If the ECG shows ischemic changes, we will obviously treat the patient in the emergency room and notify the cardiologist. If not, you will be treated as if it were angina and observed, with serial enzymes and treatment in the observation area.

A 64-year-old man with a history of hypertension and ischemic heart disease comes to the emergency department for oppressive chest pain while watching television. In the ED triage consultation, T. art values of 155/95 mmHg and a capillary O2 saturation of 95% are detected. Which of the following is the most correct course of action?

Instruct her to go to the waiting room. You will be notified for tests.

This patient should be treated in the vital emergency room (shock room).

We will notify the cardiologist on duty to evaluate the patient.

From the Triage consultation, the patient will be referred to the Coronary Unit.

We will do an ECG in less than 10 minutes.

ANESTHESIOLOGY, CRITICAL CARE AND EMERGENCY MEDICINE

Breaking bad (news) death-telling in the emergency department.

Many physicians struggle with death-telling in sudden death. Families can be negatively impacted by suboptimal death-telling. Appropriate preparation and education can make death notification less stressful for the physician and may help decrease the development of pathologic grief in the surviving family members that can occur when death is unexpected. Although still controversial, there is a growing body of evidence that family witnessed resuscitation may be beneficial to the grieving process and desired by the public. A previously healthy 21-year-old male comes toyour community emergency department (ED) for a cough that started 4 days ago. He denies fever, shortness of breath, and chest pain. He does admit to a remote history of drug abuse. He states he is feeling "OK" and is only here because his family insisted he come because they were worried he might have pneumonia. His vital signs are normal and he appears well; therefore, he is triaged to the waiting room. About 30 minutes lates the patient complains of shortness of breath and he is brought back to an exam room. The patient is now hypotensive, tachycardic, and pulse oximetry is noted to be 87% on room air. A chest x-ray reveals severe pulmonary edema and an EKG shows ST segment elevation in multiple leads. The patient is taken to the cardiac catheterization lab by the interventional cardiologist, who makes the diagnosis of a ruptured aortic valve due to damage from endocarditis. The patient is returned to the ED to await emergent transfer to a tertiary facility; however, the patient rapidly decompensates and a Code Blue is called. Despite the absence of return of spontaneous circulation, resuscitation efforts are prolonged while the ED social worker attempts to contact the patient's family to come to the ED. Finally, the resuscitation is terminated and the patient is pronounced dead. Several hours later the patient's elderly mother arrives and asks you: "What's going on with Mikey?"

Electrocardiographic recording and timeliness of clinician evaluation in the emergency department in patients presenting with chest pain.

Acute chest pain (CP), a leading symptom of persons presenting to emergency departments (EDs), may represent a life-threatening emergency or nonurgent condition requiring routine outpatient follow-up. In either case, rapid provision of an electrocardiogram and clinician evaluation are essential for determining appropriate treatment or discharge from the ED. Data from the National Hospital Ambulatory Medical Care Survey were used to estimate the proportion of hospital ED visits for a chief symptom of CP in adults aged >or=25 years with documentation of both an electrocardiogram and mean and/or median wait time to see a clinician in the ED. In 2004, adults aged >or=25 years made nearly 5.3 million (men 2.5, women 2.8) CP-ED visits. Patients arrived by means of ambulance in only 25% of visits. Overall, a quarter of the patients with CP visits waited <10 minutes to see a physician in 2003 to 2004. Mean wait time was 36 +/- 1.7 (SE) minutes, an increase of 5 minutes from that in 1997 to 1998. In 2003 to 2004, provision of an electrocardiogram was documented for about 80% of all patients with CP-related ED visits and 90% of those with visits for undifferentiated or cardiac CP. The odds of having an electrocardiogram taken in the ED increased (p <or=0.05) for older adults, men, and those triaged as emergency cases (vs unknown or no triage) or who waited <10 minutes to see a physician (vs >or=10-minute wait time). A large proportion of visits were for undifferentiated CP (54%). Cardiac CP accounted for 16% (3% ischemic) and noncardiac CP accounted for 30% of visits. Median wait times for a physician were 12 minutes for those with ischemic CP, 15 minutes for those with other cardiac CP, 18 minutes for those with undifferentiated CP, and 25 minutes for those with noncardiac CP. From 1993 to 2004, ED visits for CP increased for younger (25 to 64 years) adults (1993: 15.6 per 1,000 population, 2.5 million visits vs 2004: 20.9 per 1,000, 4.0 million) and decreased for older adults (>or=65 years) (1993: 9.7 per 1,000; 1.5 million vs 2004: 7.3 per 1,000; 1.3 million). In conclusion, most ED patient visits for undifferentiated and cardiac CP included an electrocardiogram and timely clinician evaluation.

Initial experience with a cardiologist-based chest pain unit in an emergency department in Israel.

Emergency room triage of patients presenting with chest pain syndromes may be difficult. Under-diagnosis may be dangerous, while over-diagnosis may be costly. To report our initial experience with an emergency room cardiologist-based chest pain unit in Israel. During a 5 week pilot study, we examined resource utilization and ER diagnosis in 124 patients with chest pain of uncertain etiology or non-high risk acute coronary syndrome. First assessment was performed by the ER physicians and was followed by a second assessment by the CPU team. Assessment was based on the following parameters: medical history and examination, serial electrocardiography, hematology, biochemistry and biomarkers for ACS, exercise stress testing and/or 64-slice multi-detector cardiac computed tomography angiography. Changes in decision between initial assessment and final CPU assessment with regard to hospitalization and utilization of resources were recorded. All patients had at least two cardiac troponin T measurements, 19 underwent EST, 9 echocardiography and 29 cardiac MDCT. Fourteen patients were referred for early cardiac catheterization (same/next day). A specific working diagnosis was reached in 71/84 patients hospitalized, including unstable angina in 39 (31%) and non-ST elevation myocardial infarction in 12 (10%). Following CPU assessment, 40/124 patients (32%) were discharged, 49 (39%) were admitted to Internal Medicine and 35 (28%) to the Cardiology departments. CPU assessment and extended resources allowed discharge of 30/101 patients (30%) who were initially identified as candidates for hospitalization after ER assessment. Furthermore, 13/23 patients (56%) who were candidates for discharge after initial ER assessment were eventually hospitalized. Use of non-invasive tests was significantly greater in patients discharged from the ER (85% vs. 38% patients hospitalized) (P < 0.0001). The mean ER stay tended to be longer (14.9 +/- 8.6 hours vs. 12.9 +/- 11, P = NS) for patients discharged. At 30 days follow-up, there were no adverse events (myocardial infarction or death) in any of the 40 patients discharged from the ER after CPU assessment. One patient returned to the ER because of chest pain and was discharged after reassessment. Our initial experience showed that an ER cardiologist-based chest pain unit improved assessment of patients presenting to the ER with chest pain, and enhanced appropriate use of diagnostic tests prior to a decision regarding admission/discharge from the ER.

