Improvement of emergency department patient flow using lean thinking.

OBJECTIVE: To apply lean thinking in triage acuity level-3 patients in order to improve emergency department (ED) throughtput and waiting time. DESIGN: A prospective interventional study. SETTING: An ED of a tertiary care hospital. PARTICIPANTS: Triage acuity level-3 patients. INTERVENTION(S): To apply lean techniques such as value stream mapping, workplace organization, reduction of wastes and standardization by the frontline staff. MAIN OUTCOME MEASURE(S): Two periods were compared: (i) pre-lean: April-September, 2015; and (ii) post-lean: April-September, 2016. Variables included: median process time (time from beginning of nurse preparation to the end of nurse finalization after doctor disposition) of both discharged and transferred to observation patients; median length of stay; median waiting time; left without being seen, 72-h revisit and mortality rates, and daily number of visits. There was no additional staff or bed after lean implementation. RESULTS: Despite an increment in the daily number of visits (+8.3%, P < 0.001), significant reductions in process time of discharged (182 vs 160 min, P < 0.001) and transferred to observation (186 vs 176 min, P < 0.001) patients, in length of stay (389 vs 329 min, P < 0.001), and in waiting time (71 vs 48 min, P < 0.001) were achieved after lean implementation. No significant differences were registered in left without being seen rate (5.23% vs 4.95%), 72-h revisit rate (3.41% vs 3.93%), and mortality rate (0.23% vs 0.15%). CONCLUSION: Lean thinking is a methodology that can improve triage acuity level-3 patient flow in the ED, resulting in better throughput along with reduced waiting time.

Safety and efficiency of discharge to home hospitalization directly after emergency department care of patients with acute heart failure. / Análisis de seguridad y eficiencia de la hospitalización a domicilio directamente desde urgencias en pacientes con insuficiencia cardiaca aguda.

OBJECTIVES: To analyze whether discharge to home hospitalization (HHosp) directly from emergency departments (EDs) after care for acute heart failure (AHF) is efficient and if there are short-term differences in outcomes between patients in HHosp vs those admitted to a conventional hospital ward (CHosp). MATERIAL AND METHODS: Secondary analysis of cases from the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments). The EAHFE is a multicenter, multipurpose, analytical, noninterventionist registry of consecutive AHF patients after treatment in EDs. Cases were included retrospectively and registered to facilitate prospective follow-up. Included were all patients diagnosed with AHF and discharged to HHosp from 2 EDs between March 2016 and February 2019 (3 years). Cases from 6 months were analyzed in 3 periods: March-April 2016 (corresponding to EAHFE-5), January-February 2018 (EAHFE-6), and January-February 2019 (EAHFE-7). The findings were adjusted for characteristics at baseline and during the AHF decompensation episode. RESULTS: A total of 370 patients were discharged to HHosp and 646 to CHosp. Patients in the HHosp group were older and had more comorbidities and worse baseline functional status. However, the decompensation episode was less severe, triggered more often by anemia and less often by a hypertensive crisis or acute coronary syndrome. The HHosp patients were in care longer (median [interquartile range], 9 [7-14] days vs 7 [5-11] days for CHosp patients, P .001), but there were no differences in mortality during hospital care (7.0% vs. 8.0%, P = .56), 30-day adverse events after discharge from the ED (30.9% vs. 32.9%, P = .31), or 1-year mortality (41.6% vs. 41.4%, P = .84). Risks associated with HHosp care did not differ from those of CHosp. The odds ratios (ORs) for HHosp care were as follows for mortality while in care, OR 0.90 (95% CI, 0.41-1.97); adverse events within 30 days of ED discharge, OR 0.88 (95% CI, 0.62-1.26); and 1-year mortality, OR 1.03 (95% CI, 0.76-1.39). Direct costs of HHosp and CHosp averaged €1309 and €5433, respectively. CONCLUSION: After ED treatment of AHF, discharge to HHosp requires longer care than CHosp, but short- and longterm outcomes are the same and at a lower cost.

