Than Martin P, Pickering John W, Adamson Philip, Clendon Thomas, Florkowski Christopher M, Lainchbury John, Loubser Jacques, Nankivel Alison, Aldous Sally J
Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand.
Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand.
EJIFCC. 2021 Feb 28;32(1):27-40. eCollection 2021 Feb.
The COVID-19 pandemic raised major concerns relating to hospital capacity and cross-infection patients and staff in the Emergency Department (ED) of a metropolitan hospital servicing a population of ~500,000. We determined to reduce length of stay and admissions in patients presenting with symptoms of possible myocardial infarction; the most common presentation group. After establishing stakeholder consensus, the existing accelerated diagnostic pathway (ADP) based on the ED Assessment of Chest-pain Score (EDACS), electrocardiogram, and troponin measurements with a high-sensitivity assay (hs-cTn) on presentation and two hours later (EDACS-ADP) was modified to stream patients following an initial troponin measure as follows: (i) to a very-low risk group who could be discharged home without follow-up or further testing, and (ii) to a low-risk group who could be discharged with next-day follow-up community troponin testing. Simulations were run in an extensive research database to determine appropriate hs-cTnI and EDACS thresholds for risk classification. This COVID-ADP was developed in ~2-weeks and was implemented in the ED within a further 3-weeks. A comparison of all chest pain presentations for the 3 months prior to implementation of the COVID-ADP to 3 months following implementation showed that there was a 64.7% increase in patients having only one troponin test in the ED, a 30-minute reduction of mean length of stay of people discharged home from the ED, and a 24.3% reduction in hospital admissions of patients ultimately diagnosed with non-cardiac chest pain.
新冠疫情引发了人们对一家为约50万人口服务的大都市医院急诊科的医院容量以及患者与工作人员交叉感染的重大担忧。我们决定缩短可能患有心肌梗死症状患者的住院时间和住院人数，这类患者是最常见的就诊群体。在达成利益相关者共识后，基于急诊科胸痛评分（EDACS）、心电图以及就诊时和两小时后采用高敏检测法（hs-cTn）检测肌钙蛋白的现有加速诊断路径（ADP）（EDACS-ADP）进行了修改，以便在首次检测肌钙蛋白后对患者进行分流，具体如下：（i）分到极低风险组，这些患者可以直接回家，无需后续跟进或进一步检测；（ii）分到低风险组，这些患者可以出院，并在第二天接受社区肌钙蛋白检测进行随访。在一个广泛的研究数据库中进行了模拟，以确定用于风险分类的合适的hs-cTnI和EDACS阈值。这个新冠ADP在大约两周内制定完成，并在接下来的三周内在急诊科实施。将新冠ADP实施前3个月与实施后3个月所有胸痛就诊情况进行比较，结果显示，在急诊科只进行一次肌钙蛋白检测的患者增加了64.7%，从急诊科出院回家的患者平均住院时间缩短了30分钟，最终被诊断为非心源性胸痛的患者住院人数减少了24.3%。
