基层医院远程胸痛急救会诊终端的建设与实践

急性非创伤性胸痛具有起病急骤、病情进展快、诊断困难、可救治时间短等特点。胸痛中心和基层医院远程胸痛急救会诊终端的建立,通过早期启动和快速安全转运,提高了基层医院急诊科对急性胸痛患者的诊治效率。     

Measuring Quality in the Prehospital Care of Chest Pain Patients

Background. Rates of compliance with evidence-based treatment guidelines are commonly used to evaluate hospital quality of care. This method of quality assessment has not been widely extended to the prehospital environment. Previous studies have shown that the prehospital care of chest pain patients is often incomplete. Objective. To determine how well paramedics in an urban public hospital system deliver high-quality, comprehensive care for patients with nontraumatic chest pain. Methods. Patients with a primary complaint of nontraumatic chest pain for two quarters of 2006 were identified, records were randomly sampled, anda retrospective audit was performed. Seven individual quality indexes were identified by the medical director of the Denver Health Paramedic Division. A composite metric (bundle score) was also created to assess the completeness of care. This bundle score was considered unmet if any single variable was not present. Results. Five hundred eighty-six patient care reports were evaluated. Overall, 92% of the patients received oxygen, 62% received aspirin, 97% had lung sounds assessed, 99% had vital signs assessed, 84% had an intravenous (IV) line established, 92% had an electrocardiogram (ECG) obtained, and73% were assessed for cardiac risk factors. The composite score was met for only 39% of patients. Significant differences across age groups were found in assessing cardiac risk factors, obtaining ECGs, andadministering aspirin, andin the composite measure. In all of these metrics, the prehospital care rendered to the younger patients was associated with a lower rate of provider compliance than that delivered to the older patients. Conclusions. There was generally good compliance with each individual metric, yet compliance with the comprehensive metric was poor. This manner of quality assessment, utilizing a bundle score, can be successfully applied to the prehospital arena, although future work is needed to establish criteria for measuring optimal quality of care     

Physician Variability in History Taking When Evaluating Patients Presenting with Chest Pain in the Emergency Department

Objectives: The goal of this study was to examine how physicians in the emergency department ask questions of patients presenting with chest pain and whether this varies by patient demographics.
Methods: This was a cross-sectional study with convenience sampling. A survey was administered to adult emergency department patients presenting with chest pain after emergency physicians obtained the history and performed the physical examination. No identifying data were collected from the patients. In addition to demographics, patients were asked whether or not their physician asked them about factors related to coronary syndrome and myocardial infarction etiology.
Results: A total of 308 of 332 patients (93%) participated. Patients had a mean age of 52 years, 54% were male, and 85% spoke English; classification by race was 31% African American, 28% white, 19% Hispanic, and 13% other. History taking did not differ by gender. Patients who reported being asked about the following were statistically significantly younger than those who reported not being asked: family history, other medical problems, smoking, cocaine use, and alcohol use. Nonwhite patients reported being asked about the following more frequently than white patients: smoking (94% vs. 84%), alcohol use (81% vs. 70%), and cocaine use (64% vs. 42%). In multivariate logistic regression controlling for age, nonwhite patients were more likely than white patients to be asked about smoking (odds ratio [OR], 2.79; 95% confidence interval [CI] = 1.26 to 6.19), cocaine use (OR, 2.49; 95% CI = 1.50 to 4.12), and alcohol use (OR, 1.77; 95% CI = 1.0 to 3.09).
Conclusions: The variability in questions about behavioral factors associated with chest pain etiology as reported by patients may indicate a possible cultural bias by physicians. Differences in risk identification may lead to differences in treatment decisions.     