Emergency department

Most patients will be initially assessed at triage and then passed to another area of the department, or another area of the hospital, with their waiting time determined by their clinical need. However, some patients may complete their treatment at the triage stage, for instance, if the condition is very minor and can be treated quickly, if only advice is required, or if the emergency department is not a suitable point of care for the patient. Conversely, patients with evidently serious conditions, such as cardiac arrest, will bypass triage altogether and move straight to the appropriate part of the department.

Emergent cardiac outcomes in patients with normal electrocardiograms in the emergency department.

Emergency physicians (EP) are frequently interrupted to screen electrocardiograms (ECG) from Emergency Department (ED) patients undergoing triage. Our objective was to identify discrepancies between the computer ECG interpretation and the cardiologist ECG interpretation and if any patients with normal ECGs underwent emergent cardiac intervention. We hypothesized that computer-interpreted normal ECGs do not require immediate review by an EP. This was a retrospective study of adult (≥ 18 years old) ED patients with computer-interpreted normal ECGs. Laboratory, diagnostic testing and clinical outcomes were abstracted following accepted methodologic guidelines. The primary outcome was emergent cardiac catheterization (within four hours of ED arrival). All ECGs underwent final cardiologist interpretation. When cardiology interpretation differed from the computer (discrepant ECG interpretation), the difference was classified as potentially clinically significant or not clinically significant. Data was described with simple descriptive statistics. 989 ECGs interpreted as normal by the computer were analyzed with a mean age of 50.4 ± 16.8 years (range 18-96 years) and 527 (53%) female. Discrepant ECG interpretations were identified in 184 cases including 124 (12.5%, 95% CI 10.4, 14.7%) not clinically significant and 60 (6.1%, 95% CI 4.6, 7.7%) potentially clinically significant. The 60 potentially clinically significant changes included: ST/T wave changes 45 (75%), T wave inversions 6 (10%), prolonged QT 3 (5%), and possible ischemia 10 (17%). Of these 60, 21 (35%) patients were admitted. Six patients had potassium levels >6.0 mEq/L, with one having a potentially clinically significant ECG change. No patient (0%, 95% CI 0, 0.3%) underwent immediate (within four hours) cardiac catherization whereas two underwent delayed cardiac interventions. Cardiologists frequently disagree with a computer-interpreted normal ECG. Patients with computer-interpreted normal ECGs, however, rarely had significant ischemic events. A rare number of patients will have important cardiac outcomes regardless of the computer-generated normal ECG interpretation. Immediate EP review of the ECG, however, would not have changed these patients' ED courses.

Utility of the emergency department observation unit in ensuring stress testing in low-risk chest pain patients.

Recent research has noted low rates of compliance among ED chest pain patients referred for outpatient stress testing. The practice at our institution, a 39,000 visits per year emergency department (ED), is to place chest pain patients considered low risk for acute coronary syndrome in an observation unit for serial biomarker testing and provocative cardiac testing. Our objective was to determine the rates of positive stress tests among this group and to extrapolate from this the potential missed positive stress tests if these patients were referred instead for outpatient stress testing. This was a retrospective chart review of all chest pain patients admitted to the ED observation unit between April 2006 and June 2007. Baseline information, including a history of coronary disease, was recorded. Patients underwent a treadmill stress test, nuclear stress test, or coronary CT scan at the discretion of the attending emergency physician and/or the consulting cardiologist. Rates of positive stress test or coronary CT and patient disposition (admission to an inpatient unit versus discharge for outpatient follow-up) were noted. A total of 353 patients underwent stress testing or coronary CT during the study period: 257 (72.8%) patients had an exercise treadmill echocardiogram, 61 (17.3%) patients underwent nuclear stress testing, and 35 (9.9%) patients had a coronary CT. Seventy patients (19.8%) had a history of coronary disease but had been considered appropriate for observation by the attending emergency physician. Thirty-nine stress tests were positive (11%) and 11 were indeterminate (3.1%). Among patients with no history of coronary disease, 20 stress tests were positive (7.1%), and 10 were indeterminate (3.5%). Of all patients with a positive stress test, 19 (48.7%) underwent cardiac catheterization and 1 (2.6%) had coronary artery bypass graft. Twenty-one of 39 patients with a positive stress test (54%) were ultimately admitted to an inpatient unit per the recommendation of the consulting cardiologist. Assuming a best-case scenario in which 70% of patients referred for outpatient stress testing actually have the testing done (based on a recent report of outpatient compliance), physicians would miss approximately 3.3% of patients with a positive stress test if these patients were discharged directly from the ED. Among chest pain patients admitted to an ED observation unit, the rate of positive stress tests was 11%. Approximately 3.3% of patients with positive stress tests may have been missed if these patients were instead referred for outpatient testing.

Impact of the availability of a prior electrocardiogram on the triage of the patient with acute chest pain.

To determine whether information from a prior electrocardiogram (ECG) improves diagnostic accuracy in the emergency department (ED) evaluation of patients with acute chest pain. Analysis of prospectively collected data from a cohort study. Emergency departments of four community and three university hospitals. 5,673 patients aged greater than or equal to 30 years who presented to the EDs of participating hospitals for evaluation of acute chest pain, including 772 (14%) with acute myocardial infarction (AMI). After adjusting for clinical characteristics, no significant difference was found in the sensitivities of admission to the hospital or to the coronary care unit (CCU) between AMI patients with and without prior ECGs available for review. However, non-AMI patients with prior ECGs available for review were more likely to avoid CCU admission than were non-AMI patients without prior ECGs. This improvement in specificity was most marked in the 2,024 patients whose current ED ECGs had changes consistent with ischemia or infarction: when a prior ECG was available, non-AMI patients were more than twice as likely to be discharged (26% vs. 12%) and about 1.5 times as likely to avoid CCU admission (39% vs. 27%) (both p less than 0.0001). Admission rates of AMI patients with and without prior ECGs were similar. When the current ECG is consistent with ischemia or infarction, the availability of a prior ECG for comparison to determine whether the ECG changes are old or new improves diagnostic accuracy and triage decisions by reducing the admission of patients without AMI or acute ischemic heart disease (increased specificity) without reducing the admission of patients with these diagnoses (unchanged sensitivity).

