Patients with chest pain calling 9-1-1 or self-transporting to reach definitive care: which mode is quicker?

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

BACKGROUND

Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients.

METHODS

This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations.

RESULTS

There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively.

CONCLUSIONS

Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public.

Factors associated with emergency medical service delays in suspected ST-elevation myocardial infarction in Victoria, Australia: A retrospective study

OBJECTIVE

To assess the effect of patient and system characteristics on emergency medical service (EMS) delays prior to arrival at hospital in suspected ST-elevation myocardial infarction (STEMI).

METHODS

This was a retrospective observational study of 1739 patients who presented with suspected STEMI to the EMS in Melbourne, Australia between October 2011 and January 2014. Our primary outcome measure was call-to-hospital time, defined as the time in minutes from emergency call to hospital arrival. We examined the association of patient and system characteristics on call-to-hospital time using multivariable linear regression.

RESULTS

The mean call-to-hospital time was 60.1 min (standard deviation 20.5) and the median travel distance was 13.0 km (interquartile range 7.2-23.1). In the multivariable model, patient characteristics associated with longer call-to-hospital time were age ≥75 years (2.3 min; 95% confidence interval [CI] 0.6-4.0), female sex (1.9 min; 95% CI 0.3-3.4), pre-existing mental health disorder (4.0 min; 95% CI 1.9-6.1) or musculoskeletal disease (2.7 min; 95% CI 1.0-4.4), absence of chest pain (3.0 min; 95% CI 1.1-4.8), and presentation with clinical complications. System factors associated with call-to-hospital time include lower dispatch priority (12.7 min; 95% CI 9.0-16.5) and non-12-lead electrocardiography (ECG) capable ambulance first on scene (4.5 min; 95% CI 3.1-5.8). Patients who were not initially attended by a 12-lead capable ambulance were less likely to receive a 12-lead ECG within 10 min (18.5% vs 71.0%, P < 0.001).

CONCLUSION

A range of patient and system factors may influence EMS delays in STEMI. However, optimising dispatch prioritisation and widespread availability of prehospital 12-lead ECG could lead to substantial reduction in time to treatment.

Barriers to the use of emergency medical services for ST-elevation myocardial infarction: Determining why many patients opt for self-transport

RATIONALE, AIMS, AND OBJECTIVES

Access to timely ST-elevation myocardial infarction (STEMI) care is facilitated by paramedics and emergency medical services (EMS). However, a large proportion of STEMI patients do not access care through EMS. This study sought to identify patient-reported factors for their decision to use (or not use) EMS.

METHODS

Semi-structured interviews were conducted with a sample of STEMI patients admitted to a large tertiary care centre between November 2011 and January 2012. Participants were grouped according to mode of transportation to hospital at time of index event (EMS vs self-transport). Participant responses were classified using a published framework (modified for a STEMI population) as barriers or facilitators to EMS use, and compared between groups.

RESULTS

Data were collected on 61 patients (32 EMS, 29 self-transport). Mean age was 60.3 (SD 11.5), and 23% were female. EMS users were more likely to have a Killip Class >1 (25% vs 4%; P = 0.03). Self-transport patients were more likely to perceive EMS as slower (48% vs 0%) and express concerns over resources misuse (34% vs 3%; P = 0.002), when compared to EMS patients. Patients who accessed EMS were more likely to acknowledge the benefits of EMS (44% vs 7%; P = 0.001) and were more likely to have been encouraged by a family member to call EMS (34% vs 4%; P = 0.003).

CONCLUSIONS

STEMI patient perceptions are a key factor in determining EMS use. Health care stakeholders should target the identified barriers to improve utilization of EMS, and develop strategies to optimize care for patients who do not access EMS.

Usage of ambulance transport and influencing factors in acute coronary syndrome: a cross-sectional study at a tertiary centre in China

OBJECTIVES

The aim of this study was to explore the choice of transportation mode to hospital in patients with acute coronary syndrome (ACS) and to determine the factors influencing the use of ambulance.

DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study was conducted in a tertiary and teaching hospital in China. The study was carried out between 24 August 2015 and 24 July 2016. A total of 828 patients with ACS presented at the emergency department (ED) were included. The study population was dichotomised according to their primary mode of transport (ambulance or self-transport) to hospital. Social demographics, cardiovascular history, risk factors, prehospital medications, clinical characteristics and symptom characteristics were collected. Multivariable logistic regression was used to examine the factors associated with ambulance use.

RESULTS

We found that only 179 (21.6%) patients with ACS chose taking ambulance to hospital. Factors associated with ambulance use were single (OR 1.66, 95% CI 1.07 to 2.57), taking Suxiaojiuxin pills (OR 1.91, 1.31 to 2.80) or nitrates (OR 2.91, 1.70 to 4.99) before going to hospital, diagnosed as ST-elevation myocardial infarction (STEMI) (OR 2.43, 1.45 to 4.05), with persistent symptoms (OR 1.95, 1.33 to 2.86) and symptoms accompanied with vomiting (OR 2.35, 1.19 to 4.62). The patients who had symptoms precipitated or aggravated by exercise (OR 0.37, 0.14 to 0.98) tended to choose self-transport.