Health Beliefs toward Cardiovascular Risk Reduction in Patients Admitted to Chest Pain Observation Units

Objectives: Even after acute coronary syndrome (ACS) is ruled out, observational studies have suggested that many patients with nonspecific chest pain have a high burden of cardiovascular risk factors (CRFs) and are at increased long‐term risk of ischemic heart disease (IHD)‐related mortality. The aim of this study was to evaluate the premise that evaluation in an observation unit for symptoms of possible ACS is a “teachable moment” with regard to modification of CRFs. Methods: The authors conducted a baseline face‐to‐face interview and a 3‐month telephone interview of 83 adult patients with at least one modifiable CRF who presented with symptoms of possible ACS to an academic medical center. Existing questionnaires were adapted to measure Health Belief Model (HBM) constructs for IHD. Stage of change and self‐reported CRF‐related behaviors (diet, exercise, and smoking) were assessed using previously validated measures. The paired t‐test or signed rank test was used to compare baseline and 3‐month measures of health behavior within the analysis sample. Results: Of the 83 study patients, 45 and 40% reported having received clinician advice regarding diet and physical activity during the observation unit encounter, respectively; 69% of current smokers received advice to quit smoking. Patients reported lower susceptibility to IHD (13.3 vs. 14.0, p = 0.06) and greater perceived benefit of healthy lifestyles (27.5 vs. 26.4, p = 0.0003) at 3‐month follow‐up compared to baseline. Patients also reported greater readiness to change and improved self‐reported behaviors at follow‐up (vs. baseline): decreased intake of saturated fat (10.1% vs. 10.5% of total calories, p = 0.005), increased fruit and vegetable intake (4.0 servings/day vs. 3.6 servings/day, p = 0.01), and fewer cigarettes (13 vs. 18, p = 0.002). Conclusions: Observed changes in IHD health beliefs and CRF‐related behaviors during follow‐up support the idea that observation unit admission is a teachable moment. Patients with modifiable risk factors may benefit from systematic interventions to deliver CRF‐related counseling during observation unit evaluation.     

Prevalence of Aspirin Use among Patients Calling 9-1-1 for Chest Pain

Abstract. Objective: Early aspirin administration during an acute myocardial infarction (AMI) decreases morbidity and mortality. This investigation examined the extent to which patients with a complaint of chest pain, the symptom most identified with AMI by the general population, self-administer aspirin before the arrival of emergency medical services (EMS) personnel.
Methods: In this prospective, cross-sectional prevalence study, data were derived through the analysis of EMS incident reports for patients with a complaint of chest pain from June 1, 1997, to August 31,1997.
Results: The study included 694 subjects. One hundred two (15%) took aspirin for their chest pain before the arrival of EMS personnel. Of the 322 subjects who reported taking aspirin on a regular basis, 82 (26%) took additional aspirin for their acute chest pain. Only 20 (5%) of the 370 patients who were not using regular aspirin therapy self-administered aspirin acutely (p < 0.001). In addition, patients with lower intensity of chest pain (p = 0.03) were more likely to take aspirin for their chest pain.
Conclusion: Only a relatively small fraction of individuals calling 9-1-1 with acute chest pain take aspirin prior to the arrival of EMS personnel. These individuals are more likely to self-administer aspirin if they are already taking it on a regular basis. It is also possible that they are less likely to take aspirin if their chest pain is more severe.     

Pain Management: Association with Patient Satisfaction among Emergency Department Patients

Background

Patient satisfaction with emergency care is associated with timeliness of care, empathy, technical competence, and information delivery. Previous studies have demonstrated inconsistent findings regarding the association between pain management and patient satisfaction.

Objectives

This study was undertaken to determine the association between pain management and patient satisfaction among Emergency Department (ED) patients presenting with acute painful conditions.

Methods

In this survey study, a standardized interview was conducted at the Emergency Department at the University of Toledo Medical Center in May–July 2011. Participants were asked to answer 18 questions pertaining to patient satisfaction. Additional data collected included demographic information, pain scores, and clinical management.

Results

Among 328 eligible participants, 289 (88%) participated. The mean triage pain score on the verbal numeric rating scale was 8.2 and the mean discharge score was 6.0. The majority of patients (52%) experienced a reduction in pain of 2 or more points. Participants received one pain medication dose (44%), two medication doses (14%), three medication doses (5%), or four medication doses (2%). Reduction in pain scores of 2 or more points was associated with a higher number of medications administered. Reduction in pain scores was associated with higher satisfaction as scored on questions of patient perceptions of adequate assessment and response to pain, and treatment of pain.

Conclusions

There was a significant association between patient satisfaction and a reduction in pain of 2 or more points and number of medications administered. Effective pain management is associated with improved patient satisfaction among ED patients with painful conditions.     