InternalMed_Harrison

Chest pain is common in outpatient practice, with a lifetime prevalence of 20–40% in the general population. More than 25% of patients with MI have had a related visit with a primary care physician in the previous month. The diagnostic principles are the same as in the ED. However, the pretest probability of an acute cardiopulmonary cause is significantly lower. Therefore, testing paradigms are less intense, with an emphasis on the history, physical examination, and ECG. Moreover, decision-aids developed for settings with a high prevalence of significant cardiopulmonary disease have lower positive predictive value when applied in the practitioner’s office. However, in general, if the level of clinical suspicion of ACS is sufficiently high to consider troponin testing, the patient should be referred to the ED for evaluation.

Safety of assessment of patients with potential ischemic chest pain in an emergency department waiting room: a prospective comparative cohort study.

Emergency department (ED) crowding has been associated with a variety of adverse outcomes. Current guidelines suggest that patients with potentially ischemic chest pain should undergo rapid assessment and treatment in a monitored setting to optimize the diagnosis of acute coronary syndrome. These patients may be at high risk of incorrect diagnosis and adverse events when their evaluation is delayed because of crowding. To mitigate crowding-related delays, we developed processes that enabled emergency physicians to evaluate potentially sick patients in the waiting room when all nurse-staffed stretchers are occupied. The objective of this study was to investigate the safety of waiting room chest pain evaluation. This prospective comparative cohort study was conducted in a busy urban, tertiary care ED. Explicit triage and waiting room evaluation processes were introduced. One thousand one hundred seven patients with chest pain of potential cardiac origin were triaged either to a monitored bed or a waiting room chair, depending on bed availability and triage judgment. After diagnostic evaluation, patients were followed for 30 days to identify the proportion of missed cases of acute coronary syndrome (primary outcome) and other prespecified adverse events. Analysis was based on intention to treat. Eight hundred four patients were triaged to monitored bed and 303 to waiting room evaluation. Initial vital signs were similar, but the waiting room group was younger and had lower rates of some cardiovascular risk factors. The rate of acute coronary syndrome, defined as acute myocardial infarction or objective unstable angina, was 11.7% in the monitored bed group and 7.6% in waiting room patients. There were no missed acute coronary syndrome cases in either the monitored bed group (0%; 95% confidence interval [CI] 0% to 0.4%) or the waiting room group (0%; 95% CI 0% to 1.0%). There were 32 adverse events in the monitored bed group (4.0%; 95% CI 2.6% to 5.3%) and 2 in the waiting room group (0.7%; 95% CI 0% to 1.6%). Our organized approach to triage and waiting room evaluation for stable chest pain patients was safe and efficient. Although waiting room evaluation is not ideal, it may be a feasible contingency strategy for periods when ED crowding compromises access to monitored, nurse-staffed ED beds.

Triage of patients for a rapid (5-minute) electrocardiogram: A rule based on presenting chief complaints.

A rule based on presenting chief complaints can identify patients for a rapid (5-minute) ECG and decrease delays in treatment of patients with acute myocardial infarction (MI). The presenting chief complaint was electronically collected on all patients treated in a community teaching hospital emergency department. A rule for ordering ECG on patient presentation to the ED was developed from a model set of patients presenting from July through December 1994 (22,717 patients) and then tested on a validation set of patients from January through May 1995 (18,759 patients). Outcome measures (delay in performance of ECG and delay in administration of thrombolytic agents) were prospectively collected on written data sheets before (April 1993-May 1995, n=67) and after (June 1995-March 1997, n=128) implementation of the rule at the study hospital. On the model set, 193 patients had the final diagnosis of MI, with 5 chief complaints having the best performance in identifying patients with acute MI and comprising the rapid ECG rule: older than 30 years with chest pain (130 [67.4%] patients); older than 50 years with syncope (5 [1%] patients); weakness (12 [6.2%] patients); rapid heart beat (2 [1%] patients); and difficulty breathing or shortness of breath (20 [10.4%] patients). On the validation set, 142 patients had the final diagnosis of MI, with the rule performing better than chest pain in identifying patients for a "stat" ECG (sensitivity 93.7% versus 67. 4% [95% confidence interval (CI) of the difference, 15.6% to 33.8%]), although a larger percentage of ED patients would receive a stat ECG (7.3% versus 6.3% [95% CI of the difference, 0.7% to 1.7%]). During the model and validation period, 44 (13.1%) of 335 patients with MI received thrombolytic agents. The rule had higher sensitivity on patients with MI treated with thrombolytic agents compared with patients with MI not treated with thrombolytic agents (sensitivity 100% versus 86.4% [95% CI of the difference, 1.7% to 20. 3%] and specificity of 90.4% versus 93.8% [95% CI of the difference, 3.0% to 3.8%]). For the 4-year study period, outcome improved after the implementation of the rule: mean delay in performing ECGs in patients with MI who were administered thrombolytic agents decreased from 10.0 to 6.3 minutes (95% CI of the difference, 1.1 to 6.4), and mean delay in administering thrombolytic agents decreased from 36.9 to 26.1 minutes (95% CI of the difference, 3.5 to 17.7). Use of a rule based on chief complaints can identify patients with MI for immediate ECG and decrease delays in performing ECGs and administration of thrombolytic agents.

Emergency department crowding is associated with poor care for patients with severe pain.

We study the impact of emergency department (ED) crowding on delays in treatment and nontreatment for patients with severe pain. We performed a retrospective cohort study of all patients presenting with severe pain to an inner-city, teaching ED during 17 months. Poor care was defined by 3 outcomes: not receiving treatment with pain medication while in the ED, a delay (>1 hour) from triage to first pain medication, and a delay (>1 hour) from room placement to first pain medication. Three validated crowding measures were assigned to each patient at triage. Logistic regression was used to test the association between crowding and outcomes. In 13,758 patients with severe pain, the mean age was 39 years (SD 16 years), 73% were black, and 64% were female patients. Half (49%) of the patients received pain medication. Of those treated, 3,965 (59%) experienced delays in treatment from triage and 1,319 (20%) experienced delays from time of room placement. After controlling for factors associated with the ED treatment of pain (race, sex, severity, and older age), nontreatment was independently associated with waiting room number (odds ratio [OR] 1.03 for each additional waiting patient; 95% confidence interval [CI] 1.02 to 1.03) and occupancy rate (OR 1.01 for each 10% increase in occupancy; 95% CI 0.99 to 1.04). Increasing waiting room number and occupancy rate also independently predicted delays in pain medication from triage (OR 1.05 for each waiting patient, 95% CI 1.04 to 1.06; OR 1.18 for each 10% increase in occupancy; 95% CI 1.15 to 1.21) and delay in pain medication from room placement (OR 1.02 for each waiting patient, 95% CI 1.01 to 1.03; OR 1.06 for each 10% increase in occupancy, 95% CI 1.04 to 1.08). ED crowding is associated with poor quality of care in patients with severe pain, with respect to total lack of treatment and delay until treatment.