CONCLUSION

The usage of ambulance in patients with ACS presenting to the ED was low in China. Factors like single, taking Suxiaojiuxin pills or nitrates before going to hospital, diagnosed as STEMI, accompanied with vomiting and persistent symptoms were independently associated with ambulance use. Future education programmes should focus on these factors and increase people's knowledge on ACS and the benefits of ambulance use.

Electrocardiographic indicators of acute coronary syndrome are more common in patients with ambulance transport compared to those who self-transport to the emergency department journal of electrocardiology

INTRODUCTION

The American Heart Association recommends individuals with symptoms suggestive of acute coronary syndrome (ACS) activate the Emergency Medical Services' (EMS) 911 system for ambulance transport to the emergency department (ED), which enables treatment to begin prior to hospital arrival. Despite this recommendation, the majority of patients with symptoms suspicious of ACS continue to self-transport to the ED. The IMMEDIATE AIM study was a prospective study that enrolled individuals who presented to the ED with ischemic symptoms.

OBJECTIVES

The purpose of this secondary analysis was to determine differences in patients presenting the ED for possible ACS who arrive by ambulance versus self-transport on: 1) time-to-initial hospital electrocardiogram (ECG), 2) presence of ischemic ECG changes, and 3) patient characteristics.

METHODS

Initial 12-lead ECGs acquired upon patient arrival to the ED were evaluated for ST-elevation, ST-depression, and T-wave inversion. ECG signs of ischemia were analyzed both individually and collapsed into an independent dichotomous variable (ED ECG ischemia yes/no) for statistical analysis. Patient characteristics tested included: gender, age, race, ethnicity, English speaking, living alone, mode of transport, and presenting symptoms (chest pain, jaw pain, shortness of breath, nausea/vomiting, syncope, and clinical history).

RESULTS

In 1299 patients (mean age 63.9, 46.7% male), 384 (29.6%) patients arrived by ambulance to the ED. The mean time-to-initial ECG was 47minutes for ambulance patients versus 53minutes for self-transport patients (p<0.001). Mode of transport was found to be an independent predictor for time-to-initial ECG controlling for age, gender, and race (p=0.004). There were significantly higher rates of ECG changes of ischemia for patients who arrived by ambulance versus self-transport (p=0.02), and patient characteristics differed by mode of transport to the ED.

DISCUSSION

Our findings indicate that less than 30% of individuals with symptoms of ACS activate the EMS '911' system for ambulance transport to the ED. Individuals more likely to activate 911 have timelier ECG but higher rates of ischemic changes, specifically ST-depression and T-wave inversion. Individuals least likely to activate 911 are women, younger individuals, Latino ethnicity, live with a significant other, and those experiencing chest or jaw pain.

Presenting characteristics and processing times for culturally and linguistically diverse (CALD) patients with chest pain in an emergency department: Time, Ethnicity, and Delay (TED) Study II

BACKGROUND

To date there has been limited published data presenting the characteristics and timeliness of the management in an Emergency Department (ED) for culturally and linguistically diverse (CALD) patients presenting with chest pain. This study aimed to describe the presenting characteristics and processing times for CALD patients with chest pain compared to the Australian-born population, and current guidelines.

METHODS

This study was a cross sectional analysis of a cohort of patients who presented with chest pain to the metropolitan hospital between 1 July 2012 and 30 June 2014.

RESULTS

Of the total study population (n=6640), 1241 (18.7%) were CALD and 5399 (81.3%) were Australian-born. CALD patients were significantly older than Australian-born patients (mean age 62 vs 56years, p<0.001). There were no differences in the proportion of patients who had central chest pain (74.9% vs 75.7%, p=0.526); ambulance utilisation (41.7% vs 41.1%, p=0.697); and time to initial treatment in ED (21 vs 22min, p=0.375). However, CALD patients spent a significantly longer total time in ED (5.4 vs 4.3h, p<0.001). There was no difference in guideline concordance between the two groups with low rates of 12.5% vs 13%, p=0.556. Nonetheless, CALD patients were 22% (95% CI, 0.65, 0.95, p=0.015) less likely to receive the guideline management for chest pain.

CONCLUSIONS

The initial emergency care was equally provided to all patients in the context of a low rate of concordance with three chest pain related standards from the two guidelines. Nonetheless, CALD patients spent a longer time in ED compared to the Australian-born group.

Utilizations and Perceptions of Emergency Medical Services by Patients with ST-Segments Elevation Acute Myocardial Infarction in Abu Dhabi: A Multicenter Study

BACKGROUND

Data on the use of emergency medical services (EMS) by patients with cardiac conditions in the Gulf region are scarce, and prior studies have suggested underutilization. Patient perception and knowledge of EMS care is critical to proper utilization of such services.