Characteristics of Cocaine Users Presenting to an Emergency Department Chest Pain Observation Unit

Objectives: This report examines the sociodemographic and substance use characteristics, co-occurring psychological status, substance abuse consequences, and prior experiences with substance abuse treatment among patients with cocaine-associated chest pain presenting to an emergency department chest pain observation unit. Methods: This was a consecutive cohort of patients in the emergency department chest pain observation unit aged 18–60 years with low to moderate risk for acute coronary syndrome and recent cocaine use. Responses on standardized and validated instruments were used to examine demographic and clinical characteristics of the sample and to compare patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for past three-month substance abuse or substance dependence with patients who did not. Results: Of 145 eligible patients identified between June 1, 2002, and February 29, 2004, 86% met criteria for a lifetime DSM-IV substance use disorder and 50% met past three-month criteria. Approximately one half of the total sample reported substantial symptoms of depression. Substance use frequency and consequences, depression, and psychological distress were significantly more severe among those with past three-month substance use diagnoses; however, most sociodemographic characteristics were not associated with substance use diagnoses. Interest in treatment services and treatment history was also significantly associated with the presence of a substance use disorder diagnosis. Conclusions: Findings regarding diversity in alcohol and drug involvement, current level of psychological functioning, depressive symptomatology, and interest in treatment services provide useful information for designing emergency department–based interventions for this population.     

Substernal Chest Pain and Dyspnea in a Female Patient

A 76-year-old female patient presented to the emergency department with substernal chest pain and dyspnea symptoms. She reported that the symptoms started 2 days earlier. These symptoms can arise from both cardiac and noncardiac conditions. It is difficult to ascribe chest pain and dyspnea symptoms to a single cause. Recognizing these symptoms is critical for inpatient cardiac and primary care nurse practitioners to choose the correct diagnosis and facilitate more effective treatment planning.     

The Association between Patients’ Perception of Their Overall Quality of Care and Their Perception of Pain Management in the Prehospital Setting

Abstract

Objective. Our objective was to determine whether there is an association between a patient's impression of his or her overall quality of care and his or her satisfaction with the pain management provided. We hypothesized that satisfaction with pain management would show a significant positive association with a patient's impression of overall quality of care. Methods. This was a retrospective review of patient satisfaction data initially collected by a third-party company from January 1, 2007, to September 1, 2010. Participants were randomly selected from all transported patients, proportional to their paramedic-defined acuity level, with a goal of 100 interviews per month. The proportions of patients sampled from each acuity level were 25% priority 1 (high), 50% priority 2 (medium), and 25% priority 3 (low). Patients were excluded if there was no telephone number recorded in the prehospital patient record, no transportation was recorded, or the call was labeled as a psychiatric complaint. All satisfaction questions used a five-point Likert scale with ratings from excellent to poor, which were dichotomized for analysis. The outcome variable was the patient's perception of his or her overall quality of care. The main independent variable was the patient's rating of his or her pain management by emergency medical services (EMS) staff at the scene. Demographic variables were assessed for potential confounding. Results. There were 2,741 patients with complete data for the outcome and main independent variables; 41.7% of the respondents were male and the average age was 54.1 years (standard deviation = 22.6). The overall quality of care was rated as excellent by 65.9% of the patients, whereas 59.2% rated their pain management as excellent. Of the patients who rated their pain management as excellent, 79.0% rated the overall quality of care as excellent, whereas only 21.0% of the patients rated the overall quality of care as excellent if pain management was not excellent. When the patients rated EMS staff as excellent for both helping to control or reduce pain and explaining the medications given, they were 2.7 (95% confidence interval 1.4–5.4) times more likely to rate their overall quality of care as excellent. Conclusion. Our model indicated that pain management was associated with increased perception of overall quality of care only when EMS providers explained the medications provided and their potential side effects.     

