The influence of race and gender on time to initial electrocardiogram for patients with chest pain

Race, racism, and antiracism in emergency medicine: A scoping review of the literature and research agenda for the future

OBJECTIVES

The objective was to conduct a scoping review of the literature and develop consensus-derived research priorities for future research inquiry in an effort to (1) identify and summarize existing research related to race, racism, and antiracism in emergency medicine (EM) and adjacent fields and (2) set the agenda for EM research in these topic areas.

METHODS

A scoping review of the literature using PubMed and EMBASE databases, as well as review of citations from included articles, formed the basis for discussions with community stakeholders, who in turn helped to inform and shape the discussion and recommendations of participants in the Society for Academic Emergency Medicine (SAEM) consensus conference. Through electronic surveys and two virtual meetings held in April 2021, consensus was reached on terminology, language, and priority research questions, which were rated on importance or impact (highest, medium, lower) and feasibility or ease of answering (easiest, moderate, difficult).

RESULTS

A total of 344 articles were identified through the literature search, of which 187 met inclusion criteria; an additional 34 were identified through citation review. Findings of racial inequities in EM and related fields were grouped in 28 topic areas, from which emerged 44 key research questions. A dearth of evidence for interventions to address manifestations of racism in EM was noted throughout.

CONCLUSIONS

Evidence of racism in EM emerged in nearly every facet of our literature. Key research priorities identified through consensus processes provide a roadmap for addressing and eliminating racism and other systems of oppression in EM.

Health Disparities Across the Continuum of ASCVD Risk

PURPOSE OF THE REVIEW

Despite marked progress in cardiovascular disease management in the last several decades, there remain significant, persistent disparities in cardiovascular health in historically marginalized racial and ethnic groups. Here, we outline current state of health disparities in cardiovascular disease, discuss the interplay between social determinants of health, structural racism, and cardiovascular outcomes, and highlight strategies to address these issues.

RECENT FINDINGS

Across the continuum of atherosclerotic cardiovascular disease (ASCVD) prevention, there remain significant disparities in outcomes including morbidity and mortality by race, ethnicity, and socioeconomic status (SES). These disparities begin early in childhood (primordial prevention) and continue with a higher prevalence of cardiovascular risk factors (primary prevention), and in the uptake of evidence-based therapies (secondary prevention). These disparities are driven by social determinants of health and structural racism that disproportionately disadvantage historically marginalized populations. Structural racism and social determinants of health contribute to significant disparities in cardiovascular morbidity and mortality.

Emergency Department Length of Stay and Mortality in Critically Injured Patients

OBJECTIVE

Multicenter data from 2 decades ago demonstrated that critically ill and injured patients spending more than 6 hours in the emergency department (ED) before transfer to the intensive care unit (ICU) had higher mortality rates. A contemporary analysis of ED length of stay in critically injured patients at American College of Surgeons' Trauma Quality Improvement Program (ACS-TQIP) centers was performed to test whether prolonged ED length of stay is still associated with mortality.

METHODS

This was an observational cohort study of critically injured patients admitted directly to ICU from the ED in ACS-TQIP centers from 2010-2015. Spending more than 6 hours in the ED was defined as prolonged ED length of stay. Patients with prolonged ED length of stay were matched to those with non-prolonged ED length of stay and mortality was compared.

MAIN RESULTS

A total of 113,097 patients were directly admitted from the ED to the ICU following injury. The median ED length of stay was 167 minutes. Prolonged ED length of stay occurred in 15,279 (13.5%) of patients. Women accounted for 29.4% of patients with prolonged ED length of stay but only 25.8% of patients with non-prolonged ED length of stay, P < 0.0001. Mortality rates were similar after matching-4.5% among patients with prolonged ED length of stay versus 4.2% among matched controls. Multivariable logistic regression of the matched cohorts demonstrated prolonged ED length of stay was not associated with mortality. However, women had higher adjusted mortality compared to men Odds Ratio = 1.41, 95% Confidence Interval 1.28 -1.61, P < 0.0001.

