Comparison of presenting features, diagnostic tools, hospital outcomes, and quality of care indicators in older (>65 years) to younger, men to women, and diabetics to nondiabetics with acute chest pain triaged in the emergency department.

In a total of 4,843 consecutive patients admitted to an emergency department (ED) with acute chest pain over a 1-year period, presenting features, diagnostic tools, hospital outcomes, and quality-of-care indicators were compared between older (n = 1,781) and younger (n = 3,062) patients, men (n = 3,095) and women (n = 1,748), and diabetics (n = 856) and nondiabetics (n = 3,987). The results showed that after critical pathway implementation, there was an increase in the use of evidence-based treatment strategies in the ED and improved outcomes in older patients, women, and diabetics, with no more differences in the length of ED stay, diagnostic accuracy for myocardial infarction in the ED, door-to-thrombolysis time, and door-to-balloon time compared with younger patients, men, and nondiabetics.

Critical pathways in the emergency department improve treatment modalities for patients with ST-elevation myocardial infarction in a European hospital.

BACKGROUND: The use of protocols for patients with ST-elevation myocardial infarction (MI) is growing, but no definite conclusion regarding the value of critical pathways in Europe has been drawn. HYPOTHESIS: The aim of this study was to investigate the impact of critical pathway on processes of care and outcome for patients presenting to the emergency department (ED) of a large urban European hospital because of possible ST-elevation MI. METHODS: Critical pathways for management of acute chest pain at our ED were developed in 1998 and have been revised every year. Accordingly, the records of all patients referred in 1997 to the ED because of chest pain (before pathway implementation) and in 2001 (after last pathway revision) were reviewed. An ST-elevation MI was diagnosed at ED in 520 of 5,066 (10.3%) patients with chest pain in 1997, and in 452 of 4,843 (9.3%) patients with chest pain in 2001. Patients were managed according to the ED cardiologists' decisions in 1997, whereas they entered the pathways for ST-elevation MI in 2001, with predefined criteria for diagnosis, thrombolysis, percutaneous coronary intervention, and admission to the coronary care unit. RESULTS: Comparison of treatment modalities disclosed that more patients were given thrombolysis in 1997 (49 vs. 16%, p<0.05), whereas in 2001 more patients were sent to primary angioplasty (63 vs. 11%, p<0.05). Also in 2001, patients more often received aspirin (90 vs. 61%, p<0.05) and intravenous beta blockers (60 vs. 35%, p<0.05) soon after arrival at the ED. Comparison between 1997 and 2001 revealed that admission rates to the coronary care unit (69 vs. 78%, NS) and cardiac wards were similar (19 vs. 10%, NS). Conversely, compared with 1997, patients hospitalized in 2001 had a shorter length of stay (12 +/- 5 vs. 18 +/- 6 days, p<0.05), as well as fewer major adverse coronary events (21 vs. 30%, p<0.05) and lower all-cause in-hospital mortality (12 vs. 20%, p<0.05). The quality of care indicators improved with time, as door-to-electrocardiogram interval (10 +/- 6 vs. 19 +/- 9 min, p<0.05), door-to-needle time (25 +/- 10 vs. 35 +/- 10 min, p<0.05), and door-to-balloon interval (70 +/- 15 vs. 99 +/- 20 min, p<0.05) were shorter in 2001 than in 1997. CONCLUSIONS: A critical pathway for ST-elevation MI at the ED increases the use of evidence-based treatment strategies and improves outcome and quality of care of patients presenting to a European hospital because of acute chest pain.

Gender differences in the clinical presentation to the emergency department for chest pain.

Previous studies suggest that the presentation, treatment, and outcome of acute coronary syndromes differ between women and men. Women arriving to the emergency department for acute coronary syndromes are usually older, have a higher prevalence of diabetes and hypertension, show a longer delay from symptom onset and have a slightly higher in-hospital mortality than men. In our experience including 4843 emergency department admissions for chest pain, the time to presentation was longer and diagnostic mistakes more frequent in women than in men, whereas medical treatment and the rate of revascularization procedures were similar. The introduction of Chest Pain Units with pre-defined diagnostic and therapeutic procedures should facilitate the early identification of highrisk female patients, reduce inappropriate hospitalizations, and improve the diagnosis and outcome of coronary heart disease.

[First-aid treatment for acute myocardial infarction. Experience at the San Camillo Hospital of Rome]. / Trattamento in pronto soccorso dell'infarto acuto del miocardio. L'esperienza dell'Ospedale San Camillo di Roma.

STUDY OBJECTIVE: The aim of the study is to verify: 1) the trustworthiness level of the diagnosis of AMI defined in Emergency Department (ER); 2) the frequency and the effectiveness (length of staying in hospital, mortality rate) of the invasive or not invasive treatment which are implemented in the ER area. METHODS: We have studied the crowding of the patients suffering from chest pain (CP) who asked the ER for assistance during the year 2000 and that of the patients with AMI diagnosed in ER (diagnosis at the admittance and at the discharge from the hospital, therapeutic procedures, staying in hospital, mortality rate). RESULTS: The patients suffering from CP have been the 5.4% of all the patients who reached the ER and were admitted to the hospital more than the patients who reached the ER for all the other causes (41.5% versus 22.1%). In 61.7% of the patients affected by AMI the disease was identified by the physicians of the ER; the invasive treatment has been developed in 67.7% of those patients and the not invasive in 32.3% of the same patients. The mean length of the staying in hospital for the patients who have been treated with PTCA was 10.3 days; on the contrary, the same value for the patients treated with thrombolysis was 13.8 days and the difference was significant at the 0.001 level. The mortality rate during the staying in Hospital was 5.9% in the patients treated with PTCA and 13% in the patients treated with thrombolysis but the difference was not significant because of the little number of the dead patients. CONCLUSION: The sensitivity (62%) and the specificity (100%) of the diagnosis of AMI defined in the ER demonstrate the utility of a Cardiologic Service in ER.