[Diagnosis of unstable angina in the emergency room. The clinical value and limitations of electrocardiography and other tests].

The quick and accurate diagnosis of acute coronary heart disease in the emergency department constitutes a first line medical challenge. About 5% of patients attending to the emergency department present chest pain or symptoms suggesting myocardial ischemia. A prompt diagnosis contributes to patient survival while an incorrect one can be associated to an increased risk of unfavorable outcome. On the other hand, unnecessary admissions into high technology hospital areas determine important expenses unacceptable from a cost-benefit point of view. In the present paper, the usefulness of different diagnostic tools used in emergency department (case history, electrocardiogram, nuclear perfusion imaging, echocardiography, exercise test) is reviewed, their advantages and limitations reviewed, with special emphasis on the importance of having an electrocardiogram as soon as possible, and based on the electrocardiographic findings the most appropiate management is discussed.

Chest Pain: A Relatively Benign Symptom of Type IV Hiatal Hernia.

Hiatal hernia results from the translocation of intra-abdominal contents from their usual position into the thorax. They can be categorized into type I-IV which implies varying gradations of herniation. The symptomatology can range from just chest pain in the less severe types to respiratory and hemodynamic compromise resulting from strangulation in the advanced hernias. Our patient was an 81-year-old female with a past medical history of gastroesophageal reflux disease (GERD), deep venous thrombosis (DVT), hypertension, hyperlipidemia, coronary artery disease (CAD), and cerebrovascular accident (CVA), who presented to the emergency department (ED) with the chief complaint of chest pain. Assessment of the vitals in the ED revealed a temperature of 37.2 °C, respiratory rate of 18 breaths/minute with an oxygen saturation of 100% on room air, heart rate of 95 beats/min, and blood pressure reading of 132/110 mmHg. Due to significant concern of a possible coronary pathology leading to chest pain, the patient was given 325 mg of aspirin and one tablet of sublingual nitroglycerin. Her electrocardiogram (EKG) was unremarkable but the chest X-ray revealed a large retrocardiac hernia. The finding was corroborated after a review of the computerized tomography (CT) scan performed at the outlying facility. She was treated with omeprazole, a gastroenterologist was consulted, and an esophagogastroduodenoscopy (EGD) performed which revealed significant erosions in the distal esophagus and gastric antrum. She was deemed a high-risk surgical candidate for any intervention and thus managed conservatively with proton pump inhibitor (PPI) therapy. The case highlights the pertinent facts about hiatal hernia. Although the diagnosis of chest pain with the aforementioned comorbidities could be skewed towards coronary pathology, keeping a wide differential is important so that the right diagnosis can be made in a timely fashion and complications avoided.

[Role of cardiac first aid in a level-II Emergency Department].

We report our experience in the organization and management of a Cardiac First Aid Unit (CFAU) which was developed according to the guidelines of the National Hospital Cardiologists Association as a part of a General Emergency Department. The CFAU is a 24 hour service directed by a Senior Cardiologist. The medical facilities are two monitored beds for short-term observation (cardio-pulmonary resuscitation instruments, echocardiograph, endoesophageal pacing for overdrive). The main goals of CFAU are the treatment of cardiac emergencies (acute myocardial infarction, pulmonary oedema, threatening arrhythmias, etc.) and the screening of patients presenting with chest pain or symptoms suggesting cardio-vascular involvement. In one year, there were 1700 admissions to the CFAU (3.7% of the total Medical Emergencies). The frequency of hospital admissions was 81% and coronary heart disease accounted for 38.3%. A sample of 100 consecutive patients with acute myocardial infarction admitted in the period October-November 1996 was examined to explore the impact of a CFAU on in-hospital delay in the application of thrombolysis. Thirty-nine patients were treated with thrombolysis, 15 in CFAU and 24 in Coronary Care Unit (CCU). The mean in-hospital delay to thrombolysis was 30 +/- 14 minutes for those treated in CFAU and 55 +/- 12 minutes for those treated in CCU (p < 0.0004). In a second sample of 100 consecutive patients with undetermined chest pain, by means of our protocol of short observation we identified 22 cases of acute myocardial infarction (AMI), 8 cases of angina pectoris, 18 various cardiac causes, 30 non-cardiac causes, 22 absent disease. ECG was obtained in all 100 pts, cardiac enzymes in 74, echocardiogram and chest X-ray in 48, ST monitoring in 26. In no case was diagnosed AMI after discharge. Cardiac First Aid Unit, as designed in our Hospital, suits the needs of a level II Emergency Department. It is a useful tool to shorten in-hospital delay to thrombolysis and to screen chest pain with nearly complete safety.

Mandatory triage does not identify high-acuity patients within recommended time frames.

We determine whether mandatory formal triage of walk-in emergency department (ED) patients provides timely recognition of the most acutely ill. This retrospective cross-sectional study was conducted at a US urban academic ED, annual census 39,000, which uses Emergency Severity Index-5 triage (ESI-5) for all arriving patients. ESI-5 recommends that level 1 and 2 patients be treated by a physician immediately or within 10 minutes, respectively. For all high-acuity (ESI 1 or 2) patients presenting between January 1 and December 31, 2008, data from electronic medical records and registration and tracking systems were used to determine elapsed time from arrival to completion of triage (median, range, 95th percentile), proportion of these intervals that met ESI-5 recommendations, and whether triage throughput differed during peak arrival hours. For 3,932 high-acuity walk-in visits (ESI 1=63; ESI 2=3,869), median time from arrival to triage completion was 12.3 minutes, range 0 to 128 minutes. Twenty-seven percent (95% confidence interval [CI] 26% to 29%) of high-acuity patients were taken to rooms on arrival; 41% (95% CI 40%, 43%), including those roomed immediately, completed triage within 10 minutes. Twenty-five percent (95% CI 24% to 26%) completed triage in greater than 20 minutes and 10% (95% CI 9% to 11%) greater than 30 minutes after arrival. Between 10 am and 10 pm (peak arrival hours), triage took longer for level 2 patients, and fewer met ESI recommendations. Less than half of high-acuity patients in this urban ED completed triage within time frames recommended by the ESI-5, resulting in potentially unsafe delays. Although mandatory formal triage theoretically identifies patients who should be treated most quickly, the value and safety of this process should be reassessed.

Rapid and correct diagnosis of myocardial infarction: standardized case history and clinical examination provide important information for correct referral to monitored beds.