OBJECTIVES

To estimate utilization, knowledge, and perceptions of EMS among patients with ST-elevation myocardial infarction (STEMI) in the Emirate of Abu Dhabi.

METHODS

We conducted a multicenter prospective study of consecutive patients admitted with STEMI in four government-operated hospitals in Abu Dhabi. Semi-structured interviews were conducted with patients to assess the rationale for choosing their prehospital mode of transport and their knowledge of EMS services.

RESULTS

Of 587 patients with STEMI (age 51 ± 11 years, male 95%), only 15% presented through EMS, and the remainder came via private transport. Over half of the participants (55%) stated that they did not know the telephone number for EMS. The most common reasons stated for not using EMS were that private transport was quicker (40%) or easier (11%). A small percentage of participants (7%) did not use EMS because they did not think their symptoms were cardiac-related or warranted an EMS call. Stated reasons for not using EMS did not significantly differ by age, gender, or primary language of the patients.

CONCLUSIONS

EMS care for STEMI is grossly underutilized in Abu Dhabi. Patient knowledge and perceptions may contribute to underutilization, and public education efforts are needed to raise their perception and knowledge of EMS.

Physician perceptions and recommendations about pre-hospital emergency medical services for patients with ST-elevation acute myocardial infarction in Abu Dhabi

Introduction

Physician perceptions about emergency medical services (EMS) are important determinants of improving pre-hospital care for cardiac emergencies. No data exist on physician attitudes towards EMS care of patients with ST-Elevation Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi.

Objectives

To describe the perceptions towards EMS among physicians caring for patients with STEMI in Abu Dhabi.

Methods

We surveyed a convenience sample of physicians involved in the care of patients with STEMI (emergency medicine, cardiology, cardiothoracic surgery and intensive care) in four government facilities with 24/7 Primary PCI in the Emirate of Abu Dhabi. Surveys were distributed using dedicated email links, and used 5-point Likert scales to assess perceptions and attitudes to EMS.

Results

Of 106 physician respondents, most were male (82%), practicing in emergency medicine (47%) or cardiology (44%) and the majority (63%) had been in practice for >10 years. Less than half of the responders (42%) were “Somewhat Satisfied” (35%) or “Very Satisfied” (7%) with current EMS level of care for STEMI patients. Most respondents were “Very Likely” (67%) to advise a patient with a cardiac emergency to use EMS, but only 39% felt the same for themselves or their family. Most responders were supportive (i.e. “Strongly Agree”) of the following steps to improve EMS care: 12-lead ECG and telemetry to ED by EMS (69%), EMS triage of STEMI to PCI facilities (65%), and activation of PCI teams by EMS (58%). Only 19% were supportive of pre-hospital fibrinolytics by EMS. There were no significant differences in the responses among the specialties.

Conclusions

Most physicians involved in STEMI care in Abu Dhabi are very likely to advise patients to use EMS for a cardiac emergency, but less likely to do so for themselves or their families. Different specialties had concordant opinions regarding steps to improve pre-hospital EMS care for STEMI.

Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan

Background

The utilization of ambulances in low- and middle-income countries is limited. The aim of this study was to ascertain frequency of ambulance use and characteristics of patients brought into emergency departments (EDs) through ambulance and non-ambulance modes of transportation.

Methods

The Pakistan National Emergency Departments Surveillance (Pak-NEDS) was a pilot active surveillance conducted in seven major tertiary-care EDs in six main cities of Pakistan between November 2010 and March 2011. Univariate and multivariate logistic regression was performed to investigate the factors associated with ambulance use.

Results

Out of 274,436 patients enrolled in Pak-NEDS, the mode of arrival to the ED was documented for 94. 9% (n = 260,378) patients, of which 4.1% (n = 10,546) came to EDs via ambulances. The mean age of patients in the ambulance group was significantly higher compared to the mean age of the non-ambulance group (38 ± 18.4 years versus 32.8 ± 14.9 years, p-value < 0.001). The most common presenting complaint in the ambulance group was head injury (12%) while among non-ambulance users it was fever (12%). Patients of all age groups were less likely to use an ambulance compared to those >45 years of age (p-value < 0.001) adjusted for gender, cities, hospital type, presenting complaint group and disposition. The adjusted odds ratio of utilizing ambulances for those with injuries was 3.5 times higher than those with non-injury complaints (p-value < 0.001). Patients brought to the ED by ambulance were 7.2 times more likely to die in the ED than non-ambulance patients after adjustment for other variables in the model.

Conclusion

Utilization of ambulances is very low in Pakistan. Ambulance use was found to be more among the elderly and those presenting with injuries. Patients presenting via ambulances were more likely to die in the ED.