CONCLUSION

Prolonged ED length of stay is no longer associated with mortality among critically injured patients. Women are more likely to have prolonged ED length of stay and mortality.

Sex and race differences in safety and effectiveness of the HEART pathway accelerated diagnostic protocol for acute chest pain

BACKGROUND

The HEART Pathway is an accelerated diagnostic protocol for Emergency Department patients with possible acute coronary syndrome. The objective was to compare the safety and effectiveness of the HEART Pathway among women vs men and whites vs non-whites.

METHODS

A subgroup analysis of the HEART Pathway Implementation Study was conducted. Adults with chest pain were accrued from November 2013 to January 2016 from 3 Emergency Departments in North Carolina. The primary outcomes were death and myocardial infarction (MI) and hospitalization rates at 30 days. Logistic regression evaluated for interactions of accelerated diagnostic protocol implementation with sex or race and changes in outcomes within subgroups.

RESULTS

A total of 8,474 patients were accrued, of which 53.6% were female and 34.0% were non-white. The HEART Pathway identified 32.6% of females as low-risk vs 28.5% of males (P = 002) and 35.6% of non-whites as low-risk vs 28.0% of whites (P < .0001). Among low-risk patients, death or MI at 30 days occurred in 0.4% of females vs 0.5% of males (P = .70) and 0.5% of non-whites vs 0.3% of whites (P = .69). Hospitalization at 30 days was reduced by 6.6% in females (aOR: 0.74, 95% CI: 0.64-0.85), 5.1% in males (aOR: 0.87, 95% CI: 0.75-1.02), 8.6% in non-whites (aOR: 0.72, 95% CI: 0.60-0.86), and 4.5% in whites (aOR: 0.83, 95% CI: 0.73-0.94). Interactions were not significant.

CONCLUSION

Women and non-whites are more likely to be classified as low-risk by the HEART Pathway. HEART Pathway implementation is associated with decreased hospitalizations and a very low death and MI rate among low-risk patients regardless of sex or race.

Racial Disparities are Present in the Timing of Radiographic Assessment and Surgical Treatment of Hip Fractures

BACKGROUND

Hip fractures are associated with 1-year mortality rates as high as 19% to 33%. Nonwhite patients have higher mortality and lower mobility rates at 6 months postoperatively than white patients. Studies have extensively documented racial disparities in hip fracture outcomes, but few have directly assessed racial disparities in the timing of hip fracture care.

QUESTIONS/PURPOSES

Our purpose was to assess racial disparities in the care provided to patients with hip fractures. We asked, (1) do racial disparities exist in radiographic timing, surgical timing, length of hospital stay, and 30-day hospital readmission rates? (2) Does the hospital type modify the association between race and the outcomes of interest?

METHODS

We retrospectively reviewed the records of 1535 patients aged 60 years or older who were admitted to the emergency department and treated surgically for a hip fracture at one of five hospitals (three community hospitals and two tertiary hospitals) in our health system from 2015 to 2017. Multivariable generalized linear models were used to assess associations between race and the outcomes of interest.

RESULTS

After adjusting for patient characteristics, we found that black patients had a longer mean time to radiographic evaluation (4.2 hours; 95% confidence interval, -0.6 to 9.0 versus 1.2 hours; 95% CI, 0.1-2.3; p = 0.01) and surgical fixation (41 hours; 95% CI, 34-48 versus 34 hours 95% CI, 32-35; p < 0.05) than white patients did. Hospital type only modified the association between race and surgical timing. In community hospitals, black patients experienced a 51% (95% CI, 17%-95%; p < 0.01) longer time to surgery than white patients did; however, there were no differences in surgical timing between black and white patients in tertiary hospitals. No race-based differences were observed in the length of hospital stay and 30-day hospital readmission rates.

