Determinants of fatigue in emergency department clinicians who wear personal protective equipment.

OBJECTIVE: To determine the independent predictors for clinician fatigue and decline in cognitive function following a shift in the ED during early stages of the COVID-19 pandemic. METHODS: This was a prospective, quasi-experimental study conducted in a metropolitan adult tertiary-referral hospital ED over 20 weeks in 2021. The participants were ED doctors and nurses working clinical shifts in an ED isolation area or high-risk zone (HRZ) with stringent personal protective equipment (PPE). The participants' objective and subjective fatigue was measured by the Samn-Perelli fatigue score and a psychomotor vigilance 'smart game' score, respectively. Postural signs/symptoms and urine specific gravity (SG) were measured as markers of dehydration. RESULTS: Sixty-three participants provided data for 263 shifts. Median (interquartile range) age was 33 (28-38) years, 73% were female. Worsening fatigue score was associated with working afternoon shifts (afternoon vs day, adjusted odds ratio [aOR] 5.16 [95% confidence interval (CI) 1.32-20.02]) and in non-HRZ locations (HRZ vs non-HRZ, aOR 0.23 [95% CI 0.06-0.87]). Worsening cognitive function (game score) was associated with new onset postural symptoms (new vs no symptoms, aOR 4.14 [95% CI 1.34-12.51]) and afternoon shifts (afternoon vs day, aOR 3.13 [95% CI 1.16-8.44]). Working in the HRZ was not associated with declining cognitive function. Thirty-four (37%) of the 92 participants had an end of shift urine SG >1.030. CONCLUSION: Working afternoon shifts was associated with fatigue. There was no association between HRZ allocation and fatigue, but our study was limited by a low COVID workload and fluctuating PPE requirements in the non-HRZs. Workplace interventions that target the prevention of fatigue in ED clinicians working afternoon shifts should be prioritised.

From little things, big things grow: An exploratory analysis of the national cost of peripheral intravenous catheter insertion in Australian adult emergency care.

OBJECTIVE: To estimate the total economic impact of peripheral intravenous catheter (PIVC) or cannula insertion and use in adult Australian EDs, including those cannulas that remain unused for therapeutic purposes. METHODS: Searches on Australian government websites were conducted to find rates of insertion, complications and cost of cannula; following this, gaps in national data sets were filled with MEDLINE and PubMed searches to estimate the total cost of cannula use in Australian EDs. Once the data were collected, totals were combined to establish an estimated cost for the listed categories. RESULTS: The estimated cost of cannulation in Australia may be up to A$594 million per year, including the cost of insertion (equipment and staff), cost of complications such as Staphylococcus aureus bacteraemia and phlebitis, and patient-centred costs (lost patient productivity, infiltration, occlusion and dislodgement). Approximately A$305.9 million is attributed to unused cannulas and approximately 11 790 days of clinician time is spent annually inserting cannula that remains idle. CONCLUSION: The figures developed in the present study represent an important educational opportunity to encourage thoughtful consideration of all interventions, no matter how small. ED cannula insertion represents a large economic and health cost to Australia's health system, many of which remain unused. There are no national data sets that record complications associated with PIVCs and we highlight the urgent need for improved data.

Examining the translational success of an initiative to accelerate the assessment of chest pain for patients in an Australian emergency department: a pre-post study.

