Cardiology/original researchAn Evaluation of the Accuracy of Emergency Physician Activation of the Cardiac Catheterization Laboratory for Patients With Suspected ST-Segment Elevation Myocardial Infarction
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
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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.
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Publication date: Available online September 20, 2009.
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