CONCLUSIONS

After adjusting for patient characteristics, we found that black patients experienced longer wait times to radiographic evaluation and surgical fixation than white patients. Hospitals should consider evaluating racial disparities in the timing of hip fracture care in their health systems. Raising awareness of these disparities and implementing unconscious bias training for healthcare providers may help mitigate these disparities and improve the timing of care for patients who are at a greater risk of delay.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Factors Influencing Time-Dependent Quality Indicators for Patients With Suspected Acute Coronary Syndrome

OBJECTIVES

Rapid risk stratification and timely treatment are critical to favorable outcomes for patients with acute coronary syndrome (ACS). Our objective was to identify patient and system factors that influence time-dependent quality indicators (QIs) for patients with unstable angina/non-ST elevation myocardial infarction (NSTEMI) in the emergency department (ED).

METHODS

A retrospective, cohort study was conducted during a 42-month period of all patients 24 years or older suspected of having ACS as defined by receiving an electrocardiogram and at least 1 cardiac biomarker test. Cox regression was used to model the effects of patient characteristics, ancillary service use, staffing provisions, equipment availability, and ED and hospital crowding on ACS QIs.

RESULTS

Emergency department adherence rates to national standards for electrocardiogram readout time and biomarker turnaround time were 42% and 37%, respectively. Cox regression models revealed that chief complaints without chest pain and the timing of stress testing and medication administration were associated with the most significant delays.

CONCLUSIONS

Patient and system factors both significantly influenced QI times in this cohort with unstable angina/NSTEMI. These results illustrate both the complexity of diagnosing patients with NSTEMI and the competing effects of clinical and system factors on patient flow through the ED.

Treatment and outcomes of acute coronary syndromes in women: An analysis of a multicenter quality improvement Chinese study

BACKGROUND

Variations in care and outcomes by sex in patients with acute coronary syndrome (ACS) have been reported worldwide. The aims of this study are to describe ACS management according to sex in China and the effects of a quality improvement program in Chinese male and female ACS patients.

METHODS AND RESULTS

Clinical Pathways for Acute Coronary Syndromes - Phase 2 (CPACS-2) was a cluster randomized trial to test whether a clinical pathways-based intervention would improve ACS management in China. The study enrolled 15,141 hospitalized patients [4631 (30.6%) were women] from 75 hospitals throughout China between October 2007 and August 2010. The intervention included clinical pathway implementation and performance measurement using standardized indicators with 6 monthly audit-feedback cycles. Eight key performance indicators reflecting in hospital management of ACS were measured. After adjustment for differences in patient characteristics and comorbidities at presentation, women were significantly less likely to undergo coronary angiography when indicated (RR 0.88 [0.85 to 0.92], P<0.001), less likely to receive guideline recommended medical therapies at discharge (RR 0.94 [0.91 to 0.98], P=0.003) and more likely to be hospitalized for shorter (mean difference -0.42 [-0.73 to -0.12] days, P=0.007). However, in-hospital clinical outcomes did not differ by sex. There was no evidence of heterogeneity in the relative effects of the quality improvement initiative by sex.

CONCLUSIONS

Sex disparities were apparent in some key quality of care indicators for patients with suspected with ACS presenting to hospitals in China. The beneficial effect of the quality improvement program was consistent in women and men.

CLINICAL TRIAL REGISTRATION

http://www.anzctr.org.au/default.aspx. Unique identifier: ACTRN12609000491268.

Sex and gender disparity in pathology, disability, referral pattern, and wait time for surgery in workers with shoulder injury

BACKGROUND

The role of sex as an important biological determinant of vulnerability to sustaining injury and gender as a social determinate of access to resources, referral for medical care and perceived disability remains conflicted in injured workers. The purpose of this study was to examine sex and gender disparity following a compensable work-related shoulder injury.

METHODS

This study involved cross-sectional analyses of data of two independent samples of workers with shoulder injury. Measures of disability and pain were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Numerical Pain Rating Scale (NPRS) for patients seen at an Early Shoulder Physician Assessment (ESPA) program and the American Shoulder and Elbow Surgeons (ASES) assessment form and Visual Analogue Scale (VAS) for the sample who underwent surgery.

