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Yiadom MYAB, Gong W, Patterson BW, Baugh CW, Mills AM, Gavin N, Podolsky SR, Mumma BE, Tanski M, Salazar G, Azzo C, Dorner SC, Hadley K, Bloos SM, Bunney G, Vogus TJ, Liu D. Influence of time-to-diagnosis on time-to-percutaneous coronary intervention for emergency department ST-elevation myocardial infarction patients: Time-to-electrocardiogram matters. J Am Coll Emerg Physicians Open 2024; 5:e13174. [PMID: 38726468 PMCID: PMC11079543 DOI: 10.1002/emp2.13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 02/28/2024] [Accepted: 03/15/2024] [Indexed: 05/12/2024] Open
Abstract
Objectives Earlier electrocardiogram (ECG) acquisition for ST-elevation myocardial infarction (STEMI) is associated with earlier percutaneous coronary intervention (PCI) and better patient outcomes. However, the exact relationship between timely ECG and timely PCI is unclear. Methods We quantified the influence of door-to-ECG (D2E) time on ECG-to-PCI balloon (E2B) intervention in this three-year retrospective cohort study, including patients from 10 geographically diverse emergency departments (EDs) co-located with a PCI center. The study included 576 STEMI patients excluding those with a screening ECG before ED arrival or non-diagnostic initial ED ECG. We used a linear mixed-effects model to evaluate D2E's influence on E2B with piecewise linear terms for D2E times associated with time intervals designated as ED intake (0-10 min), triage (11-30 min), and main ED (>30 min). We adjusted for demographic and visit characteristics, past medical history, and included ED location as a random effect. Results The median E2B interval was longer (76 vs 68 min, p < 0.001) in patients with D2E >10 min than in those with timely D2E. The proportion of patients identified at the intake, triage, and main ED intervals was 65.8%, 24.9%, and 9.7%, respectively. The D2E and E2B association was statistically significant in the triage phase, where a 1-minute change in D2E was associated with a 1.24-minute change in E2B (95% confidence interval [CI]: 0.44-2.05, p = 0.003). Conclusion Reducing D2E is associated with a shorter E2B. Targeting D2E reduction in patients currently diagnosed during triage (11-30 min) may be the greatest opportunity to improve D2B and could enable 24.9% more ED STEMI patients to achieve timely D2E.
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Affiliation(s)
| | - Wu Gong
- Department of Biostatistics, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Brian W. Patterson
- Department of Emergency MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Christopher W. Baugh
- Department of Emergency MedicineBrigham and Women's Hospital–Harvard UniversityBostonMassachusettsUSA
| | - Angela M. Mills
- Department of Emergency MedicineColumbia University College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Nicholas Gavin
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Seth R. Podolsky
- Legacy HealthPortlandOregonUSA
- Oregon Health & Science UniversityCollege of MedicinePortlandOregonUSA
- Elson S. Floyd College of MedicineWashington State UniversitySpokaneWashingtonUSA
| | - Bryn E. Mumma
- Department of Emergency MedicineUniversity of California–DavisDavisCaliforniaUSA
| | - Mary Tanski
- Department of Emergency MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Gilberto Salazar
- Department of Emergency MedicineUniversity of Texas SouthwesternDallasTexasUSA
| | - Caitlin Azzo
- Department of Emergency MedicineMassachusetts General Hospital, Harvard School of MedicineBostonMassachusettsUSA
| | - Stephen C. Dorner
- Department of Emergency MedicineMassachusetts General Hospital, Harvard School of MedicineBostonMassachusettsUSA
| | - Kelsea Hadley
- School of MedicineAmerican University of AntiguaOsbournAntigua and Barbuda
| | - Sean M. Bloos
- Department of Emergency MedicineStanford UniversityStanfordCaliforniaUSA
- Tulane University, School of MedicineNew OrleansLouisianaUSA
| | - Gabrielle Bunney
- Department of Emergency MedicineStanford UniversityStanfordCaliforniaUSA
| | - Timothy J. Vogus
- Owen Graduate School of ManagementVanderbilt UniversityNashvilleTennesseeUSA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical CenterNashvilleTennesseeUSA
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Bunney G, Bloos SM, Graber-Naidich A, Pasao MA, Kabeer R, Kim D, Miller K, Yiadom MYAB. Maximizing Equity in Acute Coronary Syndrome Screening across Sociodemographic Characteristics of Patients. Diagnostics (Basel) 2023; 13:2053. [PMID: 37370948 DOI: 10.3390/diagnostics13122053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/22/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
We compared four methods to screen emergency department (ED) patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI) in a 5-year retrospective cohort through observed practice, objective application of screening protocol criteria, a predictive model, and a model augmenting human practice. We measured screening performance by sensitivity, missed acute coronary syndrome (ACS) and STEMI, and the number of ECGs required. Our cohort of 279,132 ED visits included 1397 patients who had a diagnosis of ACS. We found that screening by observed practice augmented with the model delivered the highest sensitivity for detecting ACS (92.9%, 95%CI: 91.4-94.2%) and showed little variation across sex, race, ethnicity, language, and age, demonstrating equity. Although it missed a few cases of ACS (7.6%) and STEMI (4.4%), it did require ECGs on an additional 11.1% of patients compared to current practice. Screening by protocol performed the worst, underdiagnosing young, Black, Native American, Alaskan or Hawaiian/Pacific Islander, and Hispanic patients. Thus, adding a predictive model to augment human practice improved the detection of ACS and STEMI and did so most equitably across the groups. Hence, combining human and model screening--rather than relying on either alone--may maximize ACS screening performance and equity.