The value of thorough examination of the case history as a diagnostic tool on hospitalization of patients with suspected myocardial infarction was investigated in three independent prospective studies. Use of a limited number of pain-related elements (= 'criteria'), that had already been obtained in the emergency room, could improve the decision on whether or not to admit patients to the coronary-care unit. As an example, in one of the studies, use of such criteria would have reduced the number of 'unnecessary' coronary-care-unit admissions from 298 to 162, a 46% reduction (P less than 0.001). In the same patient sample, use of the criteria could have reduced the number of patients with definite acute myocardial infarction, admitted to the general wards, from 47 to 22, a 53% reduction (P less than 0.01). These favourable results were confirmed in the two independent, smaller-scale studies.

Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review protocol.

The objective of this review is to assess the sensitivity and specificity of the Manchester Triage System in the evaluation of adult patients with acute coronary syndrome in emergency departments. Acute coronary syndrome (ACS) is a group of clinical conditions that include myocardial infarction with or without elevation of the ST segment and unstable angina. The term acute myocardial infarction (AMI) can be applied when there is evidence of myocardium necrosis with a clinical sign compatible with myocardial ischaemia. Acute myocardial infarction can be identified using clinical methods including electrocardiography (ECG), elevation in myocardium necrosis biomarkers, and imaging. Acute myocardial infarction is one of the leading causes of death and disability worldwide, and may be the first manifestation of coronary artery disease.Estimating the prevalence of coronary diseases in the general population is quite a complex task. In 2010, the prevalence of coronary diseases was reported as 6.4% among the general population in the United States.One of the main manifestations of ACS is chest pain. However, even in the presence of this typical symptom, early diagnosis of ACS is a challenge for health care professionals who initially attend to these patients. Several authors have indicated the importance and difficulty of recognizing chest pain of cardiac origin, where immediate medical attention is required.Triage, or risk classification, is a clinical management tool used in emergency services to guide patient flow when the need for medical attention exceeds that available. The Manchester Triage Group was developed in 1994 in the United Kingdom. The aim was to establish a consensus among physicians and nurses in the emergency room by creating a triage pattern focused on the development of the following:Thus, the Manchester Triage System (MTS) was created. The MTS simplifies the clinical management of each patient, and consequently, the whole service, by utilizing a system that defines the clinical priority for adults and children. The assessment of clinical priority needs to be fast; therefore, it is separated from the process of medical diagnosis. Restricting the time allocated for patient classification prevents an attempt to make a medical diagnosis at the time of classification.The main goal of the MTS is to set a time limit for each patient to be attended to safely, that is, with no risk to the patient's health. One of the main principles of the system is the higher the perceived risk to the patient's health, the shorter the waiting time for medical attendance. The MTS comprises a scale of five priority levels ().(Table is included in full-text article.)The MTS is composed of 52 distinct flowcharts that "guide" the triage decision-making process. Based on the main presenting symptom of the patient seeking emergency care, the health care professional must choose one of the 52 flowcharts in order to proceed with evaluation. Classification into one of the five clinical priority levels is set for each patient using the selected flowchart.The lack of a risk classification system within an emergency room implies attendance on a first-come, first-served basis, which in many cases may jeopardize a patient's safety, as patients whose health status is more unstable or severe are not prioritized.The MTS is a tool that aims to define the degree of severity and associated safe waiting time for patients in the emergency department, establishing an order of priority for medical care. It determines the clinical priority of every patient who comes to the emergency department. It is possible to evaluate the sensitivity and specificity of the MTS by calculating the frequency of appropriately assigned clinical priority levels to patients presenting at the emergency department.A "diagnostic test" can be understood as a laboratory or imaging test: however, the concepts related to "test" also apply to clinical information from other findings, such as physical examination and patient history. The sensitivity of a test is understood as the capacity of the test to detect individuals who present with a particular condition, or the proportion of individuals with a particular condition who have been tested positive for this condition (true positive). Highly sensitive tests can be used at the beginning of the diagnostic process, when a great number of possibilities are being considered, with the intention of excluding as many options as possible. The specificity of a test is defined as the capacity of the test to identify individuals who do not have a particular medical condition, or the proportion of individuals without the condition who have a negative test (true negative). A triage system that presents a good sensitivity can minimize the occurrence of undertriage, the same way, systems with suitable specificity can avoid the occurrence of overtriage.The assessment of patients with ACS suspected using the MTS, can occur through different flow charts, since the patient does not always have typical symptoms and concerns such as chest pain as the main complaint. For this reason, in addition to the flowchart "chest pain", other flowcharts, including "shortness of breath in adults", "unwell adult", "collapsed adult", and "palpitations", enable distinguishing chest pain and other urgent conditions from non-urgent conditions, and can assist the appraiser to establish the highest priority level to treat patients with these urgent conditions.According to the algorithm from the American Heart Association, every patient who presents symptoms of chest discomfort suggestive of ischaemia must receive medical attention within 10 minutes. Therefore, in order to recognize patients in those conditions, the health care professional applying MTS must establish priority levels of "red" or "orange", thereby setting a safe waiting time for these patients.Although there are well-established criteria for the prioritization of patients with suspected ACS, several studies have reported the difficulties of evaluating patients with these conditions. Various factors can interfere with the outcome of this process, such as atypical presentation of symptoms, AMI classification, patient age, and professional skill.Primary studies have addressed the issue from different perspectives. Studies have been conducted to evaluate the ability of nurses using MTS to detect high-risk patients with chest pain, the impact of MTS on short-term mortality in AMI, and the sensitivity and specificity of MTS for patients with ACS, and to assess whether the MTS was used effectively in patients admitted to the hospital with a diagnosis of acute coronary syndrome.These studies concluded that use of the MTS by nurses is a sensitive method for identifying high risk cardiac chest pain, but further studies are required to assess whether additional training can improve the sensitivity of MTS. The MTS safeguards patients with typical AMI presentation and ST elevation during myocardial infarction, and who are under 70 years of age. The MTS has a high sensitivity in prioritization (immediate/very urgent) of patients with ACS. Additionally, most patients admitted for ACS are initially triaged as "orange" or "yellow", an indication for prompt assessment in the emergency department. This has a positive effect on time to first medical assessment, but has no effect on time to hospital admission.A systematic review addressing a similar theme was published. The review evaluated the efficacy of MTS for all groups of patients and included studies that evaluated the MTS in relation to different outcomes. This proposed review is different as it will include primary studies with a specific sub-population (patients with ACS). Another important difference lies in the fact that the published review did not include critical appraisal of the primary studies included in review. A systematic review that synthesizes the available evidence on the sensitivity of MTS to evaluate patients with an ACS medical diagnosis is necessary to guide decisions related to the use or adoption of the instrument, as well as providing data that can contribute to improvements to the system.

[The examination space of time from the beginning symptoms of the acute coronary syndrome to the time of the urgent treatment].

