Outcome of travelers who refuse transport after emergency medical services evaluation at an international airport.

OBJECTIVE: To determine the short-term outcome of patients refusing transport after emergency medical services (EMS) evaluation at an international airport. METHODS: This was a prospective, descriptive, observational study of patients who refused transport after evaluation by Philadelphia Fire Department paramedics at Philadelphia International Airport from July 2003 through March 2004. Paramedics contacted a medical command physician (MCP), who recorded the patient's contact information. Three days later, one investigator attempted to contact the patient to administer a survey of the medical course in the three days following the initial encounter. RESULTS: Of 90 patients enrolled, 64 (71%) were reached in follow-up. Their average age was 45 years (range 10 months to 80 years); 41 (63%) were female. The most common presenting complaints were trauma-related (22 patients, 34%), neurologic (12, 19%), and gastrointestinal (7, 11%). The most common reasons for refusing transport were belief that their complaint was not serious (48, 75%) and fear they would miss a flight (34 patients, 53%). In the three days following the initial encounter, no patients recontacted 9-1-1, 16 patients (25%) had a recurrence of their initial complaints, and 32 patients (50%) saw or talked to a physician. There was one hospitalization but no deaths. Among patients lost to follow-up, no deaths of U.S. citizens were detected. CONCLUSIONS: Most patients who refused transport after EMS evaluation at an international airport had good short-term outcomes. These results may assist paramedics and MCPs to manage refusals in this setting and to allow patients to make informed decisions.

Evaluation of a clinical decision rule for young adult patients with chest pain.

OBJECTIVES: The authors sought to validate a clinical decision rule that young adult (younger than 40 years) chest pain patients without known cardiac disease who had either no cardiac risk factors and/or a normal electrocardiogram (ECG) are at low risk (<1%) for acute coronary syndromes (ACS) and 30-day adverse cardiovascular (CV) events. METHODS: A prospective cohort study of patients 24-39 years old who received an ECG for chest pain from July 1999 to March 2002 were included. Cocaine users were excluded. Data collection was structured at presentation, hospital course was followed daily, and 30-day follow-up was obtained by telephone. The main outcome was 30-day adverse CV events (death, acute myocardial infarction, percutaneous intervention, and coronary artery bypass graft). Descriptive statistics were used. RESULTS: Of 4,492 visits for chest pain, 1,023 met criteria. Patients were most often female (61%) and African American (73%). Ninety-eight percent were available for 30-day follow-up. The overall risks of ACS and 30-day adverse CV events were 5.4% and 2.2%, respectively, in our entire cohort. For patients with no cardiac history and no cardiac risk factors, the risk of ACS and 30-day adverse CV events was 1.8%. The risk in patients with no cardiac history and a normal ECG was 1.3%. Patients with no cardiac history, no cardiac risk factors, and a normal ECG had a risk of 1.0%. A modified clinical decision rule found that in young adult patients without a known cardiac history, either no classic cardiac risk factors or a normal ECG, and initially normal cardiac marker studies, the risk of ACS was also extremely low (0.14%) and there were no adverse CV events at 30-day follow-up (95% confidence interval = 0.1% to 0.2%). CONCLUSIONS: A modified clinical decision rule described a group of patients with a 0.14% risk of ACS that was free from 30-day adverse CV events.

Impact of a negative evaluation for underlying coronary artery disease on one-year resource utilization for patients admitted with potential acute coronary syndromes.

UNLABELLED: Reduction in emergency department (ED) overcrowding is a major Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) initiative. One major source of ED overcrowding is patients waiting for telemetry beds. OBJECTIVE: To determine whether, in patients admitted with a potential acute coronary syndrome, a negative evaluation for underlying coronary artery disease would reduce ED and hospital revisits over the subsequent year compared with patients who did not receive an evaluation for underlying coronary artery disease. METHODS: Nine hundred ninety-nine consecutive patients admitted for potential acute coronary syndromes through the ED during a one-year period were screened for inclusion. Patients who had a negative evaluation for underlying coronary disease were compared with patients who were not evaluated for underlying coronary artery disease for subsequent ED visits, hospital admissions, and cardiac resource utilization over the year following the index visit via a health system-wide computerized record review. Patients with positive tests or biomarkers at the index visit were excluded. Each repeat visit was rated as "potentially cardiac" or "noncardiac." Results of echocardiograms, stress tests, and catheterizations and information about in-hospital deaths were obtained. RESULTS: Six hundred ninety-two patients met the inclusion criteria: 556 patients received no evaluation for underlying coronary artery disease, 116 had a negative stress test, and 20 had a negative cardiac catheterization during the index visit. Patients with no evaluation for underlying coronary artery disease and patients with a negative evaluation had similar likelihoods of a repeat ED visit (negative test 39.0% vs. no test 40.3%; p = 0.85) and repeat hospital admission (28.7% vs. 31.5%; p = 0.61). The rates of a potentially cardiac-related ED visit (21.3 vs. 23.4%; p = 0.65) and hospital admission (17.7% vs. 20.7%; p = 0.48) were not significantly different. The two populations had similar utilization rates of echocardiograms, stress tests, and catheterizations (p > 0.70 for all). CONCLUSIONS: For patients admitted to the authors' institution with a potential acute coronary syndrome, there was no association between a negative evaluation for underlying coronary artery disease and overall or potentially cardiac ED visits, admissions, or cardiac resource test utilization over the year following the index visit.