RESULTS

The files of 1000 (443 females, 557 men) consecutive patients seen at an ESPA program and 150 (44 females, and 106 men) consecutive patients who underwent rotator cuff surgery (repair or decompression) were reviewed. Significant gender disparity was observed in the referral pattern of injured workers seen at the ESPA program who were referred for surgical consultation (22 vs. 78 % for females and males respectively, p < 0.0001). The independent rotator cuff surgical group had a similar gender discrepancy (29 % vs. 71 %, p < 0.0001). The timeframe from injury to surgery was longer in women in the surgical group (p = 0.01). As well, women waited longer from the date of consent to date of surgery (p = 0.04). Women had higher incidence of repetitive injuries (p = 0.01) with men reporting higher incidence of falls (p = 0.01). Women seen at the ESPA program were more disabled than men (p = 0.02). Women in both samples had a higher rate of medication consumption than men (p = 0.01 to <0.0001). Men seen at the ESPA program had a higher prevalence of full thickness rotator cuff tears (p < 0.0001) and labral pathology (p = 0.01). However, these pathologies did not explain gender disparity in the subsample of ESPA who were referred for surgical consultation or those who had surgery.

CONCLUSIONS

Sex and gender disparity exists in workers with shoulder injuries and is evident in the mechanism of injury, perceived disability, medication consumption, referral pattern, and wait time for surgery.

Racial disparities in stress test utilization in an emergency department chest pain unit

BACKGROUND

Epidemiological studies have demonstrated racial disparities in the workup of emergency department patients with chest pain and the referral of admitted patients for intervention. However, little is known about possible disparities in stress test utilization in low-risk chest pain patients admitted to emergency department chest pain units.

METHODS

A retrospective observational study of consecutive chest pain unit patients was conducted. Eligibility criteria included age >18 years, American Heart Association low-to-intermediate risk, nondynamic electrocardiograms, and normal initial troponin I. Patients aged >75 years with a history of coronary artery heart disease were excluded. On each patient, we calculated a Thrombolysis in Myocardial Infarction (TIMI) risk prediction score and a Diamond and Forrester (D&F) score for likelihood of coronary artery disease. Two separate multivariate analyses were completed, one including the TIMI score and the other including D&F score, using logistic regression to estimate odds ratios (ORs) for receiving testing based on race, controlling for other relevant covariates.

RESULTS

Two thousand four hundred fifty-one patients were enrolled over a planned 1.5-year period. In total, 59.7% [95% confidence interval (CI) 57.8-61.7] of patients were white, 11.6% (95% CI 10.4-12.9) African American, and 28.6% (95% CI 26.9-30.4) "other." The overall stress testing rate was 50.3% (95% CI 48.4-52.3). After controlling for insurance and TIMI or D&F scores, African American patients had significantly decreased odds of stress testing (OR(TIMI) 0.68, 95% CI 0.52-0.89; OR(D&F) 0.67, 95% CI 0.51-0.89).

CONCLUSIONS

Our study confirms racial disparities in the utilization of stress testing in the chest pain unit. Further investigation is needed to identify specific provider or patient-level factors that may contribute to this disparity.

Gendered symptom presentation in acute coronary syndrome: a cross sectional analysis

BACKGROUND

The international literature suggests that the symptom presentation of acute coronary syndrome may be different for men and women, yet no definitive conclusion about the existence of gendered presentation in ACS has been provided.

OBJECTIVE

This study examines whether gendered symptom presentation exists in a well-defined sample of men and women with ACS.

DESIGN AND SETTING

A cross-sectional analysis of baseline data pertaining to symptom experience and medical profiles were recorded for all ACS patients who participated in a multi-centered randomized control trial, in 5 hospitals, in Dublin, Ireland.

PARTICIPANTS

: Patients were deemed eligible if they were admitted through the Emergency Department (ED) with a diagnosis of ACS, if they were at least 21 years of age and able to read and converse in English. Patients were excluded if they had serious co-morbidities, cognitive, hearing or vision impairment.

METHODS

Patients were interviewed 2-4 days following their ACS event and data was gathered using the ACS response to symptom index.