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Affiliation(s)
- Gabrielle Bunney
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Sean M Bloos
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
- Tulane University School of Medicine, New Orleans, LA 70112, USA
| | | | - Melissa A Pasao
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Rana Kabeer
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - David Kim
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Kate Miller
- Quantitative Sciences Unit, Stanford University, Palo Alto, CA 94304, USA
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3
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McLaren JTT, Chartier LB. In Reply to Berger and Yiadom. J Emerg Med 2022; 63:134-135. [PMID: 35940979 DOI: 10.1016/j.jemermed.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/07/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Jesse T T McLaren
- Emergency Department, University Health Network, Toronto, Ontario, Canada.
| | - Lucas B Chartier
- Emergency Department, University Health Network, Toronto, Ontario, Canada
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4
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Yiadom MYAB, Gong W, Patterson BW, Baugh CW, Mills AM, Gavin N, Podolsky SR, Salazar G, Mumma BE, Tanski M, Hadley K, Azzo C, Dorner SC, Ulintz A, Liu D. Fallacy of Median Door‐to‐ECG Time: Hidden Opportunities for STEMI Screening Improvement. J Am Heart Assoc 2022; 11:e024067. [PMID: 35492001 PMCID: PMC9238601 DOI: 10.1161/jaha.121.024067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background ST‐segment elevation myocardial infarction (STEMI) guidelines recommend screening arriving emergency department (ED) patients for an early ECG in those with symptoms concerning for myocardial ischemia. Process measures target median door‐to‐ECG (D2E) time of 10 minutes. Methods and Results This 3‐year descriptive retrospective cohort study, including 676 ED‐diagnosed patients with STEMI from 10 geographically diverse facilities across the United States, examines an alternative approach to quantifying performance: proportion of patients meeting the goal of D2E≤10 minutes. We also identified characteristics associated with D2E>10 minutes and estimated the proportion of patients with screening ECG occurring during intake, triage, and main ED care periods. We found overall median D2E was 7 minutes (IQR:4–16; range: 0–1407 minutes; range of ED medians: 5–11 minutes). Proportion of patients with D2E>10 minutes was 37.9% (ED range: 21.5%–57.1%). Patients with D2E>10 minutes, compared to those with D2E≤10 minutes, were more likely female (32.8% versus 22.6%, P=0.005), Black (23.4% versus 12.4%, P=0.005), non‐English speaking (24.6% versus 19.5%, P=0.032), diabetic (40.2% versus 30.2%, P=0.010), and less frequently reported chest pain (63.3% versus 87.4%, P<0.001). ECGs were performed during ED intake in 62.1% of visits, ED triage in 25.3%, and main ED care in 12.6%. Conclusions Examining D2E>10 minutes can identify opportunities to improve care for more ED patients with STEMI. Our findings suggest sex, race, language, and diabetes are associated with STEMI diagnostic delays. Moving the acquisition of ECGs completed during triage to intake could achieve the D2E≤10 minutes goal for 87.4% of ED patients with STEMI. Sophisticated screening, accounting for differential risk and diversity in STEMI presentations, may further improve timely detection.