Differences between Chest Pain Observation Service Patients and Admitted "Rule-out Myocardial Infarction" Patients

Objective: To compare and contrast the patient characteristics of ED patients at low risk for acute cardiac ischemia who were assigned to a chest pain observation service vs those admitted to a monitored inpatient bed for "rule-out acute myocardial infarction" (R/O MI).
Methods: This was a retrospective, cross-sectional comparison of adult patients considered at relatively low risk for cardiac ischemia and who were evaluated in 1 of 2 settings: a short-term observation service and an inpatient monitored bed. All patients had an ED final diagnosis of "chest pain," "R/O MI," or "unstable angina" during the 7-month study period. Demographic features and presenting clinical features were examined as a function of site of patient evaluation.
Results: Of 531 study patients, 265 (50%) were assigned to the observation service. Younger age (OR = 1.75, 95% CI 1.26, 2.44, for each decrement of 20 years), the complaint of "chest pain" (OR = 2.35, 95% CI 1.34, 4.12), and the absence of prior known coronary artery disease (OR = 1.64, 95% CI 1.13, 2.38) were the principal independent factors associated with assignment to a chest pain observation service bed. Conclusions: Patients evaluated in a chest pain observation service appear to have different clinical characteristics than other individuals admitted to a monitored inpatient bed for "R/O MI." Investigators should address differences in clinical characteristics when making outcome comparisons between these 2 patient groups.     

Untreated Hypercholesterolemia in an Emergency Department Chest Pain Observation Unit Population

OBJECTIVES: To describe the prevalence of hypercholesterolemia in a predominantly African American, innercity chest pain observation unit (CPOU) patient population, and to estimate the percentage of patients eligible for cholesterol-lowering therapy as indicated by the 2001 National Cholesterol Education Program guidelines. METHODS: A cross-sectional study design utilizing a convenience sample of patients from a high-volume urban hospital CPOU. Patients with chest pain suspicious of cardiac etiology who had negative initial electrocardiograms and cardiac markers were assigned to the chest pain protocol. Consenting subjects were screened for hypercholesterolemia through capillary blood point-of-care testing with a cutoff of 190 mg/dL. Those who tested positive had four-hour fasting complete lipid profiles performed by the central laboratory. RESULTS: There were 112 patients enrolled in this study (mean age = 51 years; 57% male; and 83% African American). Elevated values on the screening test were obtained on 28 [25%; 95% confidence interval (95% CI) = 16.9 to 33.0] of these patients. These patients were found to have a mean four-hour fasting total cholesterol level of 224 mg/dL, a low-density lipoprotein (LDL) level of 138 mg/dL, a high-density lipoprotein (HDL) level of 52 mg/dL, and a triglyceride level of 168 mg/dL. Of the patients identified through the screening test, 54% proved eligible for cholesterol-lowering medications and 91.7% of these patients reported an interest in initiating therapy. CONCLUSIONS: In this study, approximately 25% of inner-city CPOU patients are possible candidates for cholesterol-lowering interventions. Benefits of initiating therapy during this potential "teachable moment" in a CPOU should be investigated in a subsequent multicenter randomized trial.     

Predictive Validity of the Emergency Physician and Global Job Satisfaction Instruments

Objective: To evaluate the predictive validity of the Emergency Physician Job Satisfaction (EPJS) and Global Job Satisfaction (GJS) instruments.
Methods: Prospective mail survey of 223 Canadian emergency physicians (EPs) using a 42-item questionnaire, including 14 items evaluating their reasons for leaving emergency medicine (EM). Original (1990) EPJS and GJS scores were analyzed using 1-way ANOVA and Scheffe's test comparing the physicians who left EM with those still in their original jobs, and those who had left their original jobs but who stayed in EM. Mean scores on the 14 "reason for leaving" items were compared with scores from an earlier sample of U.S. physicians using a t-test for independent means. Criteria for statistical significance were set at a = 0.05 for all analyses.
Results: The response rate for the primary study questions was 99.1%. Of the respondents, 29.4% had left their original jobs, and 10.4% had left EM altogether. The GJS scores for the physicians who left EM were significantly different from those for the physicians who stayed (p = 0.004). The EPJS scores for the physicians who left EM were not significantly different from those for the physicians who stayed (p = 0.56). There was no significant difference in scores between the Canadian and U.S. physicians' reasons for leaving EM (all p-values > 0.05). Shiftwork scored the highest as a reason to leave EM.
Conclusions: A low GJS score is associated with physicians' leaving EM, but not with changing jobs. The EPJS instrument was not associated with either outcome. Canadian and U.S. EPs place similar levels of importance on potential reasons for leaving EM.