BACKGROUND: The Improved assessment of chest pain trial (IMPACT) protocol is an accelerated strategy for the risk stratification and management of patients presenting to the emergency department (ED) with chest pain. This study sought to describe the adoption, sustainability and health services implications of implementing the IMPACT protocol. METHODS: This was a study of adult patients in a large Australian tertiary hospital who had serial troponin testing commenced within the ED. Data from two periods were utilized; the pre-implementation period (8th April 2012 to 5th April 2014) and the post-implementation period (6th April 2014 to 2nd April 2016). The primary outcome was the proportion of patients undergoing accelerated care. Secondary endpoints were ED assessment time, hospital length of stay, and costs. Data were compared in the pre- and post-implementation periods. RESULTS: The proportion of patients receiving accelerated care increased from 3% in the pre- to 34% in the post-intervention period. This increase occurred rapidly after implementation of IMPACT and was sustained over a 2-year period. For patients with troponin concentrations <99th percentile, the mean ED assessment time reduced from 12.3 h in the pre- to 10.1 h in the post-implementation period. Mean hospital length of stay was similar in the pre- and post-implementation periods (82.4 and 80.9 h). The average cost of chest pain assessment reduced from $3520 pre implementation to $3204 post implementation; a $316 reduction per patient. CONCLUSIONS: The IMPACT protocol was rapidly adopted and utilised after implementation into standard care. The initial increase in the proportion of patients undergoing accelerated assessment, followed by a plateau towards the end of the study period indicate adoption and sustainability of the IMPACT protocol over a two-year period. Modest reductions in length of stay and cost were seen after implementation. Given the large number of patients investigated for chest pain, such reductions may have substantial impact on the overall healthcare system.

Facilitators and barriers for emergency department clinicians using a rapid chest pain assessment protocol: qualitative interview research.

BACKGROUND: Guideline-based processes for the assessment of chest pain are lengthy and resource intensive. The IMProved Assessment of Chest Pain Trial (IMPACT) protocol was introduced in one Australian hospital Emergency Department (ED) to more efficiently risk stratify patients. The theoretical domains framework is a useful approach to assist in identifying barriers and facilitators to the implementation of new guidelines in clinical practice. The aim of this study was to understand clinicians' perceptions of facilitators and barriers to the use of the IMPACT protocol. METHODS: Guided by the theoretical domains framework, semi-structured interviews with nine ED clinical staff (medical and nursing) were undertaken in 2016. Content analysis was conducted independently by two researchers to identify those theoretical domains that facilitated or hindered protocol use. RESULTS: Domains most often reported as fundamental to the use of the IMPACT protocol included 'social/professional role and identity', 'environmental context and resources' and 'social influences'. These factors seemingly influenced professional confidence, with participants noting 'goals' that included standardisation of practice, enhanced patient safety, and reduced need for unnecessary testing. The domain 'environmental context and resources' also contained the most noted barrier - the need to inform new members of staff regarding protocol use. Opportunities to overcome this barrier included modelling of protocol use by staff at all levels and education - both formal and informal. CONCLUSIONS: A range of domains were identified by ED staff as influencing their chest pain management behaviour. Fundamental to its use were champions/leaders that were trusted and accessible, as well as social influences (other staff within ED and other specialty areas) that enabled and supported protocol use. Research investigating the implementation and perceived use of the protocol at other sites, of varied geographical locations, is warranted.

Factors influencing physician risk estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome.

BACKGROUND: Emergency physicians frequently assess risk of acute cardiac events (ACEs) in patients with undifferentiated chest pain. Such estimates have been shown to have moderate to high sensitivity for ACE but are conservative. Little is known about the factors implicitly used by physicians to determine the pretest probability of risk. This study sought to identify the accuracy of physician risk estimates for ACE in patients presenting to the ED with chest pain and to identify the demographic and clinical information emergency physicians use in their determination of patient risk. METHODS: This study used data from two prospective studies of consenting adult patients presenting to the ED with symptoms of possible acute coronary syndrome. ED physicians estimated the pretest probability of ACE. Multiple linear regression analysis was used to identify predictors of physician risk estimates. Logistic regression was used to determine whether there was a correlation between physicians' estimated risk and ACE. RESULTS: Increasing age, male sex, abnormal ECG features, heavy/crushing chest pain and risk factors were correlated with physician risk estimates. Physician risk estimates were consistently found to be higher than the expected proportion of ACE from the sampled population. CONCLUSION: Physicians systematically overestimate ACE risk. A range of factors are associated with physician risk estimates. These include factors strongly predictive of ACE, such as age and ECG characteristics. They also include other factors that have been shown to be unreliable predictors of ACE in an ED setting, such as typicality of pain and risk factors.

Prospective validation of prognostic and diagnostic syncope scores in the emergency department.

