous studies have suggested that patients with an indeterminate troponin I (TnI) in the emergency department (ED) are significantly more likely to be diagnosed with acute myocardial infarction (MI). The role of the ED observation unit (EDOU) in the evaluation of these patients is unclear. ⋯ Patients evaluated in our EDOU for chest pain with an initial indeterminate TnI did not develop subsequent MI. However, these patients had an increased rate of revascularization and inpatient admission compared with controls. While our experience suggests that patients with an indeterminate TnI may be safely evaluated in an observation setting, EDOUs which treat only low-risk chest pain patients may wish to recommend inpatient admission for this patient group.