Graff L, Palmer A C, Lamonica P, Wolf S
New Britain General Hospital, New Britain, CT, USA.
Ann Emerg Med. 2000 Dec;36(6):554-60. doi: 10.1067/mem.2000.111057.
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.
基于就诊主诉制定的规则能够识别出适合快速（5分钟）进行心电图检查的患者，并减少急性心肌梗死（MI）患者的治疗延误。
在一家社区教学医院急诊科对所有接受治疗的患者的就诊主诉进行电子收集。根据1994年7月至12月就诊的一组患者（22,717例）制定了患者到急诊科就诊时开具心电图检查的规则，然后在1995年1月至5月的一组验证患者（18,759例）中进行测试。在研究医院实施该规则之前（1993年4月至1995年5月，n = 67）和之后（1995年6月至1997年3月，n = 128），前瞻性地在书面数据表上收集结果指标（心电图检查执行延迟和溶栓药物给药延迟）。
在模型组中，193例患者最终诊断为MI，5种主诉在识别急性MI患者方面表现最佳，构成了快速心电图规则：年龄大于30岁且有胸痛（130例[67.4%]患者）；年龄大于50岁且有晕厥（5例[1%]患者）；虚弱（12例[6.2%]患者）；心跳过速（2例[1%]患者）；呼吸困难或呼吸急促（20例[10.4%]患者）。在验证组中，142例患者最终诊断为MI，该规则在识别“紧急”心电图检查患者方面比胸痛表现更好（敏感性93.7%对67.4%[差异的95%置信区间（CI），15.6%至33.8%]），尽管更大比例的急诊科患者会接受紧急心电图检查（7.3%对6.3%[差异的95%CI，0.7%至1.7%]）。在模型期和验证期，335例MI患者中有44例（13.1%）接受了溶栓药物治疗。与未接受溶栓药物治疗的MI患者相比，该规则对接受溶栓药物治疗的MI患者具有更高的敏感性（敏感性100%对86.4%[差异的95%CI，1.7%至20.3%]），特异性为90.4%对93.8%[差异的95%CI，3.0%至3.8%]。在4年的研究期间，实施该规则后结果得到改善：接受溶栓药物治疗的MI患者进行心电图检查的平均延迟从10.0分钟降至6.3分钟（差异的95%CI，1.1至6.4），溶栓药物给药的平均延迟从36.9分钟降至26.1分钟（差异的95%CI，3.5至17.7）。
使用基于主诉的规则能够识别出MI患者以便立即进行心电图检查，并减少心电图检查和溶栓药物给药的延迟。