OBJETIVO: Analizar si la hospitalización domiciliaria (HDom) directamente desde los servicios de urgencias (SU) de pacientes con insuficiencia cardiaca aguda (ICA) resulta eficiente y si se asocia con diferencias en evolución a corto y largo plazo comparada con hospitalización convencional (HCon). METODO: Análisis secundario del registro Epidemiology Acute Heart Failure in Emergency departments (EAHFE), que es un registro multicéntrico, multiporpósito, analítico no intervencionista, con seguimiento prospectivo que incluye de forma consecutiva a los pacientes que acuden por episodio de ICA al SU. Se incluyeron, retrospectivamente, todos los pacientes diagnosticados de ICA en dos SU ingresados directamente en HDom entre marzo de 2016 y febrero de 2019 (3 años) y se compararon sus resultados con los pacientes diagnosticados de ICA incluidos en el registro EAHFE por esos 2 SU e ingresados en HCon durante los periodos marzo-abril 2016 (EAHFE-5), enero-febrero 2018 (EAHFE-6), y enero-febrero 2019 (EAHFE-7) (6 meses). Los resultados se ajustaron por las características basales y clínicas del episodio de descompensación. RESULTADOS: Se incluyeron 370 pacientes en HDom y 646 en HCon. El grupo HDom tenía mayor edad, mayor comorbilidad y peor situación funcional basal, pero menor gravedad del episodio de descompensación, más frecuentemente desencadenado por anemia y menos por crisis hipertensiva y síndrome coronario agudo. La duración del ingreso fue mayor [mediana (RIC) 9 (7-14) días frente a 7 (5-11) días, p 0,001], pero no hubo diferencias en mortalidad intrahospitalaria (7,0% frente a 8,0%, p = 0,56), eventos adversos a 30 días posalta (30,9% frente a 32,9%, p = 0,31) ni mortalidad al año (41,6% frente a 41,4%, p = 0,84). En el modelo ajustado, el riesgo asociado a HDom tampoco difirió significativamente en mortalidad intrahospitalaria (OR = 0,90, IC 95% = 0,41-1,97), eventos adversos posalta a 30m días (HR = 0,88, IC95% = 0,62-1,26) ni mortalidad al año (HR = 1,03, IC 95% = 0,76-1,39). El coste directo promedio del episodio en HDom y HCon fue 1.309 y 5.433 euros, respectivamente. CONCLUSIONES: En la ICA, la HDom directamente desde el SU es más prolongada que la HCon, pero consigue los mismos resultados a corto y largo plazo, y su coste es inferior.

Factors associated with erroneous emergency department noncardiac chest pain classifications in men and women. / Análisis individualizado por sexo de los factores asociados a la clasificación inicial errónea en urgencias del dolor torácico como no coronario.

OBJECTIVES: To analyze the frequency and clinical characteristics associated with erroneous initial classifications of noncardiac chest pain (NCP) in men and women. MATERIAL AND METHODS: We analyzed all case records in which chest pain was initially classified as noncardiac in origin according to clinical signs and electrocardiograms evaluated in our emergency department between 2008 and 2017. We considered the initial evaluation of NCP to be in error if the final diagnosis was acute coronary syndrome. A risk model for an erroneous initial classification of NCP was developed based on multivariable analysis of our patient data. We also used multivariable analysis to explore associations between 10 clinical signs of chest pain and an erroneous initial NCP classification. The data for men and women were analyzed separately. RESULTS: NCP was the initial classification for 8093 women; their median (interquartile range) age was 54 (38-73) years. The classification was in error for 72 women (0.9%). Odds ratios (ORs) showed that patient risk factors associated with an erroneous NCP classification in the women in our series were obesity (OR, 0.40; 95% CI, 0.17- 0.97) and cocaine consumption (OR, 5.18; 95% CI, 1.16-23.2). Clinical risk factors associated with erroneous NCP classification in women were recent physical exertion (OR, 2.01; 95% CI, 1.21-3.33), radiation exposure (OR, 2.05; 95% CI, 1.23-3.41), and vegetative symptoms (OR, 1.86; 95% CI, 1.02-3.41). For 9979 men with a median age of 47 (33-64) years, NCP was the initial classification; in 83 of the men (0.8%) the classification was erroneous. Patient factors associated with erroneous NCP classification in men were age over 40 years (OR, 1.74; 95% CI, 1.04-2.91) and hypertension (OR, 0.45; 95% CI, 0.24-0.84). No clinical signs of chest pain in men were associated with error. CONCLUSION: More clinical characteristics are associated with an erroneous classification of NCP in women. Our findings underline the need to assess the possibility of acute coronary syndrome differently in women, in whom the signs have usually been considered to be atypical.