Aim of this study is to examinate time period from the beginning of symptoms in acute coronary syndrome to the arrival time in Department of emergency medical service Zivinice where electrocardiogram is only one exact method for diagnosis of the myocardial ischemia. In retrospectively-prospectively study during one year, every patient with symptoms of acute coronary syndrome were taken beside and performed physical survay. We recorded ECG, performed ECG monitoring and/or serial ECG records. We investigated reasons for the lete arrival, sex and age and risk factors. In 167 patients with diagnostic acute coronary syndromes, average time period from beginning symptoms to the arrival time was 8.12 (+/-5,87) hours, significant longer from optimal 2 hours (p=0,001). Average age of these patients was 60,4 years. Male subjects were ill for about 9,2 years earlier than women and 1,6 times higher incidence than female subjects in all age groups. Most important risk and precipitating factors were hypertension, smoking, diabetes, hyperlipidemia, obesity. Leading factors for late arrival was unadequate attributing for importance of the acute chest pain and nonexistance of emergency medical service "on call". It is necessary to informe citizens about risiko factors of acute coronary syndrome development, its symptoms, characteristic and consequences . Necessity is to organize emergency medical service "on call" and establish modern emergency centers. It is necessery to adequately equip stationary emergency medical services and train doctors and other medical staff to point out and adopt the usage of algoritms and protocols for acute coronary syndromes management. To educate members of public services about basic principles of cardiopulmonary reanimation.

InternalMed_Harrison

Chest Discomfort David A. Morrow Chest discomfort is among the most common reasons for which patients present for medical attention at either an emergency depart-ment (ED) or an outpatient clinic. The evaluation of nontraumatic chest discomfort is inherently challenging owing to the broad variety 19 of possible causes, a minority of which are life-threatening conditions that should not be missed. It is helpful to frame the initial diagnostic assessment and triage of patients with acute chest discomfort around three categories: (1) myocardial ischemia; (2) other cardiopulmonary causes (pericardial disease, aortic emergencies, and pulmonary conditions); and (3) non-cardiopulmonary causes. Although rapid identification of high-risk conditions is a priority of the initial assessment, strategies that incorporate routine liberal use of testing carry the potential for adverse effects of unnecessary investigations.

Comparison of clinical-based and ECG-based triage of acute chest pain in the Emergency Department.

In the Emergency Department, chest pain triage systems are based on either clinical features or ECG recording. In this prospective, single-center, observational study, we aimed to compare the diagnostic performance of these triage systems in distinguishing acute coronary syndromes (ACS) from diseases of mild severity. Patients were sorted into the triage systems based on collected data at admission and on a systematic 12-lead ECG performed at triage. The final diagnosis was determined after a 30-day follow-up. For ACS, we determined a high-acuity triage score (Level 1 or 2) as being adequate, and for mild severity diseases a low-acuity triage score (Level 3, 4 or 5) as being adequate. The diagnostic performance of all studied systems was moderate (AUC from 0.644 to 0.694), with no statistically significant difference found between them. However, characteristics of the systems differed because the clinical-based systems had a higher sensitivity (87-91%) but lower specificity (32-39%) compared with the ECG-based system (sensitivity 62% and specificity 64%). A higher sensitivity limits the risk of a patient with acute coronary syndrome staying unsafely in the waiting room, while a higher specificity prevents overcrowding. ECG at triage also ensures that no STEMIs or high-risk NSTEMIs are missed. Based on these findings, each Emergency Depatment could more accurately select the triage system that fits their local particularities.

Cardiopulmonary diagnoses by nuclear medicine techniques--where we have been, where we are, where we are going.

In order to not only survive, but to carry out our mission in health care delivery, nuclear medicine procedures will have to be competitive with the many other techniques that are available for assessing cardiopulmonary structure or function. Our tests must also be shown to be cost-effective. According to the American Heart Association, cardiovascular diseases alone had an economic cost of 56.9 billion dollars in 1983. Of this enormous sum only a very small percentage could be attributed to the performance of diagnostic nuclear medicine examinations. In addition to the economic cost, cardiovascular diseases accounted for 51% of all deaths in 1980. Statistics from the U.S. Department of Health show that 8.26 million (26.3%) of the national noninstitutionalized handicapped are the result of heart conditions and hypertension. These statistics are especially tragic since cardiovascular disease tends to strike a large proportion of persons in their most productive working years. We must avoid becoming penny wise and pound foolish when we decide whether or not to perform diagnostic examinations. Information obtained from these tests can be used to evaluate the effectiveness of therapy (or lack thereof), determine those patients who are at greatest risk of subsequent events and, therefore, require the most intensive investigation and therapy, and similarly identify that population at very low risk of having subsequent cardiac events and, therefore, requiring little, if any, therapy and no further investigation. Is such an approach economically feasible? An estimated 1.5 million Americans will have a heart attack this year, and about 550,000 of them will die. Of these persons, 350,000 will die before they reach the hospital. This leaves 1,150,000 persons who will be hospitalized due to myocardial infarction. As an example, if every one of these patients had a GBP study, at an estimated cost of +350.00 per examination, the cost would be about +400,000,000 or 0.7% of the total cost of cardiovascular diseases. This figure would roughly double if either a 201Tl or GBP study was performed with stress. Thus, our examinations constitute only a small percentage of the overall cost of cardiopulmonary disease. If one of these tests results in even a day early CCU to general bed transfer, early discharge, deferment of angiography, or surgery, or long-term medical therapy, then they will be cost-effective. We believe that a strong case can be made for optimism about the continued growth and expansion of nuclear techniques.(ABSTRACT TRUNCATED AT 400 WORDS)

Sepsis, severe sepsis, and septic shock: current evidence for emergency department management.

In the middle of a busy shift, a patient arrives by ambulance from a local long-term care facility with a report of altered mental status. You enter the room to find a chronically ill-appearing 85-year-old man with fever, tachycardia, and hypotension, and it is instantly apparent that this patient is septic. What is not clear is what the source is, what modifications in treatment might be necessary based on preexisting microbial resistance, and which of the array of invasive resuscitation techniques are appropriate when meaningful recovery is questionable and efforts may not be desired by the patient and family. You order IV fluids and broad-spectrum antibiotics; send lab tests, including lactate and cultures of blood, urine, and sputum; and begin to review his extensive history to discuss goals of care with his family and primary doctor. While reviewing these issues, a 54-year-old woman with a history of asthma is brought straight back from triage with respiratory distress. You listen to her lungs, expecting wheezes, but hear decreased lung sounds at the right base, preserved air movement elsewhere, and her skin radiates heat. Now, on the monitor, she has a heart rate of 135 beats per minute, blood pressure of 90/60 mm Hg, O2 saturation of 86%, and a temperature of 39.4 degrees C (103 degrees F). You again identify sepsis and instruct your team that you will be using your department's severe sepsis protocol. Equipment for monitoring and procedures is assembled, your staff provides preprinted order and monitoring flow sheets, and the ICU is alerted. Within an hour, the patient is intubated, has a central line placed, and has received IV fluids, broad-spectrum antibiotics and norepinephrine, and you are pleased to see a MAP of 67 mm Hg, a lactate decreasing from an initial value of 7.0, CVP of 10, and ScvO2 of 78%.

