Wake Forest School of Medicine, Department of Emergency Medicine, Winston-Salem, North Carolina.
Wake Forest School of Medicine, Department of Biostatistics and Data Science, Winston-Salem, North Carolina.
West J Emerg Med. 2022 Jan 18;23(2):222-228. doi: 10.5811/westjem.2021.9.52325.
Chest pain is a common reason for ambulance transport. Acute coronary syndrome (ACS) and pulmonary embolism (PE) risk assessments, such as history, electrocardiogram, age, risk factors (HEAR); Emergency Department Assessment of Chest Pain Score (EDACS); Pulmonary Embolism Rule-out Criteria (PERC); and revised Geneva score, are well validated for emergency department (ED) use but have not been translated to the prehospital setting. The objectives of this study were to evaluate the 1) prehospital completion rate and 2) inter-rater reliability of chest pain risk assessments.
We conducted a prospective observational cohort study in two emergency medical services (EMS) agencies (April 18, 2018 - January 2, 2019). Adults with acute, non-traumatic chest pain without ST-elevation myocardial infarction or unstable vital signs were accrued. Paramedics were trained to use the HEAR, EDACS, PERC, and revised Geneva score assessments. A subset of patients (a priori goal of N = 250) also had the four risk assessments completed by their treating clinicians in the ED, who were blinded to the EMS risk assessments. Outcomes were 1) risk assessments completion rate and 2) inter-rater reliability between EMS and ED assessments. An a priori goal for completion rate was set as >75%. We computed kappa with corresponding 95% confidence intervals (CI) for each risk assessment as a measure of inter-rater reliability. Acceptable agreement was defined a priori as kappa ≥ 0.60.
During the study period, 837 patients with acute chest pain were accrued. The median age was 54 years, interquartile range 43-66, with 53% female and 51% Black. Completion rates for each risk assessment were above goal: the HEAR score was completed on 95.1% (796/837), EDACS on 92.0% (770/837), PERC on 89.4% (748/837), and revised Geneva score on 90.7% (759/837) of patients. We assessed agreement in a subgroup of 260 patients. The HEAR score had a kappa of 0.51 (95% CI, 0.41-0.61); EDACS was 0.60 (95% CI, 0.49-0.72); PERC was 0.71 (95% CI, 0.61-0.81); and revised Geneva score was 0.51 (95% CI, 0.39-0.62).
The completion rate of risk assessments for ACS and PE was high for prehospital field personnel. The PERC and EDACS both demonstrated acceptable agreement between paramedics and clinicians in the ED, although assessments with better agreement are likely needed.
胸痛是救护车转运的常见原因。急性冠状动脉综合征（ACS）和肺栓塞（PE）风险评估，如病史、心电图、年龄、危险因素（HEAR）；急诊胸痛评分（EDACS）；肺栓塞排除标准（PERC）；和修订后的日内瓦评分，在急诊科使用中得到了很好的验证，但尚未翻译成院前环境。本研究的目的是评估 1）院前完成率和 2）胸痛风险评估的组内可靠性。
我们在两个紧急医疗服务机构（2018 年 4 月 18 日至 2019 年 1 月 2 日）进行了一项前瞻性观察队列研究。招募了患有急性、非创伤性胸痛且无 ST 段抬高心肌梗死或不稳定生命体征的成年人。护理人员接受了使用 HEAR、EDACS、PERC 和修订后的日内瓦评分评估的培训。一小部分患者（预先设定的 N=250）也由他们在急诊科的主治医生完成了四项风险评估，主治医生对 EMS 风险评估并不知情。主要结局是 1）风险评估完成率和 2）EMS 和 ED 评估之间的组内可靠性。我们设定了一个预先设定的完成率目标>75%。我们为每个风险评估计算了 kapp 值和相应的 95%置信区间（CI），作为组内可靠性的衡量标准。预先定义的可接受一致性为 kapp≥0.60。
在研究期间，共纳入了 837 例急性胸痛患者。中位数年龄为 54 岁，四分位间距为 43-66 岁，女性占 53%，黑人占 51%。每个风险评估的完成率均高于目标：HEAR 评分完成率为 95.1%（796/837），EDACS 为 92.0%（770/837），PERC 为 89.4%（748/837），修订后的日内瓦评分为 90.7%（759/837）。我们在 260 名患者的亚组中评估了一致性。HEAR 评分的 kapp 值为 0.51（95%CI，0.41-0.61）；EDACS 为 0.60（95%CI，0.49-0.72）；PERC 为 0.71（95%CI，0.61-0.81）；修订后的日内瓦评分为 0.51（95%CI，0.39-0.62）。
对于院前现场人员来说，ACS 和 PE 的风险评估完成率很高。PERC 和 EDACS 都在护理人员和急诊科医生之间表现出了可接受的一致性，尽管可能需要更好的一致性评估。