OBJETIVO: Analizar de forma independiente en mujeres y hombres la frecuencia y las características clínicas asociadas a una clasificación inicial errónea (CIE) en urgencias del dolor torácico (DT) como no coronario. METODO: Se analizan todas las consultas por DT atendidas en urgencias entre 2008 y 2017 clasificadas inicialmente (historia clínica y ECG) como DT no coronario. Se consideró como CIE si el diagnóstico final fue síndrome coronario agudo (SCA). Se crearon dos modelos multivariable, uno con 10 factores de riesgo, y otro con 10 características clínicas del DT, en los que se investigó la asociación de estas variables con una CIE. Se analizaron independientemente mujeres y hombres. RESULTADOS: Se analizaron 8.093 mujeres con DT clasificado inicialmente como no coronario (edad mediana: 54 años, RIC: 38-73), 72 con CIE (0,9%). Los factores de riesgo asociados independientemente a CIE fueron obesidad (OR = 0,40; IC 95% = 0,17-0,97) y consumo de cocaína (5,18; 1,16-23,2), y las características clínicas fueron relación con el esfuerzo (2,01; 1,21-3,33), existencia de irradiación (2,05; 1,23-3,41) y síntomas vegetativos acompañantes (1,86; 1,02-3,41). Se analizaron 9.979 hombres (edad mediana: 47 años, RIC: 33-64), 83 con CIE (0,8%). Los factores de riesgo asociados a CIE fueron edad > 40 años (1,74; 1,04-2,91) e hipertensión (0,45; 0,24-0,84). No hubo características clínicas del DT asociadas a CIE. CONCLUSIONES: En las mujeres con dolor torácico, se idenfitican más características asociadas al error de clasificación que en los hombres. Este estudio remarca la necesidad de análisis independiente por sexo en el SCA, en el que clásicamente se ha considerado la clínica en las mujeres como atípica.

Factors associated with late presentation to the emergency department in patients complaining of chest pain.

OBJECTIVE: We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP). METHODS: All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS). RESULTS: The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS. CONCLUSION: Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS. PRACTICE IMPLICATIONS: Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.

Validation of a triage flowchart to rule out acute coronary syndrome.

OBJECTIVE: To validate a triage flowchart to rule out acute coronary syndrome (ACS) in chest pain patients attending the emergency department (ED). METHODS: An observational cohort study of consecutive patients. In all cases, a previously derived five-step triage flowchart (age ≤ 40 years, absence of diabetes, not previously known coronary artery disease, non-oppressive and non-retrosternal pain) was applied. Patients meeting all five discriminators were grouped as 'five-step triage non-ACS', the rest as 'five-step triage ACS'. The same strategy was used with a four-step model (without age ≤ 40 years). After ED study and 1-month follow-up, patients were definitively classified as 'true ACS' or 'true non-ACS'. Validity indexes and receiver operating characteristics curves were calculated. RESULTS: 4231 patients were included: 918 (21.7%) were 'true ACS', 3303 (78.1%) 'true non-ACS'; 10 (0.2%) were lost to follow-up. The five-step triage flowchart classified 4000 (94.8%) as 'triage ACS' and 221 (5.2%) as 'triage non-ACS'; none of the latter was 'true ACS'. The four-step model classified 3194 (75.6%) as 'triage ACS' and 1027 (24.4%) as 'triage non-ACS'. A 'true ACS' was seen in 26 patients from the latter group. Accordingly, five-step triage flowchart specificity and positive predictive value (PPV) to rule out ACS were 100% (95% CI 100% to 100%). For the four-step model specificity and PPV were 97% (95% CI 96% to 98%). CONCLUSION: The five-step triage flowchart identifies chest pain patients without an ACS. However, only 5% of these patients meet these five criteria. A simpler model allows greater patient inclusion but a higher risk of misclassification of true ACS.

Influence of previous coronary artery bypass grafting in the difficulty of acute coronary syndrome diagnosis.

