Boufous Soufiane, Kelleher Peter W, Pain Charles H, Dann Linda M, Ieraci Susan, Jalaludin Bin B, Gray Anne-Louise, Harris Susan E, Juergens Craig P
South Western Sydney Area Health Service, Sydney, NSW, Australia.
Med J Aust. 2003 Apr 21;178(8):375-80. doi: 10.5694/j.1326-5377.2003.tb05253.x.
To evaluate the impact of a chest-pain guideline on clinical decision-making and medium-term outcomes of patients presenting to a hospital emergency department (ED) with non-traumatic chest pain.
Before-and-after guideline implementation study.
Bankstown-Lidcombe Hospital, Sydney, NSW (454-bed metropolitan teaching hospital), in the six-month periods before and after guideline implementation in February 2001.
Patients presenting to the ED with non-traumatic chest pain who had chest-pain assessment forms completed by ED doctors, comprising 422/768 (54.9%) of those presenting before and 461/691 (66.7%) after guideline implementation.
Appropriateness of admission/discharge decisions compared with decision of senior cardiologist based on guideline; death, recurrent chest pain, ED re-presentation and hospital readmission in the ensuing three months.
After guideline implementation, appropriate admission/discharge decisions increased significantly from 180/265 (68%) to 261/324 (81%) (difference, 13%; 95% CI, 6%-20%). The largest increase was for patients at moderate risk of death or acute myocardial infarction within six months, from 39/96 (38%) to 57/103 (55%) (difference, 18%; 95% CI, 4%-31%). Increases were seen for both junior doctors (interns and resident medical officers) (18%; 95% CI, 7%-30%) and senior doctors (11%; 95% CI, 2%-19%). Logistic regression showed that implementation of the guideline, seniority of assessing doctor and patient history of coronary disease were independent predictors of appropriate decisions. There was a significant decline in re-presentations to ED with recurrent chest pain in patients previously presenting with cardiac or possibly cardiac pain, from 46/201 (23%) before implementation to 32/247 (13%) after (difference, 210%; 95% CI, 217% to 23%).
The chest-pain guideline resulted in a significant improvement in clinical decision-making in the ED and reduced re-presentations with cardiac/possibly cardiac chest pain.
评估胸痛指南对因非创伤性胸痛就诊于医院急诊科（ED）患者的临床决策及中期结局的影响。
指南实施前后对照研究。
新南威尔士州悉尼市班克斯敦-利德科姆医院（一家拥有454张床位的都市教学医院），于2001年2月指南实施前后各6个月期间。
因非创伤性胸痛就诊于ED且由ED医生填写了胸痛评估表的患者，指南实施前就诊患者中有422/768（54.9%），实施后有461/691（66.7%）。
与资深心脏病专家依据指南做出的决定相比，入院/出院决定的恰当性；在随后三个月内的死亡、复发性胸痛、再次就诊于ED及再次住院情况。
指南实施后，恰当的入院/出院决定显著增加，从180/265（68%）增至261/324（81%）（差异为13%；95%可信区间为6%-20%）。六个月内死亡或急性心肌梗死中度风险患者的增幅最大，从39/96（38%）增至57/103（55%）（差异为18%；95%可信区间为4%-31%）。初级医生（实习医生和住院医师）（18%；95%可信区间为7%-30%）和高级医生（11%；95%可信区间为2%-19%）的恰当决定均有增加。逻辑回归显示，指南的实施、评估医生的资历以及患者的冠心病病史是恰当决定的独立预测因素。既往有心脏性或可能为心脏性胸痛的患者因复发性胸痛再次就诊于ED的情况显著下降，从实施前的46/201（23%）降至实施后的32/247（13%）（差异为210%；95%可信区间为217%至23%）。
胸痛指南使ED的临床决策有显著改善，并减少了因心脏性/可能为心脏性胸痛的再次就诊情况。
Zotero 插件