Fitzpatrick M A, Dodd M, Schoevers D, Tracey E
Department of Cardiology, Nepean Hospital, Sydney, NSW.
Med J Aust. 1999 Oct 18;171(8):402-6.
To audit the use of management algorithms for chest pain in an emergency department.
Prospective study of all patients with chest pain presenting to the emergency department of an urban teaching hospital between 12 January and 4 May 1997. Staff were asked to complete a standardised admission form that incorporated the risk stratification algorithms for managing patients with suspected acute coronary syndrome.
Compliance with the use of management algorithms; concordance with a cardiologist's review of the triage grouping and admission/discharge decision; and major cardiovascular events over four months.
Emergency department staff documented the triage group in 223 of 503 cases (45%). Concordance with the group assigned by a cardiologist was 70% (kappa = 0.73; SE kappa = 0.04). When the management algorithm was applied correctly, 92% of triage decisions were correct (95% confidence interval [CI], 87%-96%). The triage decision was less often correct when risk stratification was not done (78% [73%-83%], P < 0.001), overestimated (77% [66%-88%], P < 0.01), or underestimated (50% [18%-82%], P < 0.001). The proportion of patients free of major cardiovascular events at four-month follow-up was 50% for those with myocardial infarction with ST-segment elevation, 47% for those with a high short-term risk of an adverse cardiac event, 82% for those with intermediate risk, and 99% for those with a low risk or non-coronary chest pain (P < 0.001).
Use of management algorithms by emergency staff was poor. When used, triage decisions were more likely to be correct. Subsequent outcome confirms that the NHMRC risk stratification algorithms are useful for prognostic stratification of patients with suspected acute coronary syndrome.
审核急诊科胸痛管理算法的使用情况。
对1997年1月12日至5月4日期间到一家城市教学医院急诊科就诊的所有胸痛患者进行前瞻性研究。要求工作人员填写一份标准化的入院表格，其中纳入了用于管理疑似急性冠状动脉综合征患者的风险分层算法。
管理算法的使用依从性；与心脏病专家对分诊分组及入院/出院决定的评估的一致性；以及四个月内的主要心血管事件。
在503例病例中，急诊科工作人员记录了223例（45%）的分诊分组。与心脏病专家指定分组的一致性为70%（kappa值=0.73；kappa值的标准误=0.04）。当正确应用管理算法时，92%的分诊决定是正确的（95%置信区间[CI]，87%-96%）。当未进行风险分层时，分诊决定正确的情况较少（78%[73%-83%]，P<0.001），高估时（77%[66%-88%]，P<0.01），或低估时（50%[18%-82%]，P<0.001）。在四个月的随访中，ST段抬高型心肌梗死患者无主要心血管事件的比例为50%，心脏不良事件短期风险高的患者为47%，中度风险患者为82%，低风险或非冠状动脉性胸痛患者为99%（P<0.001）。
急诊科工作人员对管理算法的使用情况较差。使用管理算法时，分诊决定更可能是正确的。后续结果证实，澳大利亚国家卫生与医学研究委员会（NHMRC）的风险分层算法有助于对疑似急性冠状动脉综合征患者进行预后分层。
