BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
Ann Emerg Med. 2020 Apr;75(4):502-513. doi: 10.1016/j.annemergmed.2019.11.012. Epub 2020 Jan 23.
High-sensitivity cardiac troponin assays enable myocardial infarction to be excluded in the emergency department (ED). As part of a prospective clinical trial, we explore how introducing an early rule-out pathway may affect patient experience of chest pain.
In a qualitative study, participants presenting to the ED with suspected acute coronary syndrome, and for whom the diagnosis of myocardial infarction was excluded, were interviewed before (n=23) or after (n=26) implementation of an early rule-out pathway. Preimplementation, diagnosis of myocardial infarction was excluded on serial troponin testing requiring admission to the hospital. Postimplementation, diagnosis could be excluded in the ED, enabling direct patient discharge. Semistructured interviews exploring the patients' illness experience were conducted approximately 1 week postdischarge, transcribed verbatim, and analyzed thematically. Themes emerging pre- and postimplementation are described.
Common themes emerged across both pathways: participants commonly sought health care advice before presenting to the ED; a discordance may exist between the objective interpretation of troponin results by clinicians and the patients' experience of illness; and pretest information, trust in the clinician, and active listening may enhance reassurance gained from negative test results. Other themes related to the care pathway were that routine care procedures appeared to be a source of frustration for participants requiring hospital admission, and patients assessed with the early rule-out pathway appeared less likely to appraise their future health status.
The early rule-out of myocardial infarction may be enhanced by recognition of patient out-of-hospital experience and improved communication surrounding reassurance and future cardiovascular health goals.
高敏肌钙蛋白检测可排除急诊科（ED）的心肌梗死。作为一项前瞻性临床试验的一部分，我们探讨引入早期排除途径如何影响胸痛患者的体验。
在一项定性研究中，对因疑似急性冠状动脉综合征而到急诊科就诊且心肌梗死被排除的患者在早期排除途径实施前（n=23）和实施后（n=26）进行了采访。在实施前，心肌梗死的诊断通过需要住院的连续肌钙蛋白检测排除。实施后，在急诊科即可排除诊断，使患者可直接出院。大约在出院后 1 周，对患者进行了探索其疾病体验的半结构化访谈，对访谈内容进行了逐字记录，并进行了主题分析。描述了实施前后出现的主题。
两种途径都出现了共同的主题：参与者通常在到急诊科就诊之前寻求医疗建议；临床医生对肌钙蛋白结果的客观解释与患者的疾病体验之间可能存在差异；而术前信息、对医生的信任和积极倾听可能会增强阴性检测结果带来的安心感。与护理途径相关的其他主题是，对需要住院的患者来说，常规护理程序似乎是导致挫败感的一个原因，而通过早期排除途径评估的患者似乎不太可能评估其未来的健康状况。
通过认识到患者院外的体验并改善关于安心和未来心血管健康目标的沟通，可增强对心肌梗死的早期排除。