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Affiliation(s)
| | - Wu Gong
- Department of Biostatistics Vanderbilt University Medical Center Nashville TN
| | - Brian W. Patterson
- Department of Emergency Medicine University of Wisconsin School of Medicine and Public Health Madison WI
| | - Christopher W. Baugh
- Department of Emergency Medicine Brigham and Women’s Hospital, Harvard Medical School Boston MA
| | - Angela M. Mills
- Department of Emergency Medicine Columbia University College of Physicians and Surgeons New York NY
| | - Nicholas Gavin
- Department of Emergency Medicine Columbia University College of Physicians and Surgeons New York NY
| | - Seth R. Podolsky
- Legacy Health Portland OR
- Elson S. Floyd College of Medicine at Washington State University Spokane WA
| | - Gilberto Salazar
- Department of Emergency Medicine Parkland HospitalUniversity of Texas Southwestern Medical Center Dallas TX
| | - Bryn E. Mumma
- Department of Emergency Medicine University of CaliforniaDavis, School of Medicine Sacramento CA
| | - Mary Tanski
- Department of Emergency Medicine Oregon Health & Sciences University Portland OR
| | - Kelsea Hadley
- School of Medicine American University of the Caribbean Cupecoy Sint Maarten
| | - Caitlin Azzo
- Department of Emergency Medicine University of Pennsylvania Philadelphia PA
| | - Stephen C. Dorner
- Department of Emergency Medicine Massachusetts General HospitalHarvard Medical School Boston MA
| | - Alexander Ulintz
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN
| | - Dandan Liu
- Department of Biostatistics Vanderbilt University Medical Center Nashville TN
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5
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Berger DA, Yiadom MYAB. ECG to Activation: Not an Appropriate Physician Metric, but a Worthy Process Metric. J Emerg Med 2022; 62:129-130. [PMID: 35090729 DOI: 10.1016/j.jemermed.2021.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/05/2021] [Indexed: 12/28/2022]
Affiliation(s)
- David A Berger
- Department of Emergency Medicine, Beaumont Health, Royal Oak, Michigan.
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6
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Bloos SM, Kaur K, Lang K, Gavin N, Mills AM, Baugh CW, Patterson BW, Podolsky SR, Salazar G, Mumma BE, Tanski M, Hadley K, Roumie C, McNaughton CD, Yiadom MYAB. Comparing the Timeliness of Treatment in Younger vs. Older Patients with ST-Segment Elevation Myocardial Infarction: A Multi-Center Cohort Study. J Emerg Med 2021; 60:716-728. [PMID: 33676790 DOI: 10.1016/j.jemermed.2021.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/06/2021] [Accepted: 01/23/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND ST-segment elevation myocardial infarction (STEMI) predominantly affects older adults. Lower incidence among younger patients may challenge diagnosis. OBJECTIVES We hypothesize that among patients ≤ 50 years old, emergent percutaneous coronary intervention (PCI) for STEMI is delayed when compared with patients aged > 50 years. METHODS This 3-year, 10-center retrospective cohort study included emergency department (ED) STEMI patients ≥ 18 years of age treated with emergent PCI. We excluded patients with an electrocardiogram (ECG) completed prior to ED arrival or a nondiagnostic initial ECG. Our primary outcome was door-to-balloon (D2B) time. We compared characteristics and outcomes among younger vs. older STEMI patients, and among age subgroups. RESULTS There were 576 ED STEMI PCI patients, of whom 100 were ≤ 50 years old and 476 were > 50 years old. Median age was 44 years in the younger cohort (interquartile range [IQR] 41-47) vs. 62 years (IQR 57-70) among older patients. Median D2B time for the younger cohort was 76.5 min (IQR 67.5-102.5) vs. 81.0 min (IQR 65.0-105.5) in the older cohort (p = 0.91). This outcome did not change when ages 40 or 45 years were used to demarcate younger vs. older. The younger cohort had a higher prevalence of nonwhite races (38% vs. 21%; p < 0.001) and those currently smoking (36% vs. 23%; p = 0.005). The very young (≤30 years; 6/576) and very old (>80 years; 45/576) had 5.51 and 2.2 greater odds of delays. CONCLUSION We found no statistically significant difference in D2B times between patients ≤ 50 years old and those > 50 years old. Nonwhite patients and those who smoke were disproportionately represented within the younger population. The very young and very old had higher odds of D2B times > 90 min.
