Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, United States; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States.
Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, United States; Department of Emergency Medicine, University of California Davis, Sacramento, CA, United States.
Am J Emerg Med. 2018 Aug;36(8):1397-1404. doi: 10.1016/j.ajem.2017.12.062. Epub 2017 Dec 29.
Myocardial infarction and stroke are two of the leading causes of death in the U.S. Both diseases have clinical practice guidelines (CPGs) specific to the emergency department (ED) that improve patient outcomes. Our primary objectives were to estimate differences in ED adherence across CPGs for these diseases and identify patient, provider, and environmental factors associated with adherence.
Design: Retrospective study at 3 hospitals in Colorado using standard medical record review.
Consecutive adults (≥18) hospitalized for acute coronary syndrome (ACS), ST-elevation myocardial infarction (STEMI), or acute ischemic stroke (AIS), who were admitted to the hospital from the ED and for whom the ED diagnosed or initiated treatment.
ED adherence to the CPG (primary); in-hospital mortality and length-of-stay (secondary).
Multivariable logistic regression using generalized estimating equations was used.
Among 1053 patients, ED care was adherent in 84% with significant differences in adherence between CPGs (p<0.001) and across institutions (p=0.04). When patients presented with atypical chief complaints, the odds of receiving adherent care was 0.6 (95% CI 0.4-0.9). When the primary ED diagnosis was associated but not specific to the CPG, the odds of receiving adherent care was 0.5 (95% CI 0.3-0.9) and 0.3 (95% CI 0.2-0.5) for unrelated primary diagnoses.
Adherence to ED CPGs for ACS, STEMI and AIS differs significantly between cardiovascular and cerebrovascular diseases and is more likely to occur when the diagnosis is highly suggested by the patient's complaint and acknowledged as the primary diagnosis by the treating ED physician.
心肌梗死和中风是美国两大主要死因。这两种疾病都有针对急诊科（ED）的临床实践指南（CPG），可改善患者预后。我们的主要目标是评估这些疾病的 ED 依从性在 CPG 之间的差异，并确定与依从性相关的患者、医务人员和环境因素。
设计：科罗拉多州 3 家医院的回顾性研究，采用标准病历回顾。
连续入住急性冠状动脉综合征（ACS）、ST 段抬高型心肌梗死（STEMI）或急性缺血性中风（AIS）的成年人（≥18 岁），这些患者从 ED 入院，ED 诊断或开始治疗。
ED 对 CPG 的依从性（主要）；院内死亡率和住院时间（次要）。
使用广义估计方程的多变量逻辑回归。
在 1053 名患者中，ED 护理的依从率为 84%，CPG 之间（p<0.001）和各机构之间（p=0.04）的依从率存在显著差异。当患者出现非典型主诉时，接受依从性护理的可能性为 0.6（95%CI 0.4-0.9）。当 ED 的主要诊断与 CPG 相关但不具体时，接受依从性护理的可能性为 0.5（95%CI 0.3-0.9），而当主要诊断与 CPG 不相关时，接受依从性护理的可能性为 0.3（95%CI 0.2-0.5）。
ACS、STEMI 和 AIS 的 ED CPG 依从性在心血管疾病和脑血管疾病之间存在显著差异，当患者的主诉高度提示诊断且 ED 治疗医生将其作为主要诊断时，更有可能发生依从性。
