急性胸痛且心肌缺血低风险患者管理的关键路径：建议及潜在影响

A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact.

作者信息

Nichol G, Walls R, Goldman L, Pearson S, Hartley L H, Antman E, Stockman M, Teich J M, Cannon C P, Johnson P A, Kuntz K M, Lee T H

机构信息

Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

出版信息

Ann Intern Med. 1997 Dec 1;127(11):996-1005. doi: 10.7326/0003-4819-127-11-199712010-00009.

DOI:10.7326/0003-4819-127-11-199712010-00009

PMID:9412306

Abstract

BACKGROUND

Use of resources for patients with acute chest pain may be improved with clinical strategies that integrate research, Bayesian analysis, and expert opinion.

OBJECTIVES

To 1) develop a critical pathway for management of patients with acute chest pain who are at low risk for complications of ischemic heart disease and 2) assess the potential effects of implementation of the pathway on patient safety and resource use.

DESIGN

Evidence-based consensus and prospective cohort study.

SETTING

Urban teaching hospital.

PATIENTS

Patients at least 30 years of age who were seen in the emergency department for chest pain and who did not have a history of trauma or abnormalities on radiologic study.

INTERVENTION

Physician-opinion leaders defined criteria for patient inclusion in the pathway and for remaining on the pathway after 6 or 12 hours of observation. Criteria were defined for appropriateness of direct admission, direct discharge, or 6 hours of observation followed by exercise treadmill testing.

MEASUREMENTS

Number of patients admitted to the hospital, number of days that patients were hospitalized, and clinical outcome.

RESULTS

2898 of 4585 patients (63%) were admitted to the hospital; of the 2898, 1152 (40%) were classified as potentially eligible for the pathway and 1068 (93%) had a benign clinical course during the initial observation period. The 1068 patients had a mean length of stay of 2.8 +/- 4.8 days. If 47% of these patients had been discharged after observation and exercise testing, implementation of the pathway would have reduced the number of admissions by 505 (17%) and days of hospitalization by 1407 (11%).

CONCLUSIONS

Retrospective analysis suggests that a critical pathway for patients with acute chest pain may substantially reduce resource use. Prospective study is needed to ensure increased efficiency without increased adverse outcomes.

摘要

背景

通过整合研究、贝叶斯分析和专家意见的临床策略，可改善急性胸痛患者的资源利用情况。

目的

1）为缺血性心脏病并发症低风险的急性胸痛患者制定关键治疗路径；2）评估实施该路径对患者安全和资源利用的潜在影响。

设计

循证共识和前瞻性队列研究。

地点

城市教学医院。

患者

年龄至少30岁，因胸痛在急诊科就诊且无创伤史或放射学检查异常的患者。

干预

医生意见领袖确定患者纳入该路径的标准以及观察6或12小时后继续留在该路径的标准。定义了直接入院、直接出院或观察6小时后进行运动平板试验的适宜性标准。

测量指标

入院患者数量、患者住院天数和临床结局。

结果

4585例患者中有2898例（63%）入院；在这2898例中，1152例（40%）被归类为可能符合该路径条件，1068例（93%）在初始观察期临床过程良好。这l068例患者的平均住院时间为2.8±4.8天。如果这些患者中有47%在观察和运动试验后出院，实施该路径将使入院人数减少505例（17%），住院天数减少1407天（11%）。