OBJECTIVES: To investigate whether the diagnosis of acute coronary syndrome (ACS) in coronary artery bypass grafting (CABG) patients with chest pain (CP) is more difficult based on the initial clinical and electrocardiogram (ECG) findings. METHODS: We included consecutive CP patients attended at a single emergency department (ED) during a 10-year period. CABG status and the final diagnosis of ACS were considered as stated in the ED discharge report. We evaluated the frequency of 21 CP characteristics (CPC) and four ECG signatures, their individual and collective association with ACS, and ED length of stay (LOS) in CABG and non-CABG patients. RESULTS: We included 34 429 patients [median age: 61 years; female: 41.8%; CABG: 2204 patients (6.4%)], and ACS was diagnosed in 6727 (19.5%; CABG/non-CABG 37.2%/18.3%; P < 0.001). CABG patients more frequently had CPC and ECG findings typically associated with ACS, but their final association with ACS was weaker than in non-CABG patients (only significant after adjustment for attendant diaphoresis, throat irradiation, ST-segment elevation and T-wave inversion). The collective discriminative capacity was significantly lower in CABG patients (area under the curve 0.710 vs. 0.793; P < 0.001), even after adjustment (0.708 vs. 0.790; P < 0.001). ED LOS was longer for CABG patients, overall (P < 0.001) and for patients diagnosed with ACS (P = 0.008) and non-ACS (P < 0.001), but these differences disappeared after adjustment. CONCLUSION: CABG substantially reduces the diagnostic performance of CPC and ECG findings to suggest ACS. A longer LOS in the ED in CABG patients is more related to their baseline characteristics than to CABG itself.

Randomized comparison between clinical evaluation plus N-terminal pro-B-type natriuretic peptide versus exercise testing for decision making in acute chest pain of uncertain origin.

BACKGROUND: Exercise testing constitutes the usual tool for decision making in chest pain units. This policy implies logistical constrains. Our aim was to evaluate a new strategy, combining a clinical risk score and N-terminal pro-B-type natriuretic peptide (NT-proBNP), in patients presenting to the emergency department with chest pain, without ischemic electrocardiogram changes or troponin elevation. METHODS: A total of 320 patients were randomized to either usual management, involving exercise testing, or a new strategy combining a clinical risk score and NT-proBNP without exercise testing. In the usual management, discharge decision was guided by the result of exercise test. In the new strategy, those patients with low clinical risk score and NT-proBNP were directly discharged. The primary outcome was hospitalization at the index episode. Secondary outcomes were cardiac events at 1 year. RESULTS: A total of 110 patients (69%) were hospitalized using usual management in comparison with 90 (56%) in the new strategy (P = .03). There were no differences in death or myocardial infarction (n = 11, 6.9% vs n = 6, 3.8%, P = .3) or cardiac events (n = 38, 24% vs n = 28, 18%, P = .2). Revascularizations at the index episode were more frequent under usual management (18% vs 8%, P = .01), although the new strategy was associated with higher rate of planned postdischarge revascularizations (0.6% vs 5%, P = .04). CONCLUSIONS: A strategy combining clinical history and NT-proBNP is simpler and reduced initial emergency hospitalizations in patients with chest pain, in comparison with the usual strategy involving exercise testing. Larger studies to assess its impact on long-term hard end points are needed.

Predicting bacteremic pneumonia in HIV-1-infected patients consulting the ED.

INTRODUCTION: HIV-1-infected patients have higher incidence of community-acquired pneumonia (CAP) and risk of complications. Bacteremia has been associated with a higher risk of complications in such patients. We investigated factors associated with bacteremia in HIV-1-infected patients with CAP presenting at the emergency department. METHODS: We included HIV-1-infected patients with CAP for 3 years (March 2005-February 2008). Only patients in whom blood cultures were performed were finally included. Clinical data (age; sex; CD4(+) count; serum HIV viral load; previous or current intravenous drug use and antiretroviral treatment; systolic blood pressure; and cardiac and respiratory rates), analytical data (leukocyte count, arterial oxygen content, C-reactive protein value, and urgent Streptococcus pneumoniae and Legionella spp antigen urine detection), and APACHE-II (Acute Physiology and Chronic Health Evaluation) score were compiled. The need for intensive care unit admission, mechanical ventilation, mortality, and for patients finally discharged, duration of admission were retrospectively obtained from the clinical history. A multivariate analysis using logistic regression was performed to find independent predictors of bacteremia. RESULTS: We diagnosed 129 HIV-1-infected patients with CAP. Blood cultures were performed in 118 cases (91%). Bacteremia was present in 28 (24%). Independent predictors of bacteremia were the detection of S pneumoniae antigen in urine (odds ratio, 9.0; 95% confidence interval, 1.9-42.0) and the absence of current antiretroviral treatment (odds ratio, 7.1; 95% confidence interval, 1.4-33.3). In-hospital mortality was higher in patients with bacteremia (15% vs 0%). CONCLUSION: HIV-1-infected patients with CAP who are not on current antiretroviral therapy and have positive S pneumoniae antigenuria are at increased risk of having bacteremia. Bacteremic patients have a poor outcome.

