Chest pain patients in crowded EDs suffer more post-admit complications
Chest pain patients in crowded EDs suffer more post-admit complications
'Dysfunctional' hospitals at fault, but EDs must do their part
Patients with heart attacks and other forms of chest pain are three to five times more likely to experience serious complications after hospital admission when they are treated in a crowded ED, according to a new study published online in the journal Academic Emergency Medicine.1
The study followed 4,574 patients who were admitted to the Hospital of the University of Pennsylvania in Philadelphia for symptoms of chest pain over an eight-year period. Ultimately, 802 were diagnosed with an acute coronary syndrome; of those, 273 had a true heart attack. There were 251 complications that occurred in the hospital after initial ED treatment. Complications included serious events, such as heart failure, delayed heart attacks, dangerously low blood pressure, heart arrhythmias, and cardiac arrest.
When the ED was at its highest occupancy and waiting room census, patients with acute coronary syndrome (ACS) were three times more likely to experience complications in the hospital. When the patient hours were highest, they were more than five times more likely to have a complication. "Most of these complications occurred long after the patients left the ED, but while they were still in the hospital," notes Jesse M. Pines, MD, MBA, MSCE, assistant professor of emergency medicine and epidemiology at the hospital and lead author of the paper.
The authors noted that these complications were not explained by what is or is not happening in the ED in terms of specific treatments and timing, such as giving patients aspirin or a timely EKG. Instead, they said, it pointed to a "dysfunctional" hospital.
Jim Horn, MD, FACEP, medical director of ED at the Mercy Hospital Fairfield (OH), says, "One thing I take away from this study is that expected basic quality care measures were received. I don't know if this is a marker of a 'dysfunctional' hospital, but when patients are at their sickest, you potentially see a higher rate of complications, and when the ED is at its highest capacity, you often see patients with higher acuity."
Nevertheless, the authors noted, the findings underscore the need for action on the part of hospital administrators, policy-makers, and emergency physicians.
What can ED managers do to minimize these "downstream" complications? "Patients have to be seen quickly and diagnosed appropriately," Pines says. "There must be a good review of their old medical records; and the medications the patient is currently on have to be put into the system. Once the patient is to be admitted, the inpatient team has to come down, and there has to be a smooth transition of care from the ED team."
Horn says, "I agree these are all things that we strive for."
Still, says Pines, a different approach must be taken in light of the study's findings. "ED managers need to realize that these particular patients are at higher risk," he says. "They must communicate with their physicians that during crowded times, even though it is very easy to focus on only the most critically ill patients, those with chest pain are at higher risk for having complications when the ED is crowded — regardless of whether or not they have ACS [acute coronary syndrome]." Thus, Pines says, at these times there must be an even greater focus on the different processes of emergency care.
Horn says, "We're always concerned when volume is high, but our goal is still to see every patient quickly and diagnose them appropriately but quickly. In my place, the [chest pain] patient gets an EKG as soon as he hits the door."
Reference
- Pines JM, Pollack CV Jr., Diercks DB, et al. The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med 2009; June 22. Epub ahead of print. Doi: 10.1111/j.1553-2712.2009.00456.x.
Sources
For more information on treating chest pain patients in the ED, contact:
- Jim Horn, MD, FACEP, ED Medical Director, Mercy Hospital Fairfield (OH). Phone: (513) 227-4551.
- Jesse M. Pines, MD, MBA, MSCE, Assistant Professor of Emergency Medicine and Epidemiology, Hospital of the University of Pennsylvania, Philadelphia. Phone: (215) 662-4050.
Med reconciliation, transfers are key While a recent paper in the journal Academic Emergency Medicine showed that patients with heart attacks and other forms of chest pain are three to five times more likely to experience serious complications after hospital admission when they are treated in a crowded ED, the authors do not place the blame on the ED, but rather on "dysfunctional" hospitals.1 Nevertheless, there are a number of areas ED managers can focus on to do their part to reduce those complications, says Jesse M. Pines, MD, MBA, MSCE, assistant professor of emergency medicine and epidemiology at the Hospital of the University of Pennsylvania, Philadelphia, and lead author of the paper. "One of the major and most common complications is when patients go into heart failure after their ED stay, so ensuring that patients receive the medications they are on regularly, that that information is correct, and that they get on those regular meds early on is important," says Pines. "We think having early meds reconciliation could potentially prevent some of these complications." Jim Horn, MD, FACEP, medical director of the Mercy Hospital Fairfield (OH) ED, says, "In my shop, I've not heard of any issues of meds reconciliation as volume picks up. When we get crowded, we have an admissions nurse whose job it is to manage the meds reconciliation issue." Transitions of care, in particular from the ED to inpatient status, are much more difficult when the ED is crowded, notes Pines, because there are fewer resources available. "That transition of care, a high-risk time for patients, happens at a time when you have the fewest resources to make sure that happens smoothly," he says. One of the approaches his department has taken to improve transitions is standardization, Pines says. "Typically in EDs there is a verbal transfer of care between doctors and nurses," he says. "Our policy is that this has to happen with every patient, because it can potentially make the transfer less safe when it does not happen." Horn adds, "This piece definitely needs to be pursued." In his facility they are working on ways of having the boarded patient considered more like an inpatient. "There may not be beds available upstairs, but an inpatient-type nurse can still take care of them in an inpatient way," Horn explains. Reference
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Chest pain patients need meds reconciled at arrival When a patient presents to your ED with chest pain, medication reconciliation "should occur as soon as the patient arrives," advises Jesse M. Pines, MD, MBA, MSCE, assistant professor of emergency medicine and epidemiology at the Hospital of the University of Pennsylvania, Philadelphia. In addition, he says, ED managers "should make a concerted attempt to ensure that the patient's correct meds are put into the [electronic] system and that in particular there is no delay in getting patients put back on diuretics, which we think could be causing heart failure." If necessary, he says, the ED should change procedures to ensure this step occurs early on. |
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