Emergency medical services transport delays for suspected stroke and myocardial infarction patients

BACKGROUND

Prehospital delays in receiving emergency care for suspected stroke and myocardial infarction (MI) patients have significant impacts on health outcomes. Use of Emergency Medical Services (EMS) has been shown to reduce these delays. However, disparities in EMS transport delays are thought to exist. Therefore the objective of this study was to investigate and identify disparities in EMS transport times for suspected stroke and MI patients.

METHODS

Over 3,900 records of suspected stroke and MI patients, reported during 2006-2009, were obtained from two EMS agencies (EMS 1 & EMS 2) in Tennessee. Summary statistics of transport time intervals were computed. Multivariable logistic models were used to identify predictors of time intervals exceeding EMS guidelines.

RESULTS

Only 66 and 10 % of suspected stroke patients were taken to stroke centers by EMS 1 and 2, respectively. Most (80-83 %) emergency calls had response times within the recommended 10 min. However, over 1/3 of the calls had on-scene times exceeding the recommended 15 min. Predictors of time intervals exceeding EMS guidelines were EMS agency, patient age, season and whether or not patients were taken to a specialty center. The odds of total transport time exceeding EMS guidelines were significantly lower for patients not taken to specialty centers. Noteworthy was the 72 % lower odds of total time exceeding guidelines for stroke patients served by EMS 1 compared to those served by EMS 2. Additionally, for every decade increase in age of the patient, the odds of on-scene time exceeding guidelines increased by 15 and 19 % for stroke and MI patients, respectively.

CONCLUSION

In this study, prehospital delays, as measured by total transport time exceeding guideline was influenced by season, EMS agency responsible, patient age and whether or not the patient is transported to a specialty center. The magnitude of the delays associated with some of the factors are large enough to be clinically important although others, though statistically significant, may not be large enough to be clinically important. These findings should be useful for guiding future studies and local health initiatives that seek to reduce disparities in prehospital delays so as to improve health services and outcomes for stroke and MI patients.

Comparison of outcomes of ambulance users and nonusers in ST elevation myocardial infarction

In a systematic province-wide evaluation of care and outcomes of ST elevation myocardial infarction (STEMI), we sought to examine whether a previously documented association between ambulance use and outcome remains after control for clinical risk factors. All 82 acute care hospitals in Quebec (Canada) that treated at least 30 acute myocardial infarctions annually participated in a 6-month evaluation in 2008 to 2009. Medical record librarians abstracted hospital chart data for consecutive patients with a discharge diagnosis of myocardial infarction who presented with characteristic symptoms and met a priori study criteria for STEMI. Linkage to administrative databases provided outcome data (to 1 year) and co-morbidities. Of 1,956 patients, 1,222 (62.5%) arrived by ambulance. Compared with nonusers of an ambulance, users were older, more often women, and more likely to have co-morbidities, low systolic pressure, abnormal heart rate, and a higher Thrombolysis In Myocardial Infarction risk index at presentation. Ambulance users were less likely to receive fibrinolysis or to be sent for primary angioplasty (78.5% vs 83.2% for nonusers, p = 0.01), although if they did, treatment delays were shorter (p <0.001). The 1-year mortality rate was 18.7% versus 7.1% for nonusers (p <0.001). Greater mortality persisted after adjusting for presenting risk factors, co-morbidities, reperfusion treatment, and symptom duration (hazard ratio 1.56, 95% confidence interval 1.30 to 1.87). In conclusion, ambulance users with STEMI were older and sicker than nonusers. Mortality of users was substantially greater after adjustment for clinical risk factors, although they received faster reperfusion treatment overall.

Factors related to the use of reperfusion strategies in elderly patients with acute myocardial infarction

Background

About eighty percent of acute myocardial infarction (AMI) cases occur in the elderly, we aim to examine the use of reperfusion strategies in elderly patients (≥65 years) with AMI and to investigate the factors affecting the use of these strategies.

Methods

A total of 352 consecutive elderly patients (≥65 years) with ST-elevated AMI (STAMI) were admitted, they were divided into 2 groups based on reperfusion treatment (thrombolysis or percutaneous coronary intervention, PCI): reperfusion therapy group (n = 268) and non-reperfusion therapy group (n = 84). Demographic and medical data were collected for comparison. Odds ratios (OR) and 95% confidence interval (C.I.) were calculated directly from the estimated regression coefficients.

Results

About 76.1% of the elderly patients with AMI received reperfusion treatment (62.5% received PCI, and 13.6% received thrombolysis). Stepwise Logistic regression analysis revealed that a patient age ≥75 years (95% CI: 0.194 ~ 0.590, OR = 0.338, P = 0.000) and medical history of angina (95% CI: 0.281 ~ 0.928, OR = 0.501, P = 0.014) were determining factors for receiving less reperfusion therapy. Complications including right ventricular myocardial infarction (MI) (95% CI: 1.618 ~ 12.907, OR = 4.472, P = 0.003), unbearable symptoms (95% CI: 1.132 ~ 3.928, OR = 1.839, P = 0.021) and medical insurance (95% CI: 1.313 ~ 4.524, OR = 2.429, P = 0.004) were independent predictors of reperfusion therapy. The reperfusion therapy subset analysis revealed that intracranial hemorrhage (2.7% vs. 8.3%, P = 0.000), left ventricular ejection fraction (LVEF) <45% (13.2% vs. 29.2%, P = 0.019) and mortality rate within 1 year (2.7% vs. 6.3%, P = 0.045) were significantly decreased in the PCI group as compared with thrombolysis.