InternalMed_Harrison

Source: K Thygesen: Eur Heart J 33:2551, 2012. of performing resuscitative maneuvers, including defibrillation; (3) expeditious transportation of the patient to a hospital facility that is continuously staffed by physicians and nurses skilled in managing arrhythmias and providing advanced cardiac life support; and (4) expeditious implementation of reperfusion therapy (Fig. 295-3). The greatest delay usually occurs not during transportation to the hospital but, rather, between the onset of pain and the patient’s decision to call for help. This delay can best be reduced by health care professionals educating the public concerning the significance of chest discomfort and the importance of seeking early medical attention. Regular office visits with patients having a history of or who are at risk for ischemic heart disease are important “teachable moments” for clinicians to review the symptoms of STEMI and the appropriate action plan.

What do patients want? Survey of patient desires for education in an urban university hospital.

This study examines the emergency department (ED) waiting room (WR) population's knowledge about the ED process and hospital function and explores the types of educational materials that might appeal to patients and their companions in an ED waiting room. Our goal was to identify potential high-impact opportunities for patient education. A 32-question survey about demographics, usage of primary care physicians (PCP), understanding of the ED and triage process, desire to know about delays, health education and understanding of teaching hospitals was offered to all qualified individuals. Five hundred and forty-four surveys were returned. Fifty-five percent reported having a PCP, of which 53% (29% of all WR patients) called a PCP prior to coming to the ED. It was found that 51.2% can define triage; 51% as an acuity assessment and 17% as a vital signs check. Sixty-nine percent knew why patients were seen according to triage priority. Seventy-two percent wanted to know about delays, yet only 25% wanted to know others' wait times. People wanted updates every 41 minutes and only three percent wanted a physician to do this. Forty-one percent wanted information on how the ED functions, 60% via handouts and 43% via video. Information on updates and common medical emergencies is significantly more important than material on common illnesses, finding a PCP, or ED function (p<0.05). Median estimated time for medical workup ranged from 35 minutes for radiographs, to one hour for lab results, computed tomography, specialist consult, and admission. Sixty-nine percent knew the definition of a teaching hospital and of those, 87% knew they were at a teaching hospital. Subgroup analysis between racial groups showed significantly reduced knowledge of the definitions of triage and teaching hospitals and significantly increased desire for information on ED function in minority groups (p<0.05). The major findings in this study were that many visitors would like handouts about ED function and medical emergencies over other topics. Additionally, the knowledge of functions such as triage and teaching hospitals were 70% and 69%, respectively. This was reduced in non-Caucasian ethnicities, while there was an increased desire for information on ED function relative to Caucasians. This research suggests increasing updates and educational materials in the waiting room could impact the waiting room and overall hospital experience.

Evaluation of chest pain in the ED: factors affecting triage decisions.

The emergency physician's (EP) fast and correct diagnosis of patients with chest pain is crucial for preventing inappropriate discharge and dire consequences. To determine which factors affect admission decisions in the ED, we studied epidemiologic characteristics of both discharged and admitted patients, and the percentage of discharged patients who returned to the ED with acute myocardial infarction. The study included 185 patients seen in the ED because of chest pain between July 1 and 31, 1997 (every third day not included). Ninety patients were admitted: 36.7% were admitted for "observation of chest pain" and 63.3% met the criteria for active coronary heart disease. A form was used to collect personal data, medical history, risk factors, clinical examination, electrocardiogram interpretation, laboratory data, and admittance decision. EPs' diagnosis of cardiac chest pain demonstrated a sensitivity of 93.4%, a specificity of 73.4%, and a positive predictive value of 63.3%. Sensitivity for diagnosing acute myocardial infarct was 100%, with no erroneous discharges. The EP's ability to integrate the medical history information, including risk factors and pain characteristics, had a marked influence on the admittance decision. Efforts to reduce missed diagnoses are warranted.

Computer-aided simple triage

Examples CAST for coronary artery disease CAST system is available for the detection of significant (>50%) coronary stenosis in coronary CT angiography (cCTA) studies. The system exhibits "per study" specificity of 60–70%, while keeping the sensitivity above 90%. It can be used for chest pain patient triage in emergency room. CAST for Intracranial Hemorrhages A deep learning system is available for automatic detection of Intracranial Hemorrhages in acute care settings. See also Aidoc References Medical expert systems Radiology Health informatics

Just point and click. Is your system ready for point-of-care testing?

Your ALS service is called to evaluate a 47-year-old female with epigastric pain that came on suddenly about six hours ago; she has vomited once. She thought it was the flu and that it would subside, but it has not. She smokes, is overweight and has a family history of early cardiac disease. Her vital signs are unremarkable and her belly is nontender. You perform a 12-lead ECG that shows nonspecific ST-T wave changes inferiorly. You place a few drops of blood obtained as part of your field-drawn bloods into an i-STAT cartridge. The result surprises you: Her cardiac enzyme (troponin I) is markedly elevated. Should she be transported to the closer facility without primary coronary intervention (PCI) capability or further down the road to a facility that has it?

The impact of crowding on time until abdominal CT interpretation in emergency department patients with acute abdominal pain.

We assessed the relationship between emergency department (ED) crowding and delays in care in patients presenting with abdominal pain who receive abdominal computed tomography (CT). Prospective cohort study of adults who presented over a 1-year period to 2 urban academic EDs with abdominal pain and received CT. Each subject had 3 validated crowding measures assigned at enrollment (ED census, waiting room number, number of admitted patients). These were normalized to quartiles to signify least to most crowded. The Cuzick test was used for trend and log-linear regression and tested the association between ED crowding and time from triage to CT read. The time interval was further decomposed into triage to room, room to CT order, and order to CT read times. The adjusted analysis controlled for age, sex, race, pain score, time of day, triage level, and site. 767 patients were enrolled (mean age, 44 +/- 17 years; 61% female; 60% black). Median time from triage to CT read was 375 minutes (interquartile range [IQR], 276-497). Individual time intervals included triage to room (46 minutes [IQR, 16-111]), room to CT order (83 minutes [IQR, 38-151]), and order to CT read (203 minutes [IQR, 138-375]). Across waiting room quartiles, triage to CT read was associated with progressively longer times (318 vs 364 vs 414 vs 445 minutes; P < 0.001 for trend). Similar trends were noted for waiting room number and admitted patients (P < 0.001). In multivariable analysis, the association between ED crowding and time from triage to CT read remained significant and consistent across all crowding measures (P < 0.001). When decomposed into time intervals, triage to room time showed the greatest difference (22 vs 38 vs 72 vs 92 minutes; P < 0.001). ED crowding is associated with an approximately 2-hour delay to CT interpretation availability. Attempts to reduce delays in abdominal CTs may include earlier provider evaluation and placement in the queue for scanning.

