Diercks Deborah B, Roe Matthew T, Chen Anita Y, Peacock W Franklin, Kirk J Douglas, Pollack Charles V, Gibler W Brian, Smith Sidney C, Ohman Magnus, Peterson Eric D
University of California, Davis, School of Medicine, Sacramento, CA, USA.
Ann Emerg Med. 2007 Nov;50(5):489-96. doi: 10.1016/j.annemergmed.2007.03.033. Epub 2007 Jun 20.
We evaluate the association of emergency department (ED) length of stay with use of guideline-recommended therapies for acute treatments and clinical outcomes. Prolonged ED stays often reflect ED crowding or limited hospital capacity. We hypothesized that patients with non-ST-segment-elevation myocardial infarction who have ED stays of greater than 8 hours may have lower quality of care and worse outcomes.
Using a secondary analysis of data from an observational registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines, CRUSADE), we compared rates of use of 5 individual acute (<24 hours) guideline-recommended therapies in patients with non-ST-segment-elevation myocardial infarction according to ED length of stay. Patients were grouped by length of stay (short [<4 hours], average [4 to 8 hours], or long [>8 hours]). Multivariable analyses were used to determine independent association of ED length of stay with acute medications and inhospital outcomes (death and myocardial infarction).
This analysis included 42,780 patients with non-ST-segment-elevation myocardial infarction. The median ED length of stay was 4.3 hours (25th to 75th percentile 2.9, 6.3); 15% of patients stayed longer than 8 hours. Patients who had long ED stays were more likely to be women and nonwhite and less likely to have health maintenance organization or private insurance. After adjustment, patients with long ED stays less often received guideline-recommended acute myocardial infarction therapies. Although risk-adjusted inhospital mortality rates were similar among groups, the rate of recurrent myocardial infarction increased among patients with long ED stays (odds ratio 1.23; 95% confidence interval 1.01 to 1.48) compared with those with average ED length of stay.
For patients with non-ST-segment-elevation myocardial infarction, long ED stays were associated with decreased use of guideline-recommended therapies and a higher risk of recurrent myocardial infarction. However, there was no observed difference in mortality. Factors associated with prolonged ED length of stay should be evaluated to optimize treatments and outcomes of patients with non-ST-segment-elevation myocardial infarction.
我们评估急诊科（ED）住院时长与急性治疗中使用指南推荐疗法及临床结局之间的关联。急诊科住院时间延长往往反映了急诊科拥挤或医院容量有限。我们假设，急诊科住院时间超过8小时的非ST段抬高型心肌梗死患者可能接受的治疗质量较低，结局较差。
通过对一项观察性登记研究（能否通过早期实施ACC/AHA指南抑制不稳定型心绞痛患者不良结局的快速风险分层，CRUSADE）的数据进行二次分析，我们比较了非ST段抬高型心肌梗死患者根据急诊科住院时长使用5种单独的急性（<24小时）指南推荐疗法的比例。患者按住院时长分组（短[<4小时]、平均[4至8小时]或长[>8小时]）。多变量分析用于确定急诊科住院时长与急性药物治疗及住院结局（死亡和心肌梗死）之间的独立关联。
该分析纳入了42,780例非ST段抬高型心肌梗死患者。急诊科住院时长的中位数为4.3小时（第25至75百分位数为2.9、6.3）；15%的患者住院时间超过8小时。急诊科住院时间长的患者更可能为女性和非白人，且拥有健康维护组织或私人保险的可能性较小。调整后，急诊科住院时间长的患者较少接受指南推荐的急性心肌梗死治疗。尽管各组间经风险调整的住院死亡率相似，但与急诊科平均住院时长的患者相比，急诊科住院时间长的患者复发性心肌梗死的发生率有所增加（比值比1.23；95%置信区间1.01至1.48）。
对于非ST段抬高型心肌梗死患者，急诊科住院时间长与指南推荐疗法的使用减少及复发性心肌梗死风险较高相关。然而，未观察到死亡率的差异。应评估与急诊科住院时间延长相关的因素，以优化非ST段抬高型心肌梗死患者的治疗及结局。