Conclusion

Elderly patients with a medical history of angina, right ventricular MI, unbearable symptoms and medical insurance are likely be recipients of reperfusion strategies.

Use of emergency medical services expedites in-hospital care processes in patients presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

To determine whether door-to-balloon (DTB) times of patients presenting with ST-elevation myocardial infarction (STEMI) were reduced in patients transported by emergency medical services (EMS) compared to those who were self-transported. DTB time is an important measure of hospital care processes in STEMI. Use of EMS may expedite in-hospital processing and reduce DTB times. A total of 309 consecutive STEMI patients who underwent primary percutaneous coronary intervention in our institution were analyzed. Excluded were patients who received fibrinolytics, presented in cardiac arrest, were intubated, or were transferred from another hospital. EMS-transported patients (n=83) were compared to self-transported patients (n=226). The primary outcome measure was DTB time and its component time intervals. Secondary end points included symptom-to-door and symptom-to-balloon times, and correlates for DTB >90 minutes. A higher percentage of EMS-transported patients reached the time goal of DTB <90 minutes compared to self-transported patients (83.1 versus 54.3%; p<0.001). EMS-transported patients had shorter DTB times [median (IQR) minutes, 65 (50-86) versus 85 (61-126); p<0.001] due to a reduction of emergency department processing (door-to-call) time, whereas catheterization laboratory processing (call-to-balloon) times were similar in both groups. EMS-transported patients had shorter symptom-to-door [median (IQR) hours, 1.2 (0.8-3.5) versus 2.3 (1.2-7.5); p<0.001] and symptom-to-balloon [median (IQR) hours, 2.5 (1.9-4.7) versus 4.3 (2.6-9.1); p<0.001]. Independent correlates of DTB times >90 minutes were self-transport (odds ratio 5.32, 95% CI 2.65-10.70; p<0.001) and off-hours presentation (odds ratio 2.89, 95% CI 1.60-5.22; p<0.001). Use of EMS transport in STEMI patients significantly shortens time to reperfusion, primarily by expediting emergency department processes. Community education efforts should focus not only on the importance of recognizing symptoms of myocardial infarction, but also taking early action by calling the EMS.

Self-referral to chest pain units: results of the German CPU-registry

BACKGROUND

Chest pain units (CPUs) are increasingly established in emergency cardiology services. With improved visibility of CPUs in the population, patients may refer themselves directly to these units, obviating emergency medical services (EMS). Little is known about characteristics and outcomes of self-referred patients, as compared with those referred by EMS. Therefore, we described self-referral patients enrolled in the CPU-registry of the German Cardiac Society and compared them with those referred by EMS.

METHODS AND RESULTS

From 2008 until 2010, the prospective CPU-registry enrolled 11,581 consecutive patients. Of those 3789 (32.7%) were self-referrals (SRs), while 7792 (67.3%) were referred by EMS. SR-patients were significantly younger (63.6 vs. 70.1 years), had less prior myocardial infarction or coronary artery bypass surgery, but more previous percutaneous coronary interventions (PCIs). Acute coronary syndromes were diagnosed less frequently in the SR-patients (30.3 vs. 46.9%; p<0.0001). SR-patients showed ST-segment changes in their initial ECG in 19.6% of cases. EMS-patients underwent more coronary angiographies (60.0 vs. 47.5%; p<0.0001), while SR-patients underwent more stress tests (11.3 vs. 7.8%; p<0.001). PCI was performed in 32.6% of the EMS- and in 24.0% of the SR-group (p<0.0001).

CONCLUSION

These data demonstrate that patients who contact a CPU as a self-referral are younger, less severely ill and have more non-coronary problems than those calling an emergency medical service. Nevertheless, 30% of self-referral patients had an acute coronary syndrome.

Relationship between time from ambulance call to arrival at emergency center and level of consciousness at admission in severe stroke patients

INTRODUCTION

Timely access to acute medical treatment can be critical for patients suffering from severe stroke. Little information is available about the impact of prehospital delays on the clinical conditions of stroke patients, but it is possible that prehospital delays lead to neurological deterioration. The aim of this study was to examine the impact of prehospital delays related to emergency medical services on the level of consciousness at admission in patients with severe stroke.

METHODS

This retrospective study assessed 712 consecutive patients diagnosed with cerebrovascular diseases who were admitted to an intensive care unit in Tokyo, Japan, from April 1998 through March 2008. Data, including the time from the call to the ambulance service to the arrival of the ambulance at the patient location (on-scene), and the time from the arrival of the ambulance on-scene to its arrival at the emergency center were obtained. The following demographic and clinical information also were obtained from medical records: sex, age, and Glasgow Coma Scale (GCS) score at admission.