[Influence of patient's sex in the form of presentation and the management of acute heart failure in Spanish emergency rooms]. / Influencia del sexo del paciente en la forma de presentación y en el tratamiento de la insuficiencia cardíaca aguda en los servicios de Urgencias españoles.

BACKGROUND AND OBJECTIVE: To evaluate the differences by sex in clinic presentation, diagnostic approach and initial treatment in patients with acute heart failure who are attended in emergency rooms. PATIENTS AND METHODS: Prospective, evaluated, descriptive, transverse and multicentric study, which includes all patients attended by acute heart failure in emergency rooms of 10 Spanish centers between April 15th and May 15th, 2007 (n=944). Data were recorded regarding socio-demographic, comorbidity, previous heart disease, complementary explorations, previous home treatment, and therapeutic measurements in emergency. RESULTS: Regarding men, women (n=501; 53%) were older (79+/-9 and 75+/-10, P<.001), and had more hypertension (83,4% vs 74,9%, P<.01), valvular heart disease (23,1% vs 17,8%, P<.05) and obesity (21,9% vs 15,6%, P<.05); however, they also had less prevalence of coronary heart disease (26,5% vs 43,3%, P=.001) and smoking (4,4 % vs 18,7%, P<.001). According to outpatient treatment, women were less likely to be treated with beta blockers (19,6% vs 30,2%, P<.001) and antithrombotics (34,1% vs 41,3%, P<.05). Treatment administered in the emergency was similar in both groups, yet women received more frequently digoxin (25,7% vs 17,4%, P<.01). Moreover, women were admitted to the cardiology department less often (8,0% vs 13,8%, P<.01). CONCLUSIONS: In emergency, the diagnostic and therapeutic approach is very similar in both sexes and the most cases, differences can be justified due to the different patients' profile and the ambulatory handling before their consultation to emergency.

External validation of an emergency department triage algorithm for chest pain patients.

BACKGROUND: We aimed to externally validate an emergency department triage algorithm including five hierarchical clinical variables developed to identify chest pain patients at low risk of having an acute coronary syndrome justifying delayed rather than immediate evaluation. METHODS: In a single-centre cohort enrolling 29,269 consecutive patients presenting with chest pain, the performance of the algorithm was compared against the emergency department discharge diagnosis. In an international multicentre study enrolling 4069 patients, central adjudication by two independent cardiologists using all data derived from cardiac work-up including follow-up served as the reference. Triage towards 'low-risk' required absence of all five clinical 'high-risk' variables: history of coronary artery disease, diabetes, pressure-like chest pain, retrosternal chest pain and age above 40 years. Safety (sensitivity and negative predictive value (NPV)) and efficacy (percentage of patients classified as low risk) was tested in this initial proposal (Model A) and in two additional models: omitting age criteria (Model B) and allowing up to one (any) of the five high-risk variables (Model C). RESULTS: The prevalence of acute coronary syndrome was 9.4% in the single-centre and 28.4% in the multicentre study. The triage algorithm had very high sensitivity/NPV in both cohorts (99.4%/99.1% and 99.9%/99.1%, respectively), but very low efficacy (6.2% and 2.7%, respectively). Model B resulted in sensitivity/NPV of 97.5%/98.3% and 96.1%/89.4%, while efficacy increased to 14.2% and 10.4%, respectively. Model C resulted in sensitivity/NPV of 96.7%/98.6% and 95.2%/91.3%, with a further increase in efficacy to 23.1% and 15.5%, respectively. CONCLUSION: A triage algorithm for the identification of low-risk chest pain patients exclusively based on simple clinical variables provided reasonable performance characteristics possibly justifying delayed rather than immediate evaluation in the emergency department.