RESULTS

The study included 1947 patients of whom 28% (n=545) were women. Chest pain was the most commonly experienced symptom in men and women, reported by 71% of patients. Using logistic regression and adjusting for clinical and demographic variables, women had greater odds of experiencing shortness of breath (50% vs 43%; odds ratio [OR]=1.32; 95% CI=1.08-1.62; p=.006) palpitations (5.5% vs 2.8%; OR=2.17; CI=1.31-3.62; p=.003) left arm pain (34% vs 30.5%; OR=1.27; CI=1.02-1.58; p=.03) back pain (7.5% vs 4.8%; OR=1.56; CI=1.03-2.37; p=.034) neck or jaw pain (21.5% vs 13.8%; OR=1.84; CI=1.41-2.40; p=.001) nausea (28% vs 24%; OR=1.30; CI=1.03-1.65; p=.024) a sense of dread (13.4% vs 10.5%; OR=1.47; CI=1.08-2.00; p=.014) and fatigue (29% vs 21.5%; OR=1.64; CI=1.29-2.07; p=.001) than their male counterparts.

CONCLUSIONS

Although chest pain is the most commonly experienced symptom by men and women, other ACS symptomology may differ significantly between genders.

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

Background

The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.

In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.

This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.

Method

A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.

Results

In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).

With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.

In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke.

Conclusion

Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.

Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006

OBJECTIVES

This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain.

METHODS

A nationally representative ED data sample for all adults (>or=18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997-2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics.

RESULTS

Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51 to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered.

CONCLUSIONS

Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes.

Influence of sex on the out-of-hospital management of chest pain

BACKGROUND

Sex disparities in the diagnosis and treatment of chest pain or suspected angina have been demonstrated in multiple clinical settings. Out-of-hospital (OOH) care for chest pain is protocol-driven and may be less likely to demonstrate differences between men and women.

OBJECTIVES

The objectives were to investigate the relationship between sex and the OOH treatment of patients with chest pain. The authors sought to test the hypothesis that OOH care for chest pain patients would differ by sex.

METHODS

A 1-year retrospective cohort study of 683 emergency medical services (EMS) patients with a complaint of chest pain was conducted. Included were patients taken to any one of three hospitals (all cardiac referral centers) by a single municipal EMS system. Excluded were patients transported by basic life support (BLS) units, those younger than 30 years, and patients with known contraindications to any of the outcome measures. Multivariable regression was used to adjust for potential confounders. The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured.

RESULTS

A total of 342 women and 341 men were included. Women were less likely than men to receive aspirin (relative risk [RR] = 0.76; 95% confidence interval [CI] = 0.59 to 0.96), nitroglycerin (RR = 0.76; 95% CI = 0.60 to 0.96), or an IV (RR 0.86; 95% CI = 0.77 to 0.96). These differences persisted after adjustment for demographics and emergency department (ED) evaluation for acute coronary syndrome (ACS) as a blunt marker for cardiac risk. Women were also less likely to receive these treatments among the small subgroup of patients who were later diagnosed with acute myocardial infarction (AMI).

CONCLUSIONS

For OOH patients with chest pain, sex disparities in treatment are significant and do not appear to be explained by differences in patient age, race, or underlying cardiac risk.

Initial ECG acquisition within 10 minutes of arrival at the emergency department in persons with chest pain: time and gender differences

INTRODUCTION

The American Heart Association recommends all patients presenting to the emergency department with complaints of chest pain/anginal equivalent symptoms receive an initial ECG within 10 minutes of presentation. The Synthesized Twelve-lead ST Monitoring & Real-time Tele-electrocardiography (ST SMART) study is a prospective randomized clinical trial that enrolls all subjects who call 911 for ischemic complaints in Santa Cruz County, California. ST SMART is a 5-year study ending in 2008. The primary aim of the ST SMART study is to determine whether subjects who receive prehospital ECG have more timely hospital intervention and better outcomes.

OBJECTIVE

The aims of this secondary analysis of a subset of ST SMART study data were to determine (1) the rate of adherence to the American Heart Association goal in smaller community hospitals in less populous areas of receiving initial hospital ECG within the recommended 10 minutes and (2) whether there were gender differences in meeting this goal.