BACKGROUND: Various scores have been derived for the assessment of syncope patients in the emergency department (ED) but stay inconsistently validated. We aim to compare their performance to the one of a common, easy-to-use CHADS2 score. METHODS: We prospectively enrolled patients ≥ 40 years old presenting with syncope to the ED in a multicenter study. Early clinical judgment (ECJ) of the treating ED-physician regarding the probability of cardiac syncope was quantified. Two independent physicians adjudicated the final diagnosis after 1-year follow-up. Major cardiovascular events (MACE) and death were recorded during 2 years of follow-up. Nine scores were compared by their area under the receiver-operator characteristics curve (AUC) for death, MACE or the diagnosis of cardiac syncope. RESULTS: 1490 patients were available for score validation. The CHADS2-score presented a higher or equally high accuracy for death in the long- and short-term follow-up than other syncope-specific risk scores. This score also performed well for the prediction of MACE in the long- and short-term evaluation and stratified patients with accuracy comparative to OESIL, one of the best performing syncope-specific risk score. All scores performed poorly for diagnosing cardiac syncope when compared to the ECJ. CONCLUSIONS: The CHADS2-score performed comparably to more complicated syncope-specific risk scores in the prediction of death and MACE in ED syncope patients. While better tools incorporating biochemical and electrocardiographic markers are needed, this study suggests that the CHADS2-score is currently a good option to stratify risk in syncope patients in the ED. TRIAL REGISTRATION: NCT01548352.

Evaluating Rapid Rule-out of Acute Myocardial Infarction Using a High-Sensitivity Cardiac Troponin I Assay at Presentation.

BACKGROUND: Low concentrations of cardiac troponin (cTn) have been recommended for rapid rule-out of acute myocardial infarction (AMI). We examined the Beckman Coulter Access high-sensitivity cardiac troponin I (hs-cTnI) assay to identify a single test threshold that can safely rule out AMI. METHODS: This analysis used stored samples collected in 2 prospective observational studies. In all, 1871 patients presenting to a tertiary emergency department with symptoms of acute coronary syndrome had blood taken for measurement of cTnI on presentation. The endpoint was type 1 myocardial infarction (T1MI). Sensitivity and negative predictive value (NPV) were calculated for hs-cTnI values below the 99th percentile. RESULTS: Ninety-eight patients had T1MI (5.2%), and 638 (34.1%) patients had an hs-cTnI <2 ng/L (limit of detection), with sensitivity of 99.0% (95% CI, 94.4%-100%) and NPV of 99.8% (95% CI, 99.1%-100%). No hs-cTnI value above a concentration of 2 ng/L achieved sensitivity of 99%. However, an NPV of 99.5% was achieved at values <6 ng/L. A cutoff <6 ng/L enabled 1475 (78.8%) patients to be ruled out on presentation with sensitivity of 93.9% (95% CI, 87.1%-97.7%). CONCLUSIONS: A single baseline cTn <2 ng/L measured with the Access hs-cTnI assay performed well for rule-out of AMI. This cutoff concentration identified 99% of patients with AMI and could reduce the number of patients requiring lengthy assessment. A cutoff of <6 ng/L yielded a high NPV but missed more cases of AMI than would be acceptable to clinicians.

Characteristics and occurrence of type 2 myocardial infarction in emergency department patients: a prospective study.