RESULTS

The mean time from ambulance call to arrival on-scene was 7 (SD=3) minutes, and the mean time from ambulance call to arrival at the center was 37 (SD=8) minutes. A logistic regression model for predicting GCS scores of 3 and 4 at admission was produced. After adjusting for sex, age, and time from arrival on-scene to arrival at the center, a longer call-to-on-scene time was significantly associated with poor GCS scores (OR = 1.056/min; 95% confidence interval, [CI] = 1.008-1.107). After adjusting for sex and age, a longer call-to-arrival at the center time also was significantly associated with poor GCS scores (OR = 1.020; 95% CI = 1.002-1.038).

CONCLUSIONS

Prehospital delays were significantly associated with decreased levels of consciousness at admission in patients suffering from a stroke. As level of consciousness is the strongest predictor of outcome, reducing prehospital delays may be necessary to improve the outcomes in patients with severe stroke.

Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines

BACKGROUND

Activation of emergency medical services (EMS) is critical for the early triage and treatment of patients experiencing ST-segment-elevation myocardial infarction, yet data regarding EMS use and its association with subsequent clinical care are limited.

METHODS AND RESULTS

We performed an observational analysis of 37 634 ST-segment-elevation myocardial infarction patients treated at 372 US hospitals participating in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines between January 2007 and September 2009, and examined independent patient factors associated with EMS transportation versus patient self-transportation. We found that EMS transport was used in only 60% of ST-segment-elevation myocardial infarction patients. Older patients, those living farther from the hospital, and those with hemodynamic compromise were more likely to use EMS transport. In contrast, race, income, and education level did not appear to be associated with the mode of transport. Compared with self-transported patients, EMS-transported patients had significantly shorter delays in both symptom-onset-to-arrival time (median, 89 versus 120 minutes; P<0.0001) and door-to-reperfusion time (median door-to-balloon time, 63 versus 76 minutes; P<0.0001; median door-to-needle time, 23 versus 29 minutes; P<0.0001).

CONCLUSIONS

Emergency medical services transportation to the hospital is underused among contemporary ST-segment-elevation myocardial infarction patients. Nevertheless, use of EMS transportation is associated with substantial reductions in ischemic time and treatment delays. Community education efforts are needed to improve the use of emergency transport as part of system-wide strategies to improve ST-segment-elevation myocardial infarction reperfusion care.

Delays in presentation with acute coronary syndrome in people with coronary artery disease in Australia and New Zealand

OBJECTIVES

To report time from the onset of symptoms to hospital presentation in Australian and New Zealand patients with subsequently confirmed acute coronary syndrome, and to identify factors associated with prehospital delay time in these patients.

METHODS

Patients with coronary artery disease enrolled in a randomized clinical trial testing an intervention to reduce delay in responding to acute coronary syndrome symptoms had been followed for 24 months. In cases of admission to the ED for possible acute coronary syndrome, medical records were reviewed to determine the diagnosis, prehospital delay time, mode of transport to the hospital and aspirin use before admission. Clinical and demographic data were taken from the trial database.

RESULTS

Patients (n= 140) had an average (SD) age of 67.3 (11.5) years; 36% were female. Two-thirds of patients went to hospital by ambulance and 89.3% had a final diagnosis of unstable angina. The median time from onset of symptoms to arrival at the ED was 2 h and 25 min (interquartile range 1:25-4:59); 12.1% arrived ≤ 1 h and 66% within 4 h. Multiple linear regression analysis showed that use of ambulance (Beta = 0.247, P= 0.012) and younger age (Beta = 0.198, P= 0.043) were independent predictors of shorter delay times.

CONCLUSION

The time from the onset of symptoms to hospital presentation was too long for maximal benefit from treatment in most patients. Further efforts are needed to reduce treatment-seeking delay in response to symptoms of acute coronary syndrome.

An organized system of emergency care for patients with myocardial infarction: a reality?

An organized system of emergency care is an essential requirement for the modern treatment of ST-elevation acute myocardial infarction. There is a strong need to deliver reperfusion therapy as soon as possible, with primary percutaneous coronary intervention being the preferred option if performed in a timely manner and thrombolytic therapy, particularly in the prehospital setting, being a good alternative if the primary percutaneous coronary intervention-related delay exceeds the equipoise. In this situation, emergency medical services have a primary role in rescuing patients from cardiac arrest, performing prehospital diagnosis, triage and treatment and safely transporting them to the most appropriate cardiological center, including interhospital transfer. A complete reorganization of the healthcare systems in different countries is frequently needed to build an ST-elevation acute myocardial infarction system of care, focusing on fast transport, use of telemedicine and diversion protocols to skip the unsuited centers.

Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf States

BACKGROUND

Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States.