Nontraumatic chest pain and suspicion of acute coronary syndrome: associated clinical and electrocardiographic findings on initial evaluation. / Asociación entre los datos clínicos y electrocardiográficos iniciales en pacientes con dolor torácico no traumático y la sospecha inicial y el diagnóstico final de síndrome coronario agudo.

OBJECTIVES: To analyze clinical data and electrocardiographic (ECG) findings obtained during the initial evaluation of patients with nontraumatic chest pain (NTCP). To explore associations between these findings and the initial and final diagnoses of acute coronary syndrome (ACS). To assess which variables initially over- or underestimate risk ACS. MATERIAL AND METHODS: Consecutive patients with NTCP attended in a chest pain unit during the 10-year period of 2008-2017 were included if the suspected and discharge diagnoses of interest (ACS or non-ACS) had been recorded. Thirtythree independent variables (demographic, 2; cardiovascular, 5; chest pain, 22; ECG, 4). We included all variables in models to calculate crude and adjusted odds ratios (ORs) between each independent variable and the initial and final diagnoses. The adjusted ORs were compared to determine whether the initial and final diagnoses of ACS differed significantly in relation to the variables. RESULTS: A total of 34 552 patient visits were attended. The ORs for the 33 variables were significantly associated with initial and final NTCP classification as ACS or non-ACS, and in many cases the association was confirmed by the adjusted ORs. The adjusted ORs for 19 variables were significantly different in their relation to the initial and final diagnoses of ACS: 10 overpredicted the probability of the diagnosis and 9 underpredicted it. CONCLUSION: The variables traditionally used to warn of ACS in emergency patients with NTCP identify individuals likely to be initially and finally diagnosed with ACS. However, some of these variables overestimate or underestimate the risk of a final ACS diagnosis. Emergency medicine physicians should be aware of variables associated with underestimation of risk.

OBJETIVO: Evaluar la utilidad del cuestionario COPD Asessment Test (CAT) para valorar la recuperación de la exacerbación de la enfermedad pulmonar obstructiva crónica (EA-EPOC). Evaluar si la puntuación CAT aumenta la capacidad predictiva de mala evolución de una escala de gravedad para EA-EPOC. METODO: Se incluyeron las consultas consecutivas por DTNT en una unidad de dolor torácico durante 10 años (2008-2017) en las que se disponía de los diagnósticos inicial de sospecha (SCA/no SCA) y final de alta de urgencias (SCA/no SCA). Se incluyeron 33 variables independientes (2 demográficas, 5 comorbilidad cardiovascular, 22 dolor torácico, 4 datos ECG). Se calcularon las odds ratio (OR) para la clasificación (inicial y final) como SCA para cada variable independiente, crudas y ajustadas en modelos globales que incluían todas ellas. En estos modelos ajustados se comparó si las OR para la clasificación inicial y final como SCA eran significativamente diferentes. RESULTADOS: Se incluyeron 34.552 visitas. Las 33 variables analizadas mostraron asociación significativa para la clasificación inicial y final del DTNT como SCA, y en muchos casos esta asociación se mantuvo en el modelo ajustado. Diecinueve variables mostraron OR significativamente diferentes para la sospecha inicial de SCA que para el diagnóstico final de SCA: 10 sobrestimaban la asociación final y 9 la subestimaban. CONCLUSIONES: Los datos clínicos iniciales clásicamente utilizados para sospechar SCA pacientes con DTNT en urgencias identifican todos ellos individualmente a pacientes con riesgo incrementado de ser clasificado inicial y finalmente como SCA; sin embargo, algunos de ellos sobreestiman y otros subestiman inicialmente el riesgo final. Los urgenciólogos debieran sensibilizarse más con estos datos subestimados.

Predictors and outcomes of frequent chest pain unit users.