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Affiliation(s)
- Sean M Bloos
- Master of Public Health Program, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Karampreet Kaur
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kendrick Lang
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Nicholas Gavin
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Angela M Mills
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Christopher W Baugh
- Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian W Patterson
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Seth R Podolsky
- Emergency Services Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gilberto Salazar
- Department of Emergency Medicine, University of Texas Southwestern, Parkland Hospital, Dallas, Texas
| | - Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis, Sacramento, California
| | - Mary Tanski
- Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Kelsea Hadley
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christianne Roumie
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee; Veterans Health Administration, Tennessee Valley Healthcare System, Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee
| | - Candace D McNaughton
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Veterans Health Administration, Tennessee Valley Healthcare System, Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee
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7
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Yiadom MYAB, Olubowale OO, Jenkins CA, Miller KF, West JL, Vogus TJ, Lehmann CU, Antonello VD, Bernard GR, Storrow AB, Lindsell CJ, Liu D. Understanding timely STEMI treatment performance: A 3-year retrospective cohort study using diagnosis-to-balloon-time and care subintervals. J Am Coll Emerg Physicians Open 2021; 2:e12379. [PMID: 33644777 PMCID: PMC7890036 DOI: 10.1002/emp2.12379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE From the perspective of percutaneous coronary intervention (PCI) centers, locations of ST-segment elevation myocardial infarction (STEMI) diagnosis can include a referring facility, emergency medical services (EMS) transporting to a PCI center, or the PCI center's emergency department (ED). This challenges the use of door-to-balloon-time as the primary evaluative measure of STEMI treatment pathways. Our objective was to identify opportunities to improve care by quantifying differences in the timeliness of STEMI treatment mobilization based on the location of the diagnostic ECG. METHODS This 3-year, single-center, retrospective cohort study classified patients by diagnostic ECG location: referring facility, EMS, or PCI center ED. We quantified door-to-balloon-time and diagnosis-to-balloon-time with its care subintervals. RESULTS Of 207 ED STEMI patients, 180 (87%) received PCI. Median diagnosis-to-balloon-times were shortest among the ED-diagnosed (78 minutes [interquartile range (IQR), 61-92]), followed by EMS-identified patients (89 minutes [IQR, 78-122]), and longest among those referred (140 minutes [IQR, 119-160]), reflecting time for transport to the PCI center. Conversely, referred patients had the shortest median door-to-balloon-times (38 minutes [IQR, 34-43]), followed by the EMS-identified (64 minutes [IQR, 47-77]), whereas ED-diagnosed patients had the longest (89 minutes [IQR, 70-114]), reflecting diagnosis and catheterization lab activation frequently occurring before PCI center ED arrival for referred and EMS-identified patients. CONCLUSIONS Diagnosis-to-balloon-time and its care subintervals are complementary to the traditional door-to-balloon-times as measures of the STEMI treatment process. Together, they highlight opportunities to improve timely identification among ED-diagnosed patients, use of out-of-hospital cath lab activation for EMS-identified patients, and encourage pathways for referred patients to bypass PCI center EDs.
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Affiliation(s)
- Maame Yaa A. B. Yiadom
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Olayemi O. Olubowale
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Cathy A. Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Karen F. Miller
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Jennifer L. West
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Timothy J. Vogus
- Owen Graduate School of ManagementVanderbilt UniversityNashvilleTennesseeUSA
| | - Christoph U. Lehmann
- Department of Biomedical Informatics & PediatricsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Victoria D. Antonello
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Gordon R. Bernard
- Department of Medicine, Division of Critical CareVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Alan B. Storrow
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | | | - Dandan Liu
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
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Choi SJ, Johnson ME, Lehmann CU. Data breach remediation efforts and their implications for hospital quality. Health Serv Res 2019; 54:971-980. [PMID: 31506956 PMCID: PMC6736905 DOI: 10.1111/1475-6773.13203] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To estimate the relationship between breach remediation efforts and hospital care quality. DATA SOURCES Department of Health and Human Services' (HHS) public database on hospital data breaches and Medicare Compare's public data on hospital quality measures for 2012-2016. MATERIALS AND METHODS Data breach data were merged with the Medicare Compare data for years 2012-2016, yielding a panel of 3025 hospitals with 14 297 unique hospital-year observations. STUDY DESIGN The relationship between breach remediation and hospital quality was estimated using a difference-in-differences regression. Hospital quality was measured by 30-day acute myocardial infarction mortality rate and time from door to electrocardiogram. PRINCIPAL FINDINGS Hospital time-to-electrocardiogram increased as much as 2.7 minutes and 30-day acute myocardial infarction mortality increased as much as 0.36 percentage points during the 3-year window following a breach. CONCLUSION Breach remediation efforts were associated with deterioration in timeliness of care and patient outcomes. Thus, breached hospitals and HHS oversight should carefully evaluate remedial security initiatives to achieve better data security without negatively affecting patient outcomes.
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Affiliation(s)
- Sung J. Choi
- Department of Health Management and InformaticsUniversity of Central FloridaOrlandoFlorida
| | - M. Eric Johnson
- Owen Graduate School of ManagementVanderbilt UniversityNashvilleTennessee
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