OBJECTIVE: To identify differences in prevalence, demographics, clinical features and outcomes for type 1 myocardial infarction (T1MI) and type 2 myocardial infarction (T2MI) in a cohort of patients presenting to the Emergency Department (ED) with chest pain. METHODS: This was a post hoc analysis of data collected from two prospective studies. Data were collected between November 2008 and February 2011 for the first study, and between February 2011 and March 2014 for the second. Participants were patients presenting to the ED with symptoms suggestive of acute coronary syndrome (ACS). The outcome was 30-day diagnosis; classified into T1MI, T2MI or non-MI. Descriptive statistics were used to compare the demographics, clinical history and presenting symptoms across diagnoses (T1MI, T2MI and non-MI). Cumulative mortality over 1 year was compared for T1MI and T2MI. RESULTS: 147 patients (6.3%; 95% CI 5.3% to 7.3%) were classified as T1MI and 52 (2.2%; 95% CI 1.7% to 2.9%) were classified as T2MI. T2MIs were more likely to be female (OR 4.71, 95% CI 2.28 to 9.76), have an abnormal but non-ischaemic ECG (OR 2.95, 95% CI 1.45 to 6.00), report prior hypertension (OR 2.83, 95% CI 1.35 to 6.12), have tachycardia (OR 9.26, 95% CI 3.08 to 30.77) and pain at rest (OR 3.04, 95% CI 1.28 to 8.02) compared with T1MI. One-year mortality was similar between T1MI and T2MI (9% and 14.6%, respectively, p=0.37). CONCLUSIONS: T2MIs comprised one quarter of all MIs diagnosed in the ED. Among patients presenting to the ED with symptoms of ACS, symptoms do not allow clinicians to reliably differentiate patients with T1MI and T2MI. Prior hypertension, tachycardia and abnormal non-ischaemic ECGs are seen more often in T2MI compared with T1MI. One-year mortality was substantial in patients with T1MI and T2MI, but low power precludes conclusions about mortality differences between groups.

Modification of the Thrombolysis in Myocardial Infarction risk score for patients presenting with chest pain to the emergency department.

OBJECTIVE: To develop a modified Thrombolysis in Myocardial Infarction (TIMI) score to effectively risk stratify patients presenting to the ED with chest pain. METHODS: A prospective observational study was conducted at two metropolitan EDs. Data were obtained during patient interview. The primary outcome was major adverse cardiovascular events (MACE) within 30 days of presentation. Two separate modifications of the TIMI score were developed. These scores were compared to the original TIMI in terms of the area under the receiver operating characteristic curve and diagnostic accuracy statistics (sensitivity, specificity, positive and negative predictive values). RESULTS: Of 1760 patients, 364 (20.7%) experienced 30 day MACE. The first modified TIMI score was a simplified TIMI (s-TIMI) including four variables: age ≥65 years, three or more risk factors, high-sensitivity troponin (hs-cTnI) and electrocardiogram changes. The second score included the same four variables plus two Global Registry of Acute Coronary Events (GRACE) variables (systolic blood pressure and estimated glomerular filtration rate). This score was termed the GRACE TIMI (g-TIMI). s-TIMI had a lower sensitivity compared to the original TIMI score (93.41 and 96.98%), but higher specificity (45.49 and 24.50%). The g-TIMI had a sensitivity of 98.90% and specificity of 14.90%. CONCLUSIONS: Attempts to modify the TIMI score yielded two scores with added predictive utility in comparison to the original TIMI model. The addition of GRACE variables (g-TIMI) increased sensitivity for MACE, but decreased the specificity of the model. The s-TIMI score yielded good specificity but had sensitivity that would not be acceptable by emergency physicians. The s-TIMI may be useful as part of an accelerated chest pain protocol.

Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study.

OBJECTIVES: The objective was to examine cannulation practice and effectiveness of a multimodal intervention to reduce peripheral intravenous cannula (PIVC) insertion in emergency department (ED) patients. METHODS: A prospective before and after study and cost analysis was conducted at a single tertiary ED in Australia. Data were collected 24 hours a day for 2 weeks pre- and post implementation of a multimodal intervention. PIVC placement and utilization within 24 hours were evaluated in all eligible patients. RESULTS: A total of 4,173 participants were included in the analysis. PIVCs were placed in 42.1% of patients' pre intervention and 32.4% post intervention, a reduction of 9.8% (95% confidence interval [CI] = 6.8 to -12.72%). PIVC usage within 24 hours of admission was 70.5% pre intervention and 83.4% post intervention, an increase of 12.9% (95% CI = 8.8% to 17.0%). Sixty-six patients were observed in the ED for cost analysis. The mean time per PIVC insertion was 15.3 (95% CI = 12.6 to 17.9) minutes. PIVC insertion cost, including staff time and consumables per participant, was A$22.79 (95% CI = A$19.35 to A$26.23). CONCLUSIONS: The intervention reduced PIVC placement in the ED and increased the percentage of PIVCs placed that were used. This program benefits patients and health services alike, with potential for large cost savings.

