Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany.
Faculty of Informatics, Heilbronn University of Applied Sciences, Heilbronn, Germany.
BMJ Open. 2020 Oct 8;10(10):e041757. doi: 10.1136/bmjopen-2020-041757.
Fast diagnostic algorithms using high-sensitivity troponin (hsTn) in suspected acute coronary syndrome (ACS) are regarded as beneficial to expedite diagnosis and safe discharge of patients in crowded emergency departments (ED). This study investigates the effects of crowding on process times related to the diagnostic protocol itself or other time delays, and outcomes.
Prospective single-centre observational study.
ED (Germany).
Final study population of 2525 consecutive patients with suspected ACS within 12 months, after exclusion of patients with ST-elevation myocardial infarction, missing blood samples, referral from other hospitals or repeated visits.
Use of fast algorithms as per 2015 European Society of Cardiology guidelines.
Crowding was defined as mismatch between patient numbers and monitoring capacities, or mean physician time per case, categorised as normal, high and very high crowding. Outcome measures were length of ED stay, direct discharge from ED, laboratory turn around times (TAT), utilisation of fast algorithms, absolute and relative non-laboratory time, as well as mortality.
Crowding was associated with increased length of ED stay (3.75-4.89 hours, p<0.001). While median TAT of the first hsTnT increased (53-57 min, p<0.001), total TAT of serial hsTnT did not increase significantly with higher crowding (p=0.170). Lower utilisation of fast algorithms (p=0.009) and increase of additional hsTnT measurements after diagnosis (p=0.001) were observed in higher crowding. Most importantly, crowding was significantly associated with prolonged absolute (p<0.001), and particularly relative non-laboratory time (63.3%-71.3%, p<0.001). However, there was no significant effect of crowding on mortality, even after adjustment for relevant clinical variables.
Process times, and particularly non-laboratory times, are prolonged in a crowded ED diminishing some positive effects of fast diagnostic algorithms in suspected ACS. Higher crowding levels were not significantly associated with higher all-cause mortality rates.
NCT03111862.
在疑似急性冠状动脉综合征（ACS）中使用高敏肌钙蛋白（hsTn）的快速诊断算法被认为有利于加快诊断和拥挤的急诊科（ED）患者的安全出院。本研究调查了拥挤对诊断方案本身或其他时间延迟相关的过程时间以及结果的影响。
前瞻性单中心观察性研究。
ED（德国）。
在排除 ST 段抬高型心肌梗死、血液样本缺失、转院或复诊患者后，在 12 个月内对 2525 例疑似 ACS 的连续患者进行最终研究人群。
根据 2015 年欧洲心脏病学会指南使用快速算法。
拥挤定义为患者人数与监测能力之间不匹配，或每位患者的平均医生时间，分为正常、高和极高拥挤。观察指标包括 ED 停留时间、ED 直接出院、实验室周转时间（TAT）、快速算法的使用、绝对和相对非实验室时间以及死亡率。
拥挤与 ED 停留时间延长相关（3.75-4.89 小时，p<0.001）。虽然首次 hsTnT 的中位 TAT 增加（53-57 分钟，p<0.001），但随着拥挤程度的增加，连续 hsTnT 的总 TAT 并未显著增加（p=0.170）。较高的拥挤程度观察到快速算法的使用率降低（p=0.009）和诊断后额外 hsTnT 测量的增加（p=0.001）。最重要的是，拥挤与绝对（p<0.001），尤其是相对非实验室时间（63.3%-71.3%，p<0.001）的延长显著相关。然而，即使在调整了相关临床变量后，拥挤对死亡率也没有显著影响。
在拥挤的 ED 中，过程时间，特别是非实验室时间延长，降低了快速诊断算法在疑似 ACS 中的一些积极作用。较高的拥挤程度与较高的全因死亡率无显著相关性。
NCT03111862。