OBJECTIVE

To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE).

METHODS

Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other).

RESULTS

Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03-1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48-2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34-1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02-1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09-1.51), and current smoking (OR 1.30; 95% CI 1.13-1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30 min of arrival at the ED.

CONCLUSION

Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.

Time to treatment for acute coronary syndromes: the cost of indecision

BACKGROUND AND RESEARCH OBJECTIVES

: Multiple sociodemographic and environmental factors have been associated with urgent treatment-seeking behaviors for patients experiencing acute coronary syndromes (ACSs). However, variables that directly affect the decision to seek care in the emergency department (ED) have been less well defined. The objective of this study was to explore the factors associated with a decision to seek care for symptoms of ACSs and to describe patient characteristics associated with time to presentation.

SUBJECTS AND METHODS

: A cross-sectional, descriptive design was used. The nonprobability sample included 256 patients admitted to the hospital with ACSs. The study was conducted on cardiac step-down units at 2 large urban medical centers. Reasons for seeking care were elicited during structured interviews in the patient's room. These factors and other patient characteristics were treated as predictor variables in an analysis of time from symptom onset to arrival in the ED.

RESULTS AND CONCLUSIONS

: Five categories of decision making were identified through descriptive content analyses and were labeled new onset of chest pain, ongoing evaluation of symptom severity, symptoms other than chest pain that worsened or were unrelieved, externally motivated, and internally motivated. Median time from symptom onset to arrival in the ED was 9.5 hours for women and 6 hours for men. Patients who experienced constant pain (hazard ratio, 1.44; P =.01) and those with ST-segment elevation myocardial infarction (hazard ratio, 1.59; P = .004) sought treatment significantly sooner than patients with intermittent pain. Older patients sought treatment later (hazard ratio, 0.99; P = .02). Patients who are older and experience intermittent pain should be encouraged to seek emergent treatment for symptoms that may represent ACSs. New evidence of patients' decision-making processes and dangerous delay in time to treatment provides knowledge needed to counsel patients about the benefits of seeking care quickly when symptoms begin.

Mode of arrival does not predict myocardial infarction in patients who present to the ED with chest pain

Aims

This study aims to determine if patients who arrive by ambulance with a chief complaint of chest pain have a higher risk of myocardial infarction (MI) than those who arrive via alternate transportation.

Methods

All patients ages 18–99 who presented to an urban academic ED between January 2006 and July 2006 with a chief complaint that included “chest pain” were eligible for retrospective analysis. Patients who were transferred or who left without being seen or against medical advice were excluded. Myocardial infarction was defined as patients who were admitted and who had elevated troponin I or went urgently to catheterization laboratory and had >90% occlusion of a vessel, with a final clinical impression of MI.

Results

There were 690 visits for chest pain during the study period, representing 4% of total ED census. A total of 39 visits met exclusion criteria, and 37 patients had 52 repeat visits, leaving 599 unique patients included for analysis. Mean age was 48.8 ± 1.4 years (SD 17.7), 44.6% were female, and 35 patients (5.8%) were diagnosed with MI. In all, 157 patients (26.2%) arrived via EMS. Patients who arrived by ambulance did not have a significant difference in rate of MI when compared with alternate transportation [7.0% vs. 5.4%, OR (95% CI) = 1.3 (0.6–2.7), p = 0.469]. Only 31.4% (11/35) of patients who ultimately were diagnosed with MI arrived by ambulance.

Conclusion

We were unable to show a significant difference in rate of MI between patients who arrived via ambulance or private transportation. Equal consideration and urgency should be given to both types of patients when they arrive at the ED.

Elapsed time in emergency medical services for patients with cardiac complaints: are some patients at greater risk for delay?

BACKGROUND

In patients with a major cardiac event, the first priority is to minimize time to treatment. For many patients, first contact with the health system is through emergency medical services (EMS). We set out to identify patient-level and neighborhood-level factors that were associated with elapsed time in EMS.

METHODS AND RESULTS

A retrospective cohort study was conducted in 10 municipalities in Dallas County, Tex, from January 1 through December 31, 2004. The data set included 5887 patients with suspected cardiac-related symptoms. The region was served by 29 hospitals and 98 EMS depots. Multivariate models included measures of distance traveled, time of day, day of week, and patient and neighborhood characteristics. The main outcomes were elapsed time in EMS (continuous; in minutes) and delay in EMS (dichotomous; >15 minutes beyond median elapsed time). We found positive associations between patient characteristics and both average elapsed time and delay in EMS care. Variation in average elapsed time was not large enough to be clinically meaningful. However, approximately 11% (n=647) of patients were delayed >or=15 minutes. Women were more likely to be delayed (adjusted odds ratio, 1.52; 95% confidence interval, 1.32 to 1.74), and this association did not change after adjusting for other characteristics, including neighborhood socioeconomic composition.