Diagnostic Accuracy of a New High-Sensitivity Troponin I Assay and Five Accelerated Diagnostic Pathways for Ruling Out Acute Myocardial Infarction and Acute Coronary Syndrome.

STUDY OBJECTIVE: This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman's Access high-sensitivity troponin I assay. METHODS: High-sensitivity troponin I was measured with presentation and 2-hour blood samples in 1,811 patients who presented to an emergency department (ED) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome. Measures of diagnostic accuracy for each rule were calculated. RESULTS: Data included 96 patients (5.3%) with acute myocardial infarction and 139 (7.7%) with acute coronary syndrome. The new Vancouver Chest Pain Rule and No Objective Testing Rule had high sensitivity for acute myocardial infarction (100%; 95% confidence interval [CI] 96.2% to 100% for both) and acute coronary syndrome (98.6% [95% CI 94.9% to 99.8%] and 99.3% [95% CI 96.1% to 100%]). The m-ADAPT, EDACS, and HEART pathways also yielded high sensitivity for acute myocardial infarction (96.9% [95% CI 91.1% to 99.4%] for m-ADAPT and 97.9% [95% CI 92.7% to 99.7%] for EDACS and HEART), but lower sensitivity for acute coronary syndrome (≤95.0% for all). The m-ADAPT, EDACS, and HEART rules classified more patients as being at low risk (64.3%, 62.5%, and 49.8%, respectively) than the new Vancouver Chest Pain Rule and No Objective Testing Rule (28.2% and 34.5%, respectively). CONCLUSION: In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.

Engaging African Americans in Research: The Recruiter's Perspective.

Purpose: To examine barriers recruiters encounter when enrolling African American study participants, identify motivating factors to increase research participation, and provide recommendations to facilitate successful minority recruitment. Background: Recruiters are often the first point of contact between the research study and potential African American participants. While challenges in enrolling African Americans into clinical and epidemiologic research has been reported in numerous studies the non-physician recruiter's role as a determinant of overall participation rates has received minimal attention. Methods: We conducted four 90-minute teleconference focus groups with 18 recruiters experienced in enrolling African Americans for clinical and epidemiologic studies at five academic/medical institutions. Participants represented diverse racial and ethnic backgrounds and were asked to reflect on barriers preventing African Americans from participating in research studies, factors that motivated participation, and recommendations to increase participation of African Americans in research. Multi-coder and thematic data analysis was implemented using the Braun and Clarke method. Results: Prominent concerns in recruitment of African Americans in research include fear and mistrust and inflexible research protocols. The participants suggest that improved recruitment could be achieved through cross-cultural and skillset building training opportunities for recruiters, greater community engagement among researchers, and better engagement with clinic staff and research teams.

Improved Assessment of Chest pain Trial (IMPACT): assessing patients with possible acute coronary syndromes.

OBJECTIVE: To examine the safety and efficacy of the Improved Assessment of Chest pain Trial (IMPACT) protocol, a strategy for accelerated assessment of patients presenting to emergency departments (EDs) with chest pain. DESIGN, SETTING AND PARTICIPANTS: IMPACT was an intervention trial at a single tertiary referral hospital (Royal Brisbane and Women's Hospital) during February 2011 - March 2014. 1366 prospectively recruited patients presenting to the ED with symptoms of suspected acute coronary syndrome (ACS) were stratified into groups at low, intermediate or high risk of an ACS. INTERVENTION: High risk patients were treated according to NHFA/CSANZ guidelines. Low and intermediate risk patients underwent troponin testing (sensitive assay) 0 and 2 hours after presentation. Intermediate risk patients underwent objective testing after the second troponin test; low risk patients were discharged without further objective testing. MAIN OUTCOME MEASURES: The primary outcome was an ACS within 30 days of presentation. Secondary outcomes were ED and hospital lengths of stay (LOS). RESULTS: The IMPACT protocol stratified 244 (17.9%) patients to low risk, 789 (57.7%) to intermediate risk, and 333 (24.4%) to high risk categories. The overall 30-day ACS rate was 6.6%, but there were no ACS events in the low risk group, and 14 (1.8%) in the intermediate risk group. The median hospital LOS was 5.1 hours (IQR, 4.2-5.6 h) for low risk and 7.7 hours (IQR, 6.1-21 h) for intermediate risk patients. CONCLUSIONS: The IMPACT protocol safely and efficiently allowed a large proportion of patients presenting to EDs with chest pain to undergo accelerated assessment for risk of an ACS. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12611000206921.

