¿Es diferente el manejo de la fibrilación auricular en las urgencias de hospitales con y sin residentes? / Is the management of atrial fibrillation in the outpatient emergency clinic different in hospitals with and without resident physicians?

RESUMEN

Objetivo: Identificar posibles diferencias en el manejo de la fibrilación auricular entre hospitales con y sin médicos residentes. Métodos: Estudio de casos-controles anidado, realizado en el año 2000. Ámbito doce servicios de urgencias de hospitales públicos de Madrid, once de ellos docentes. Población pacientes con fibrilación auricular objetivada por electrocardiograma. Protocolo Recogida de datos (variables clínico-epidemiológicas y decisiones terapéuticas) prospectiva en una hoja codificada. No se efectuaron recomendaciones previas acerca del tratamiento. Estadística Se comparan los centros con y sin residentes. Resultados: Se incluyen 1.178 pacientes 1.045 en centros docentes y 133 en uno no docente. Las características de ambas poblaciones fueron homogéneas. Se intentó la cardioversión en 42,6% y 32,4% (p = 0,24) de los casos de reciente aparición (100 lpm, con mayor efectividad en el centro no docente (41% vs 60%, p= 0,03). En ambos grupos el fármaco elegido más frecuentemente fue la digoxina (69,2% vs 82,5%, p= 0,08). Finalmente, se prescribió anticoagulación a 21,5% y 22,4% (p = 0,83) de los pacientes con factores de riesgo para enfermedad tromboembólica arterial. Conclusión: La presencia o no de médicos residentes en los servicios de urgencias no modifica sustancialmente el manejo global de la fibrilación auricular, aunque sí se detectan diferencias en la efectividad del control de la frecuencia ventricular y en la elección de fármacos para el control del ritmo (AU)

ABSTRACT

Objective: The presence of resident training programs could influence the quality of health-care given in different clinical settings. We analyze the impact of the presence of residents in the emergency department (ED) management of atrial fibrillation (AF). Methods: This was a nested case-control study carried out in 12 EDs (11 of them with residents). Adults in whom AF was demonstrated in an ECG obtained in the ED were included. AF management in EDs with (R-EDs) and without residents (noR-EDs) was compared. Results: We included 1178 patients 1045 in R-EDs and 133 in noRED. Baseline characteristics in both groups were comparable. Rhythm control was attempted in 42.6% and 32.4% (p =0.24) of recent onset episodes (<48 hours), respectively, no differences on effectiveness (69.7 vs. 63.5%, p =0.53). In both groups, antiarrhythmic drugs were preferred in most of cases (96 % vs. 99%, p =0.53) amiodarone in RED (48.4% vs. 8.3, p =0.08 of cases) and flecainide in noR-ED (66.7% vs. 22%, p =0.001). Rate control was performed in 70.7% and 66.1% (p = 0.47) of patients with rapid ventricular response with higher effectiveness in noR-ED (60% vs. 41%, p=0.03); digoxin was the preferred drug in both groups (69.2% in R-ED and 82.5% in noR-ED, p=0.08). Anticoagulation was prescribed to 21.5% and 22.4% (p =0.83) of patients with risk factors for stroke, respectively. Conclusion: We found differences in the effectiveness of rate control and in the regimes selected for rhythm control between EDs with and without residents. However, the overall AF management had very similar features in both groups of EDs (AU)