CONCLUSIONS

Compared with otherwise similar men, women have 50% greater odds of being delayed in the EMS setting. The determinants of delay should be a special focus of EMS studies in which time to treatment is a priority.

Factors that influence the use of ambulance in acute coronary syndrome

BACKGROUND

National guidelines recommend activation of the emergency medical service by patients who have symptoms of acute coronary syndrome (ACS). In spite of this, only 50% to 60% of persons with myocardial infarction initiate care by using the emergency medical service. The aim of this study was to define factors influencing the use of ambulance in ACS.

METHODS

The method used in this study was a national survey comprising intensive cardiac care units at 11 hospitals in Sweden; 1,939 patients with diagnosed ACS and symptom onset outside the hospital completed a questionnaire a few days after admission.

RESULTS

Half of the patients went to the hospital by ambulance. Factors associated with ambulance use were knowledge of the importance of quickly seeking medical care and calling for an ambulance when having chest pain (odds ratio [OR] 3.61, 95% CI 2.43-5.45), abrupt onset of pain reaching maximum intensity within minutes (OR 2.08, 1.62-2.69), nausea or cold sweat (OR 2.02, 1.54-2.65), vertigo or near syncope (OR 1.63, 1.21-2.20), ST-elevation ACS (OR 1.58, 1.21-2.06), increasing age (per year) (OR 1.03, 1.02-1.04), previous history of heart failure (OR 2.48, 1.47-4.26), and distance to the hospital of >5 km (OR 2.0, 1.55-2.59). Those who did not call for an ambulance thought self-transport would be faster or did not believe they were sick enough.

CONCLUSIONS

Symptoms, patient characteristics, ACS characteristics, and perceptions and knowledge were all associated with ambulance use in ACS. The fact that knowledge increases ambulance use and the need for behavioral change pose a challenge for health-care professionals.

Prehospital transport of patients with acute myocardial infarction: a community-wide perspective

OBJECTIVE

The objectives of this population-based study were to examine the use of emergency medical services (EMS) in greater Worcester, Massachusetts, residents (2000 census = 478,000) hospitalized with acute myocardial infarction (AMI) at all metropolitan Worcester medical centers in four biennial periods between 1997 and 2003. A secondary study aim was to describe the demographic and clinical characteristics of patients with AMI transported to metropolitan Worcester hospitals by EMS, compared with those transported by other means, and their hospital outcomes.

METHODS

We reviewed the medical records of 3805 patients hospitalized for confirmed AMI at 11 greater Worcester medical centers during 1997, 1999, 2001, and 2003. Information about the use of EMS, patient characteristics, and hospital outcomes was obtained through the review of hospital charts.

RESULTS

A total of 2693 greater Worcester residents with AMI (70.8%) were transported to area hospitals by ambulance. Patients transported by ambulance were older, were more likely to be women, had a greater prevalence of comorbidities, and had a different symptom profile than patients transported by other means. Patients arriving at greater Worcester hospitals by ambulance were more likely to develop serious clinical complications, including heart failure and cardiogenic shock, and die during hospitalization compared with patients not transported by EMS.

CONCLUSIONS

Our results suggest that the majority of greater Worcester residents seeking care for AMI are transported by EMS. Patients transported by ambulance differ from patients transported by other means and are more likely to experience adverse hospital outcomes. The reasons why patients use EMS in the setting of AMI need to be further explored and patients' care-seeking behavior enhanced.

Symptoms Across the Continuum of Acute Coronary Syndromes: Differences Between Women and Men

Background The urgency and level of care provided for acute coronary syndromes partially depends on the symptoms manifested.

Objectives To detect differences between women and men in the type, severity, location, and quality of symptoms across the 3 clinical diagnostic categories of acute coronary syndromes (unstable angina, myocardial infarction without ST-segment elevation, and myocardial infarction with ST-segment elevation) while controlling for age, diabetes, functional status, anxiety, and depression.

Methods A convenience sample of 112 women and 144 men admitted through the emergency department and hospitalized for acute coronary syndromes participated. Recruitment took place at 2 urban teaching hospitals in the Midwest. Data were collected during structured interviews in each patient’s hospital room. Forty-eight symptom descriptors were assessed. Demographic characteristics, health history, functional status, anxiety, and depression levels also were measured.

Results Regardless of clinical diagnostic category, women reported significantly more indigestion (β = 0.25; confidence interval [CI] = 0.01–0.49), palpitations (β = 0.31; CI = 0.06–0.56), nausea (β = 0.37; CI = 0.10–0.65), numbness in the hands (β = 0.29; CI = 0.02–0.57), and unusual fatigue (β = 0.60; CI = 0.27–0.93) than men reported. Differences between men and women in dizziness, weakness, and new-onset cough did differ by diagnosis. Reports of chest pain did not differ between men and women.

Conclusions Women with acute coronary syndromes reported a higher intensity of 5 symptoms (but not chest pain) than men reported. Whether differences between the sexes in less typical symptoms are clinically significant remains unclear.