Differences in Presentation, Management and Outcomes in Women and Men Presenting to an Emergency Department With Possible Cardiac Chest Pain.

BACKGROUND: Research suggests that female patients with acute coronary syndrome (ACS) experience delays in emergency department (ED) management and are less likely to receive guideline-based treatments and referrals for follow-up testing. Women are often found to have poorer clinical outcomes in comparison to men. This study aimed to assess current sex differences in the presentation, management and outcomes of patients with undifferentiated chest pain presenting to a tertiary ED. METHODS: Data were analysed from two prospective studies conducted at a single Australian site between 2007 and 2014. Eligible patients were those of 18 years of age or older presenting with at least 5 minutes of chest pain or other symptoms for which the treating physician planned to investigate for possible ACS. Presenting symptoms, ED time measures, follow-up testing and outcomes, including 30-day ACS and mortality, were measured and compared between male and female patients. RESULTS: Of 2349 (60% men) patients presenting with chest pain, 153 men and 51 women were diagnosed with ACS within 30days . Presenting symptoms were similar in men and women with confirmed ACS. Time from symptom onset to ED presentation, time spent in the ED and total time in hospital were similar between the sexes. Male and female patients had similar rates of follow-up provocative testing. After adjustment for clinical factors, the odds of undergoing angiography were 1.8 (95% CI: 1.36-2.40) times higher for men than women. Of those undergoing coronary angiography within 30 days, a smaller proportion of women, compared to men, received revascularisation. Within 30 days, three (0.2%) male and one (0.1%) female patient died. CONCLUSION: Minimal sex differences were observed in the contemporary emergency management of patients presenting with suspected ACS. Thirty-day outcomes were similarly low in men and women despite lower rates of coronary angiography and revascularisation in women. Further research is required to replicate these results in different hospital systems and cultural settings.

Panic Disorder in Patients Presenting to the Emergency Department With Chest Pain: Prevalence and Presenting Symptoms.

BACKGROUND: Patients with panic disorder experience symptoms such as palpitations, chest pain, dizziness, and breathlessness. Consequently, they may attend the Emergency Department (ED) to be assessed for possible emergency medical conditions. Recognition of panic disorder within the ED is low. We sought to establish the prevalence of panic disorder in patients presenting for ED investigation of potential acute coronary syndrome. We also sought to characterise the cohort of patients with panic disorder in terms of presenting symptoms, risk factors, medical history and major adverse cardiac events (MACE). METHODS: This was an observational study of 338 adult patients presenting to the Emergency Department of a tertiary hospital in Australia. Research nurses collected clinical data using a customised case report form. The outcome was panic disorder, assessed using the Mini International Neuropsychiatric Interview. RESULTS: The average age of participants was 50.2 years and 37.9% were female. Thirty-day MACE occurred in 7.7% of the cohort. The clinical diagnosis of panic disorder was made in 5.6% (95% CI: 3.4-8.6%) of patients. Compared to patients without panic disorder, patients with panic disorder were slightly more likely to report that their pain felt heavy (48.9% and 73.7% respectively, p=0.04). All other reported symptoms were similar in the two groups. CONCLUSIONS: The prevalence of panic disorder was low in patients presenting to an Australian ED with chest pain. Clinical signs or symptoms that are routinely collected as part of the chest pain workup cannot be used to distinguish patients with and without panic disorder.

Factors influencing choice of pre-hospital transportation of patients with potential acute coronary syndrome: An observational study.