METHODS

The dataset included patients 30 years of age and older who were transported by ambulance to 1 of 2 rural hospitals in Santa Cruz County. All patients received an initial hospital ECG after arrival at the emergency department.

RESULTS

In this analysis of 425 patients (mean age, 70.4 years; 53% male), the mean time for all patients from ED arrival to initial ECG was 43 minutes (±145). The mean time to initial ECG was 34 minutes (±125) in male patients versus 53 minutes (±165) in female patients (Mann-Whitney test, P = .001). Forty-one percent of all patients presenting with ischemic symptoms received an initial ECG within 10 minutes of arrival. Forty-nine percent of male patients versus 32% of female patients received an initial ECG in 10 minutes or less (Fisher exact test, P = .000).

CONCLUSION

In this analysis, the majority of patients with ischemic symptoms did not receive an ECG within 10 minutes of hospital presentation as recommended in evidence-based guidelines. There is a significant delay in door to time-to-ECG for women. ED nurses are in a unique position to initiate efforts to establish processes to decrease time to initial ECG for patients with ischemic symptoms. Attention to timely ECG acquisition in women may improve treatment of acute coronary syndromes in this group.

A method for improving arrival-to-electrocardiogram time in emergency department chest pain patients and the effect on door-to-balloon time for ST-segment elevation myocardial infarction

OBJECTIVES

The objectives were to determine if an emergency department (ED) could improve the adherence to a door-to-electrocardiogram (ECG) time goal of 10 minutes or less for patients who presented to an ED with chest pain and the effect of this adherence on door-to-balloon (DTB) time for ST-segment elevation myocardial infarction (STEMI) cardiac catheterization (cath) alert patients.

METHODS

This was a planned 1-month before-and-after interventional study design for implementing a new process for obtaining ECGs in patients presenting to the study ED with chest pain. Prior to the change, patients were registered and triaged before an ECG was obtained. The new procedure required registration clerks to identify those with chest pain and directly overhead page or call a designated ECG technician. This technician had other ED duties, but prioritized performing ECGs and delivering them to attending physicians. A full registration process occurred after the clinical staff performed their initial assessment. The primary outcome was the total percentage of patients with chest pain who received an ECG within 10 minutes of ED arrival. The secondary outcome was DTB time for patients with STEMI who were emergently cath alerted. Data were analyzed using mean differences, 95% confidence intervals (CIs), and relative risk (RR) regression to adjust for possible confounders.

RESULTS

A total of 719 patients were studied: 313 before and 405 after the intervention. The mean (+/-standard deviation [SD]) age was 50 (+/-16) years, 54% were women, 57% were African American, and 36% were white. Patients walked in 89% of the time; 11% arrived by ambulance. Thirty-nine percent were triaged as emergent and 61% as nonemergent. Patients presented during daytime 68% of the time, and 32% presented during the night. Before the intervention, 16% received an ECG at 10 minutes or less. After the intervention, 64% met the time requirement, for a mean difference of 47.3% (95% CI = 40.8% to 53.3%, p < 0.0001). Results were not affected by age, sex, race, mode of arrival, triage classification, or time of arrival. For patients with STEMI cath alerts, four were seen before and seven after the intervention. No patients before the intervention had ECG time within 10 minutes, and one of four had DTB time of <90 minutes. After the intervention, all seven patients had ECG time within 10 minutes; the three arriving during weekday hours when the cath team was on site had DTB times of <90 minutes, but the four arriving at night and on weekends when the cath team was off site had DTB times of >90 minutes.

CONCLUSIONS

The overall percentage of patients with a door-to-ECG time within 10 minutes improved without increasing staffing. An ECG was performed within 10 minutes of arrival for all patients who were STEMI cath alerted, but DTB time under 90 minutes was achieved only when the cath team was on site.

