Cardiology/original research
An Evaluation of the Accuracy of Emergency Physician Activation of the Cardiac Catheterization Laboratory for Patients With Suspected ST-Segment Elevation Myocardial Infarction

https://doi.org/10.1016/j.annemergmed.2009.08.011Get rights and content

Study objective

Current recommendations indicate that emergency physicians should activate cardiac catheterization laboratory personnel by a single page for ST-segment elevation myocardial infarction (STEMI) patients. We assessed the accuracy of emergency physician cardiac catheterization laboratory activations, angiographic findings, outcomes, and treatment times among patients with and without STEMI.

Methods

We classified the appropriateness and outcomes of consecutive emergency physician STEMI pages between June 2006 and September 2008. Emergency physician activations of the cardiac catheterization laboratory were classified according to the findings of the initial ECG compared with cardiology interpretation for the presence of STEMI and presence of coronary disease.

Results

During a 27-month period, emergency physician activation of the cardiac catheterization laboratory occurred 249 times. There were 188 (76%) patients with a true STEMI, of whom 13 did not receive emergency angiography. Of the 37 (15%) patients who had ECG findings meeting STEMI criteria and who ultimately did not have myocardial necrosis and underwent emergency angiography, 12 had significant disease and 5 had revascularization performed. Eleven patients had ECGs concerning for but not meeting STEMI criteria; all had emergency angiography (n=11) or received a diagnosis of non-STEMI (n=6). Only 13 patients were considered as having received unnecessary cardiac catheterization laboratory activations (5.2%) in which emergency angiography was not performed and myocardial infarction was excluded.

Conclusion

A significant number of emergency physician STEMI cardiac catheterization laboratory activations are for patients who did not meet standard STEMI criteria. However, most had ECG findings and symptoms that lead to emergency angiography, had significant disease, or were diagnosed with non-STEMI. Only a small percentage of patients received unnecessary cardiac catheterization laboratory activations. Our findings support current recommendations for emergency physician cardiac catheterization laboratory activation for potential STEMI patients.

Introduction

Patients presenting with an initial ECG consistent with ST-segment elevation myocardial infarction (STEMI) represent a cardiovascular emergency in which timely restoration of coronary blood flow can reduce mortality.1 Current American College of Cardiology/American Heart Association guidelines recommend that the time to reperfusion in patients undergoing primary percutaneous coronary intervention as the reperfusion strategy be within 90 minutes of emergency department (ED) arrival, or “door-time.”1 Results of clinical investigations have led to specific recommendations, with the goal to improve door-to-reperfusion (ie, door-to-balloon) time.2, 3 One recommendation from the American College of Cardiology D2B Alliance2 is that the emergency physician be empowered to activate the cardiac catheterization laboratory staff directly by a single page independent of routine cardiology consultation.

For a routine strategy of emergency physician activation of the cardiac catheterization laboratory to be accepted, the number of unnecessary, or “false-positive,” cardiac catheterization laboratory activations should be low. Although anecdotal evidence suggests that this is an infrequent occurrence,3 quantitative data on the number of unnecessary cardiac catheterization laboratory activations by emergency physicians are limited.4, 5

The primary goal of this study was to report on the accuracy of emergency physician cardiac catheterization laboratory activation for ED patients with potential STEMI. The secondary goals were to report on the presence of coronary disease in the different groups and its effect on composite door-to-balloon time and other relevant intervals.

Section snippets

Study Design and Setting

This study was a descriptive case series conducted from June 2006 to September 2008 and performed at a 600-bed urban tertiary care hospital with approximately 82,000 ED visits and 1,500 coronary care unit admissions a year. In 2006, as part of an initiative to reduce time to reperfusion for STEMI patients, we began a process in which the attending emergency physician, after review of the initial ECG and the patient's history, could activate the cardiac catheterization laboratory by making 1

Results

Throughout the 27 months of the study, after exclusions, ED activation of the cardiac catheterization laboratory by the STEMI page occurred 249 times. For 12 patients, the initial ECG result was thought suspicious but not entirely consistent with STEMI, and immediate cardiology consultation was obtained. Of these 12 patients, 6 patients had STEMI, 3 patients had false-positive STEMI (group 2), and 3 patients had no STEMI (group 3). There were no cases in which STEMI was not recognized by the

Limitations

Our investigation has several limitations. Although the entire staff of each affected department was aware of the increased institutional scrutiny on STEMI care during the study period, the multidisciplinary hospital-wide initiative to improve door-to-balloon time started some 9 months earlier. This investigation was conducted at a single tertiary care, academic center, which has the potential to limit generalizability. However, the proportion of patients who did not undergo coronary

Discussion

Prolonged time to reperfusion in patients with STEMI is associated with worse outcomes, including increased incidence of heart failure, shock, and death.1 Among the recommendations made to reduce door-to-balloon times, empowering the emergency physician to activate the cardiac catheterization laboratory with a single page, independent of cardiology consultation, has faced resistance in some centers out of concern for unnecessary cardiac catheterization laboratory activations, particularly

References (18)

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Supervising editor: Deborah B. Diercks, MD

Author contributions: M. C. Kontos concieved of the study and wrote the initial article. M. C. Kontos, M. C. Kurz, CSR, SEJ, LK, and JPO assisted in data collection. M. C. Kontos, M. C. Kurz, CSR, SEJ, LK, JPO, and GWV assisted in data analysis and contributed to the revisions. M. C. Kontos takes responsibility for the paper as a whole.

Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

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Reprints not available from the authors.

Publication date: Available online September 20, 2009.

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