[Evaluation of patients' knowledge regarding counsels provided in case of chest pain after an acute myocardial infarction].

an early call to the department of urgent medical assistance--Center 15 (SAMU-centre 15) is associated to shortest delays of reperfusion in case of myocardial infarction. However, patients are not always aware of this. to assess the assimilated counsels by patients after an acute myocardial infarction. from January 1998 to June 2004, patients managed by SAMU 93 and having benefited from thrombolytic therapy prior to hospitalization and/or primary angioplasty for a ST+ acute coronary syndrome with a confirmation of acute myocardial infarction during their hospital stay were prospectively enrolled into this study. A questionnaire was administered by phone from december 2003 to july 2005, assessing the knowledge about the necessity to alert SAMU-center 15 in case of chest pain and availability of medical files data. among the 976 patients: 111 (11%) were lost during follow-up, 162 (19%) were deceased when phone contact and 119 (12%) could not be interrogated. Among the 584 (60%) remaining subjects interrogated with a median follow-up period of 985 days (413-1596), 290 (50%) patients answered they received counseling, including 156 (27%) for taking nitrates, 19 (29%) stated they know that they should call SAMU-center 15. Patients with a high level of education and those treated by thrombolytic therapy prior to hospitalization were better informed; 464 (79%) patients declared having a prescription, 392 (67%) a hospital report, 406 (69%) an electrocardiogram, 227 (39%) a CD with their coronary angiography, and 79(14%) their medical file. the level of knowledge regarding the recommended attitude in case of chest pain is poor. The availability of medical data was better. Arch Mal Cceur

A randomized controlled trial of the effect of service delivery information on patient satisfaction in an emergency department fast track.

The objective was to determine the effect on patient satisfaction of providing patients with predicted service completion times. A randomized controlled trial was conducted in an urban, community teaching hospital. Emergency department (ED) patients triaged to fast track on weekdays between October 26, 2009, and December 30, 2009, from 9 am to 5 pm were eligible. Patients were randomized to: 1) usual care (n = 342), 2) provided ED process information (n = 336), or 3) provided ED process information plus predicted service delivery times (n = 333). Patients in group 3 were given an "average" and "upper range" estimate of their waiting room times and treatment times. The average and upper range predictions were calculated from quantile regression models that estimated the 50th and 90th percentiles of the waiting room time and treatment time distributions for fast track patients at the study site based on 2.5 years of historical data. Trained research assistants administered the interventions after triage. Patients completed a brief survey at discharge that measured their satisfaction with overall care, the quality of the information they received, and the timeliness of care. Satisfaction ratings of very good versus good, fair, poor, and very poor were modeled using logistic regression as a function of study group; actual service delivery times; and other patient, clinical, and temporal covariates. The study also modeled satisfaction ratings of fair, poor, and very poor compared to good and very good ratings as a function of the same covariates. Survey completion rates and patient, clinical, and temporal characteristics were similar by study group. Median waiting room time was 70 minutes (interquartile range [IQR] = 40 to 114 minutes), and median treatment time was 52 minutes (IQR = 31 to 81 minutes). Neither intervention affected any of the satisfaction outcomes. Satisfaction was significantly associated with actual waiting room time, individual providers, and patient age. Every 10-minute increase in waiting room time corresponded with an 8% decrease (odds ratio [OR] = 0.92; 95% confidence interval [CI] = 0.89 to 0.95) in the odds of reporting very good satisfaction with overall care. The odds of reporting very good satisfaction with care were lower for several triage nurses and fast track nurses, compared to the triage nurse and fast track nurse who treated the most study patients. Each 10-minute increase in waiting room time was also associated with a 10% increase in the odds of reporting very poor, poor, or fair satisfaction with overall care (OR = 1.10; 95% CI = 1.06 to 1.14). The odds of reporting very poor, poor, or fair satisfaction with overall care also varied significantly among the triage nurses, fast track doctors, and fast track nurses. The odds of reporting very poor, poor, or fair satisfaction with overall care were significantly lower among patients aged 35 years and older compared to patients aged 18 to 34 years. Satisfaction with overall care was influenced by waiting room time and the clinicians who treated them and not by service completion time estimates provided at triage.

Can an ECG performed during emergency department triage and interpreted as normal by computer analysis safely wait for clinician review until the time of patient assessment? A pilot study.

Electrocardiograms (ECGs) are frequently performed during patient triage in Emergency Departments (EDs). Emergency Physicians (EPs) are interrupted during other tasks to review ECGs. Critics believe this practice could lead to distraction with consequent medical error and decision fatigue. ECGs can be interpreted by computer software at the time of capture; some evidence exists to suggest that an ECG performed during ED triage with an immediate computer interpretation (ICI) of 'normal' will seldom contain information necessitating a change to triage management. All ED triage ECGs performed in the Royal Derby Hospital between 13th July 2017 and 12th July 2018 in patients without chest pain and with an ICI of 'normal' were identified through a database search. Forty were randomly selected and reviewed by two EPs (blinded to patient details, ICI and outcome) who were asked to identify those that required a change to triage management. The study processes were feasible. At least one of the two EP reviewers felt that a change to triage management was required in 48% of cases (e.g. "review patient", "obtain blood gas", "review old ECGs"); they agreed on the need for change of management in 13% of cases. An ICI of normal had a NPV of 53% (95% CI 37-67%) for the need for a change to triage management based upon ECG findings. Inter-observer agreement was poor (kappa = 0.17). Based on these results, ED triage ECGs should still be presented to EPs for immediate review regardless of the ICI. Inter-observer agreement between EPs was poor. Further research is required to link triage ECG interpretation, need for intervention and patient outcome.

Emergency department

Critical conditions handled Cardiac arrest Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency department already in this state. Treatment is basic life support and advanced life support as taught in advanced life support and advanced cardiac life support courses. Heart attack Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG; aspirin will be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine will be given for pain; sub lingual (under the tongue) or buccal (between cheek and upper gum) glyceryl trinitrate (nitroglycerin) (GTN or NTG) will be given, unless contraindicated by the presence of other drugs.