Characteristics of hospital observation services: a society of cardiovascular patient care survey.

INTRODUCTION: Little is known about the setting in which observation services are provided, or how observation patients are managed in settings such as accredited cardiovascular patient care centers. OBJECTIVE: To describe the characteristics of observation services in accredited Cardiovascular Patient Care hospitals, or those seeking accreditation. METHODS: This is a cross-sectional survey of hospitals either accredited by the Society of Cardiovascular Patient Care, or considering accreditation in 2010. The survey was a web-based free service linked to an e-mail sent to Cardiovascular Patient Care coordinators at the respective institutions. The survey included 17 questions which focused on hospital characteristics and observation services, specifically management, settings, staffing, utilization, and performance data. RESULTS: Of the 789 accredited hospitals, 91 hospitals (11.5%) responded to the survey. Responding hospitals had a median of 250 inpatient beds (interquartile range [IQR] 277), 32.5 emergency department (ED) beds or hall spots, with an average annual ED census of 41,660 (IQR 30,149). These hospitals had an average of 8 (IQR 9) observation unit beds whose median length of stay (LOS) was 19 hours (IQR 8.1), with a discharge rate of 89.1% (IQR 15). There was an average of 1 observation bed to 3.8 ED beds. Observation units were most commonly administered by emergency medicine (48.5%), but staffed by a broad spectrum of specialties. Nonemergency medicine units had longer LOSs, which were not significant. Most common conditions were chest pain and abdominal pain. CONCLUSIONS: Accredited chest pain centers have observation units whose LOSs and discharge rates are comparable to prior studies with utilization patterns that may serve as benchmarks for similar hospitals.

Ability of triage decision rules for rapid electrocardiogram to identify patients with suspected ST-elevation myocardial infarction.

BACKGROUND: : The American College of Cardiology/American Heart Association guidelines for ST-elevation myocardial infarction state that an electrocardiogram (ECG) should be performed on patients with suspected acute coronary syndrome upon presentation to the emergency department (ED) within 10 minutes. OBJECTIVE: : To determine how previously published clinical criteria for obtaining an ECG at ED triage perform in a population of patients receiving emergency cardiac catheterization for suspected myocardial infarction. This rule was originally derived by Graff to identify clinical criteria for obtaining an ECG at triage to rapidly identify patients with acute myocardial infarction. The Graff rule was developed in a setting where lytic therapy was the primary reperfusion strategy. A modification proposed by Glickman adds several more criteria in an effort to capture additional patients. We hypothesized that the Graff rule would identify most patients for whom the cardiac catheterization laboratory (CCL) was activated and that the Glickman rule would capture the remaining patients. METHODS: : Three trained physician reviewers retrospectively applied the Graff decision rule to 430 consecutive patients from a database of emergency CCL activations by ED physicians. The Graff rule recommends that patients between the ages of 30 and 49 years received a rapid ECG if they complained of chest pain and those aged 50 years or older received a rapid ECG when they complained of chest pain, shortness of breath, palpitations, weakness, or syncope. The newly developed Glickman rule, which included nausea and vomiting in patients over the age of 80 years, was applied to the patients where the Graff rule was negative. The triage note or earliest medical contact documentation was used to determine whether the patient's complaints would have resulted in a rapid ECG by the decision rule. Each case was reviewed for acute myocardial infarction as defined by high-grade stenosis on the subsequent emergent cardiac catheterization. A single data collection Microsoft Excel spreadsheet was used, and descriptive statistics were performed in Excel and Stata. RESULTS: : Of the 430 CCL activations, 415 (97%; 95% confidence interval, 95%-99%) were identified by the Graff rule. Of the 12 patients who were not identified by the rule, only 2 more were identified by the Glickman criteria. Among patients with confirmed ST-elevation myocardial infarction (79% of CCL activations), the Graff rule was 98% sensitive (95% confidence interval, 96%-99%). CONCLUSIONS: : The Graff ECG triage rule identified almost all patients for whom the CCL was activated. Modification of the rule as proposed by Glickman added very little to the rule's sensitivity, while increasing the number of ECGs required at triage.

Impact of an emergency department observation unit transient ischemic attack protocol on length of stay and cost.

This study examined the impact of an emergency department (ED) observation unit's accelerated diagnostic protocol (ADP) on hospital length of stay (LOS), cost of care, and clinical outcome of patients who had sustained a transient ischemic attack (TIA). All patients with TIA presenting to the ED over a 18-consecutive month period were eligible for the study. During the initial 11 months of the study (pre-ADP period), all patients were admitted to the neurology service. Over the subsequent 7 months (post-ADP period), patients were either managed using the ADP or were admitted based on ADP exclusion criteria or at a physician's discretion. All patients had orders for serial clinical examinations, neurologic evaluation, cardiac monitoring, vascular imaging of the brain and neck, and echocardiography. A total of 142 patients were included in the study (mean age, 67.9 ± 13.9 years; 61% female; mean ABCD(2) score, 4.3 ± 1.4). In the post-ADP period, 68% of the patients were managed using the ADP. Of these patients, 79% were discharged with a median LOS of 25.5 hours (ED + observation unit). Compared with the pre-ADP patients, the post-ADP patients (ADP and non-ADP) had a 20.8-hour shorter median LOS (95% confidence interval, 16.3-25.1 hours; P < .01) than pre-ADP patients and lower median associated costs (cost difference, $1643; 95% confidence interval, $1047-$2238). The stroke rate at 90 days was low in both groups (pre-ADP, 0%; post-ADP, 1.2%). Our findings indicate that introduction of an ED observation unit ADP for patients with TIA at a primary stroke center is associated with a significantly shorter LOS and lower costs compared with inpatient admission, with comparable clinical outcomes.

Transthoracic dobutamine stress echocardiography in patients undergoing bariatric surgery.

BACKGROUND: The feasibility and value of transthoracic dobutamine stress echocardiography (DSE) in patients scheduled for bariatric surgery has not been investigated. METHODS: We evaluated 611 patients (86.6% female, 42 +/- 10 years, 136 +/- 18 kg, BMI 48.0 +/- 6.1 kg/m2) referred for DSE prior to surgery between February 2000 and July 2005. Mortality and major cardiovascular events (cardiac death, acute coronary syndrome, and urgent revascularization) were recorded 30-days postoperatively and at 6 months. RESULTS: Adequate baseline imaging quality was achieved in 590 patients (96.6%), with use of echocardiographic contrast agents in 426 patients (72.2%); the remaining 21 patients (3.4%) were referred for alternative preoperative testing. There were no serious adverse events during DSE, which was negative in 545 patients (92.4%). The test was inconclusive in 38 patients (6.4%), requiring alternative investigations, and positive in 7 patients (1.2%). Eventually, 595 patients proceeded to surgery: 539 with DSE-based risk stratification and 56 with risk stratification based on alternative testing. Laparoscopic procedures were employed in 77.0% of patients. There were 3 perioperative deaths, all attributed to sepsis (perioperative mortality 0.50%), but no major cardiovascular events at 30-days. One patient (evaluated prior to surgery with alternative testing) experienced an acute coronary syndrome during the following 6 months (event rate 0.17%). CONCLUSION: Transthoracic DSE is feasible and safe in morbidly obese patients undergoing bariatric surgery; implementation of echocardiographic contrast agents allows for adequate imaging quality in the majority of these patients. However, the very low risk of contemporary bariatric procedures questions the need for routine preoperative stress testing in asymptomatic patients.