Department of Emergency Medicine, Johns Hopkins University, Hopkins Bayview Medical Center, Baltimore, MD, USA.
Acad Emerg Med. 2009 Nov;16(11):1242-50. doi: 10.1111/j.1553-2712.2009.00502.x.
The objectives were to examine the feasibility of offering abdominal aortic aneurysm (AAA) screening to consecutive, asymptomatic high-risk patients in a busy emergency department (ED) and to compare the prevalence of undetected AAA among ED patients to the prevalence among similarly aged men from the general population.
A prospective cohort study was conducted at an academic community ED with an annual census of 58,000 patients. Dedicated study coordinators attempted to approach all consecutive male ED patients >50 years who presented in June-August 2007 during hours of high patient volume. To be eligible, older males had to have a smoking history or a family history of AAA. Patients were excluded if they presented with AAA symptoms, had a previous history of AAA screening or repair, had hemodynamic instability, or had an altered mental status. Study coordinators completed a brief interview with all enrolled subjects to obtain demographic and health information. A credentialed ED provider performed the ultrasound (US) screening exam and documented all findings. The US director reviewed representative images of the sonographic exam for correct visualization and measurement during quality assurance. The ED sonographers also completed a survey regarding their attitudes toward AAA screening in the ED. The primary study outcomes were the feasibility of AAA screening in the ED (screening rate, enrollment rate, US success rate, and providers' opinions) and the prevalence of AAA (aortic diameter of > or =3.0 cm) in the study sample.
During the 12-week study period, the study coordinators successfully approached 96% (700/729) of males > 50 years who were in the ED during study enrollment hours. Of those approached, 278 were eligible (40%), 25% were ineligible, 20% were not at high risk, and for 15% we could not determine risk factor status because of altered mental status. Of the 278 eligible, 196 (70%) underwent an US exam; 10% were not scanned because the providers were too busy, and 20% declined participation. Of those scanned, the ED sonographer was able to completely visualize and correctly measure the abdominal aortas of 71% of subjects. The prevalence rate of AAA in the study sample was 5.7% (95% confidence interval [CI] = 1.9% to 9.6%), similar to reported rates of 6 or 7% in other studies. More than half of the ED sonographers reported that US screening for AAA improved the quality of ED care (58%) and patient satisfaction (63%). However, 47% reported that AAA screening reduced ED efficiency, and 74% felt that the ED was not an appropriate setting for routine AAA screening.
Routine screening for asymptomatic AAA required substantial ED resources for a relatively low success rate of completed screens. The prevalence rate of AAA in our ED sample was not significantly different than prevalence estimates obtained from older men in the general population. ED sonographers reported benefits of screening in terms of improving the quality of emergency care and patient satisfaction, but also reported that it reduced operational efficiency. For EDs that have problems with crowding, we do not recommend implementing a routine screening program for AAA, even among high-risk patients.
本研究旨在检验在繁忙的急诊科（ED）中连续为无症状高危患者提供腹主动脉瘤（AAA）筛查的可行性，并比较 ED 患者中未检出的 AAA 患病率与一般人群中同龄男性的患病率。
本研究为前瞻性队列研究，在一家学术社区 ED 进行，该 ED 每年的就诊患者人数为 58000 人。专门的研究协调员试图接触 2007 年 6 月至 8 月期间在高患者流量时段就诊的所有连续的 50 岁以上男性 ED 患者。要符合条件，老年男性必须有吸烟史或 AAA 家族史。如果患者出现 AAA 症状、有 AAA 筛查或修复的既往史、血流动力学不稳定或精神状态改变，则将其排除在外。研究协调员对所有入组患者进行简短的访谈，以获取人口统计学和健康信息。经过认证的 ED 医生进行超声（US）筛查检查，并记录所有发现。US 主任在质量保证期间审查超声检查的代表性图像，以确保正确的可视化和测量。ED 超声医师还完成了一项关于他们对 ED 中 AAA 筛查态度的调查。主要研究结果是 ED 中 AAA 筛查的可行性（筛查率、入组率、US 成功率和提供者的意见）以及研究样本中 AAA 的患病率（主动脉直径>3.0cm）。
在 12 周的研究期间，研究协调员成功接触了在研究登记时段在 ED 就诊的 96%（700/729）50 岁以上的男性。在接触到的男性中，有 278 人符合条件（40%），25%不符合条件，20%不属于高危人群，对于 15%的人，由于精神状态改变，我们无法确定危险因素状态。在 278 名符合条件的男性中，有 196 名（70%）接受了 US 检查；10%的人由于医生太忙而未进行扫描，20%的人拒绝参与。在接受扫描的患者中，ED 超声医师能够完全可视化并正确测量 71%的患者的腹主动脉。研究样本中 AAA 的患病率为 5.7%（95%置信区间 [CI]为 1.9%至 9.6%），与其他研究报告的 6%或 7%的患病率相似。超过一半的 ED 超声医师报告称，AAA 的 US 筛查提高了 ED 护理的质量（58%）和患者满意度（63%）。然而，47%的人报告说，AAA 筛查降低了 ED 的效率，74%的人认为 ED 不是常规筛查 AAA 的合适场所。
对无症状 AAA 进行常规筛查需要大量 ED 资源，但完成筛查的成功率相对较低。我们 ED 样本中的 AAA 患病率与一般人群中同龄男性的患病率无显著差异。ED 超声医师报告说，筛查在提高急诊护理质量和患者满意度方面有好处，但也报告说它降低了运营效率。对于存在拥挤问题的 ED，我们不建议在高危患者中实施常规的 AAA 筛查计划。