OBJECTIVE: To determine factors associated with ambulance use in patients with confirmed and potential acute coronary syndrome presenting to the ED. METHODS: A convenience sample of patients (n = 247) presenting to the ED from April 2014 to January 2015 with suspected acute coronary syndrome were included in the study. Data on mode of transport and patient demographics were collected from the Emergency Department Information System database. Clinical data were collected from chart records and information systems. A questionnaire assessed reasons for using a chosen method of transport, symptom timing and characteristics, acute coronary syndrome knowledge, and awareness of the National Heart Foundation Early Warning Symptoms campaign. RESULTS: Approximately half the patients (49.4%) assessed with symptoms of potential acute coronary syndrome used ambulance transport to the ED. Patients who arrived by ambulance were older than those not arriving by ambulance (mean 56.7 years vs 51.7 years, P = 0.01). Risk factors were not associated with ambulance use. Dizziness (P < 0.01), sweating (P = 0.03), nausea (P = 0.03) and vomiting (P = 0.04) were associated with increased ambulance use. Mean systolic blood pressure was lower in the ambulance group (136 mmHg, standard deviation [SD] = 19.8) than in the non-ambulance group (143 mmHg, SD = 25.9). Awareness of the National Heart Foundation Heart Attack Warning Signs campaign was not associated with ambulance use. CONCLUSIONS: Patients with possible ischaemic symptoms who are at a high risk of cardiac disease do not utilise ambulance services more than low risk patients. In general, transport to hospital using ambulance services by patients with symptoms of possible acute coronary syndrome is low despite community campaigns.

The Association of Electrocardiographic Abnormalities and Acute Coronary Syndrome in Emergency Patients With Chest Pain.

OBJECTIVES: The electrocardiograph (ECG) is an essential tool in initial management and risk stratification of patients with suspected acute coronary syndrome (ACS). A six-point reporting criterion has been proposed to facilitate standardized clinical assessment of patients presenting to the emergency department (ED) with suspected ACS. We set out to evaluate the efficacy of these criteria in identifying patients with major adverse cardiac events (MACE), Type 1 myocardial infarction (T1MI), Type 2 myocardial infarction (T2MI), and 1-year mortality in a cohort of emergency patients with chest pain. METHODS: This was an analysis of data from 2,349 patients who presented to the ED with chest pain between 2008 and 2013. Data were collected as part of two prospective trials. ECGs were recorded at presentation and categorized according to the six-point criteria by local cardiologists blinded to all clinical information. The primary outcome was 30-day MACE, including T1MI, T2MI, unstable angina pectoris, revascularization, and 30-day mortality. The outcome was adjudicated by cardiologists on the basis of all clinical information and test results. Likelihood ratios and odds ratios for 30-day MACE were reported for each ECG category. RESULTS: Major adverse cardiac events were diagnosed in 264 (11.3%) patients. Increasing ischemic abnormalities in ECGs, as categorized by the standardized reporting criteria, were associated with increasing rates of MACE. Within 30 days, T1MI occurred in 148 (6.3%) patients and T2MI occurred in 59 (2.5%) patients. Risk for T1MI increased with higher classification of ECG abnormalities. T2MI rates were highest in patients with ECGs of nonspecific changes. CONCLUSIONS: The rates of MACE, T1MI, and 1-year death can be stratified according to standardized ECG criteria in patients presenting to the ED with chest pain. The ECG findings in patients with T2MI are variable, and the ECG is less helpful in defining risk in this group.

Does Uric Acid Level Provide Additional Risk Stratification Information in Emergency Patients With Symptoms of Possible Acute Coronary Syndrome?

OBJECTIVE: Elevated uric acid levels have been associated with the presence and severity of coronary artery disease (CAD). This study aimed to assess the clinical utility of serum uric acid levels to identify patients at high risk of acute coronary syndrome (ACS) in those who presented to the emergency department (ED) with chest pain. METHODS: This was a prospective observational study of 951 adult patients who were being evaluated for ACS in a single ED. Serum uric acid was taken on presentation. Patients were followed up 30 days and 1 year after initial presentation. The primary outcome was a diagnosis of ACS within 30 days of initial attendance. A logistic regression analysis was performed to identify whether elevated uric acid levels were predictive of ACS. Kaplan-Meier curves were generated to identify 1-year mortality in those who were available for 1-year follow-up and Cox regression was performed to identify whether uric acid levels were an independent predictor of mortality. RESULTS: ACS was diagnosed in 88 patients and 140 patients had elevated uric acid levels. A total of 679 patients agreed to 1-year follow-up. Elevated uric acid levels were not associated with a diagnosis of ACS (p = 0.96). Patients with elevated uric acid had a higher 1-year death rate (8/101; 7.92%) compared with patients with normal uric acid levels (12/596; 2.01%, p < 0.01). CONCLUSIONS: Uric acid levels lack diagnostic utility for ACS but may be useful for identifying ED patients with chest pain who are at high risk for 1-year mortality. Elevated uric acid levels correlate with the presence of other risk factors of CAD and are a marker for poor long-term outcome.