Disparities in use of computed tomography for patients presenting with headache

OBJECTIVE

Headache is a common presenting complaint in the emergency department (ED). Physicians may choose to screen for causes of headache using computed tomography (CT). It is not known whether patient characteristics influence this decision. This study sought to identify patient demographic factors associated with CT evaluation for adult patients with headache.

METHODS

This study used a retrospective cohort review at an academic, urban ED. Study eligibility was based on chief complaint of headache and final diagnosis of the same. Detailed demographic (age, sex, race/ethnicity, insurance) and clinical (Emergency Severity Index [ESI], Charlson comorbidity score, pain score) data were abstracted from the ED medical record. The main outcome studied was whether a head CT was part of clinical evaluation.

RESULTS

One hundred fifty-five patients were reviewed. Mean age was 42 years (SD, +/-18 years); 75% female, 17% white, 41% black, and 33% Hispanic; 73% were insured; mean ESI was 3.06 (SD, +/-0.64); and Charlson score was 0.60 (SD, +/-1.55). Thirty-seven percent of patients underwent head CT. In multivariable analyses, patients were more likely to undergo head CT if they had greater acuity (ESI < or = 3; odds ratio [OR], 5.11; P < .01) but were less likely to undergo head CT if they were black (OR, 0.21; P < .01) when adjusting for each other as well as older age, sex, comorbidity, insurance status, and history of migraine.

CONCLUSION

In this study, patients who were black were significantly less likely to undergo head CT during their ED evaluation for headache, independent of clinical and demographic factors.

A framework to analyse gender bias in epidemiological research

The design and analysis of research may cause systematic gender dependent errors to be produced in results because of gender insensitivity or androcentrism. Gender bias in research could be defined as a systematically erroneous gender dependent approach related to social construct, which incorrectly regards women and men as similar/different. Most gender bias can be found in the context of discovery (development of hypotheses), but it has also been found in the context of justification (methodological process), which must be improved. In fact, one of the main effects of gender bias in research is partial or incorrect knowledge in the results, which are systematically different from the real values. This paper discusses some forms of conceptual and methodological bias that may affect women's health. It proposes a framework to analyse gender bias in the design and analysis of research carried out on women's and men's health problems, and on specific women's health issues. Using examples, the framework aims to show the different theoretical perspectives in a social or clinical research context where forms of selection, measurement and confounding bias are produced as a result of gender insensitivity. Finally, this paper underlines the importance of re-examining results so that they may be reinterpreted to produce new gender based knowledge.

Emergency department management of acute pain episodes in sickle cell disease

OBJECTIVES

To characterize the initial management of patients with sickle cell disease and an acute pain episode, to compare these practices with the American Pain Society Guideline for the Management of Acute and Chronic Pain in Sickle-Cell Disease in the emergency department, and to identify factors associated with a delay in receiving an initial analgesic.

METHODS

This was a multicenter retrospective design. Consecutive patients with an emergency department visit in 2004 for an acute pain episode related to sickle cell disease were included. Exclusion criteria included age younger than 18 years. A structured medical record review was used to abstract data, including the following outcome variables: analgesic agent and dose, route, and time to administration of initial analgesic. Additional variables included demographics, triage level, intravenous access, and study site. Mann-Whitney U test or Kruskal-Wallis test and multivariate regression were used to identify differences in time to receiving an initial analgesic between groups.

RESULTS

There were 612 patient visits, with 159 unique patients. Median time to administration of an initial analgesic was 90 minutes (25th to 75th interquartile range, 54-159 minutes). During 87% of visits, patients received the recommended agent (morphine or hydromorphone); 92% received the recommended dose, and 55% received the drug by the recommended route (intravenously or subcutaneously). Longer times to administration occurred in female patients (mean difference, 21 minutes; 95% confidence interval = 7 to 36 minutes; p = 0.003) and patients assigned triage level 3, 4, or 5 versus 1 or 2 (mean difference, 45 minutes; 95% confidence interval = 29 to 61 minutes; p = 0.00). Patients from study sites 1 and 2 also experienced longer delays.

CONCLUSIONS

Patients with an acute painful episode related to sickle cell disease experienced significant delays to administration of an initial analgesic.