Agreement Between Patient-reported and Cardiology-adjudicated Medical History in Patients With Possible Ischemic Chest Pain: An Observational Study.

OBJECTIVE: Obtaining an accurate medical history is essential in the assessment of patients, particularly in emergency department (ED) patients with acute chest pain, as there can be a time imperative for diagnosis and commencement of treatment. We aimed to evaluate reliability of patient-reported compared with physician-adjudicated medical history by assessing patient's recall and communication of personal events and its influence on the accuracy of the medical history. METHODS: A total of 776 patients presenting at ED with suspected cardiac chest pain were recruited. Data collection included self-reported patient history, electrocardiogram testing, and troponin I measurements. Independent assessment of risk factors and medical history was adjudicated by cardiologists. Diagnosis of acute coronary syndrome (ACS) at 30 days after presentation was assessed. Cohen's kappa measured patient-cardiologist agreement. Cardiologist adjudicated events were taken as true to assess accuracy. RESULTS: A total of 83 participants (10.7%) were diagnosed with ACS at 30 days after presentation. "Previous coronary artery bypass grafting" showed highest agreement (K = 1.00) between patient-reported and cardiologist-adjudicated events. Lowest agreement between patient-reported and cardiologist-adjudicated events was found for "prior ventricular dysrhythmia" (K = 0.33). Accuracy of reported "prior congestive heart failure" differed significantly between patients with and without diagnosed ACS at 30 days (92.8% and 97.5%, respectively). CONCLUSIONS: Accuracy of patient's recall and communication of medical history and risk factors was substantial but not perfect in the assessment of patients with ACS in the ED context. Our study reinforces the importance in the utilization of medical records and collateral information to address possible discrepancies in the medical history and improve patient care.

Two-Hour Algorithm for Triage toward Rule-Out and Rule-In of Acute Myocardial Infarction by Use of High-Sensitivity Cardiac Troponin I.

BACKGROUND: The early triage of patients toward rule-out and rule-in of acute myocardial infarction (AMI) is challenging. Therefore, we aimed to develop a 2-h algorithm that uses high-sensitivity cardiac troponin I (hs-cTnI). METHODS: We prospectively enrolled 1435 (derivation cohort) and 1194 (external validation cohort) patients presenting with suspected AMI to the emergency department. The final diagnosis was adjudicated by 2 independent cardiologists. hs-cTnI was measured at presentation and after 2 h in a blinded fashion. We derived and validated a diagnostic algorithm incorporating hs-cTnI values at presentation and absolute changes within the first 2 h. RESULTS: AMI was the final diagnosis in 17% of patients in the derivation and 13% in the validation cohort. The 2-h algorithm developed in the derivation cohort classified 56% of patients as rule-out, 17% as rule-in, and 27% as observation. Resulting diagnostic sensitivity and negative predictive value (NPV) were 99.2% and 99.8% for rule-out; specificity and positive predictive value (PPV) were 95.2% and 75.8% for rule-in. Applying the 2-h algorithm in the external validation cohort, 60% of patients were classified as rule-out, 13% as rule-in, and 27% as observation. Diagnostic sensitivity and NPV were 98.7% and 99.7% for rule-out; specificity and PPV were 97.4% and 82.2% for rule-in. Thirty-day survival was 100% for rule-out patients in both cohorts. CONCLUSIONS: A simple algorithm incorporating hs-cTnI baseline values and absolute 2-h changes allowed a triage toward safe rule-out or accurate rule-in of AMI in the majority of patients.