AIM: To determine predictors of frequent chest pain unit (CPU) users and to identify characteristics and outcomes of their CPU visits. PATIENTS AND METHODS: Observational prospective case-control study. Frequent CPU user was defined by 3 or more CPU visits within the study year. A control patient and a control visit were randomly selected for each case patient and case visit. Demographic, clinical, and outcome variables were collected from medical record and phone interview performed in a 30-day interval. A multivariate logistic regression analysis was used to identify frequent CPU users' predictors. RESULTS: Of 1934 patients presenting during the year, 80 (4.1%) met the definition for case patient. They accounted for 352 (13%) of 2709 CPU visits. Sixty-seven (83.7%) case patients and 71 (88.7%) control patients were contacted. The final predictors were the following: Karnofsky Performance Scale of 70 or lesser (odds ratio [OR], 5.24 [95% confidence interval {CI}, 1.71-16.06]), previous hospitalization (OR, 3.76 [95% CI, 1.49-9.49]), previously known coronary artery disease (OR, 3.72 [95% CI, 1.32-10.52]), and symptoms of depression (OR, 2.98 [95% CI, 1.14-7.78]). Case visits were more likely at night (OR, 2.41 [95% CI, 1.64- 3.52]), generated more diagnostic uncertainty (OR, 2.39 [95% CI, 1.71-3.35]), but did not increase the need of hospital admission. CONCLUSIONS: Frequent CPU user is associated with previously known coronary artery disease, previous hospitalization, impaired performance status, and presence of symptoms of depression. They are more likely to arrive on CPU at night and generate more diagnostic uncertainty.

Changes in cases of nontraumatic chest pain treated in a chest pain unit over the 10-year period of 2008-2017. / Evolución de las características de las visitas por dolor torácico no traumático en una unidad de dolor torácico durante un periodo de 10 años (2008-2017).

OBJECTIVES: To analyze changes in the characteristics of consecutively treated patients attended in the chest pain unit of a hospital emergency department over a 10-year period. MATERIAL AND METHODS: All patients presenting with nontraumatic chest pain (NTCP) were included. We analyzed changes over time in epidemiologic characteristics, initial diagnostic classification (on clinical and electrocardiographic evaluation), final diagnosis (on discharge), and time until these diagnoses. RESULTS: A total of 34 552 consecutive patients with a mean (SD) age of 59 (13) years were included; 42% were women. The annual number of visits rose over time. Visits were fewer in summer and more numerous on workdays and between the hours of 8 AM and 4 PM (P<.001, both comparisons). The number of women increased over time (up 0.29% annually, P<.05) as did the number of patients under the age of 50 years (up 0.92% annually, P<.001). With time, patients had fewer cardiovascular risk factors and less often had a history of ischemic heart disease. Fewer cases of NTCP had signs suggestive of acute coronary syndrome (ACS). ACS was ruled out at the time of initial and final diagnoses in 52.2% and 80.4%, respectively, and these percentages which rose over the 10-year period by 1.86% (P<.001) and 0.56% (P=.04). Time to initial diagnosis did not change. However, time to final diagnosis did increase (P<.001), and the delay was longer in patients diagnosed with ACS (P<.001). CONCLUSION: The chest pain unit was more active at the end of the period, in keeping with the increase in patients with NTCP whose characteristics were not typical of coronary disease. The percentages of patients initially and finally diagnosed with ACS decreased with time.

OBJETIVO: Analizar la evolución de las características epidemiológicas de las visitas atendidas de forma consecutiva en una unidad de dolor torácico (UDT) de un servicio de urgencias hospitalario (SUH) durante un periodo de 10 años. METODO: Se incluyeron todas las visitas por dolor torácico no traumático (DTNT), analizándose la evolución temporal de las características epidemiológicas, de la clasificación diagnóstica inicial (evaluación clínica inicial y electrocardiograma) y final (al alta de la UDT), y los tiempos necesarios para alcanzar las mismas. RESULTADOS: Se incluyeron 34.552 pacientes consecutivos con una edad media 59 (DE 13) años, el 42% mujeres. Se observó un incrementó en el número anual de visitas a la UDT (p < 0,001), menor afluencia los meses de verano (p < 0,001), y mayor los días laborables (p < 0,001) y de 8-16 horas (p < 0,001). Se comprobó que progresivamente más pacientes eran mujeres (+0,29% anual, p < 0,05), menores de 50 años (+0,92%, p < 0,001), con más factores de riesgo cardiovascular, menos antecedentes de cardiopatía isquémica y con DTNT menos sugestivo de síndrome coronario agudo (SCA). La clasificación diagnóstica inicial y final descartó SCA en un 52,2% y un 80,4% de pacientes, respectivamente, hecho que aumentó progresivamente durante el periodo evaluado (+1,86%, p < 0,001; y +0,56%, p = 0,04; respectivamente). El tiempo de clasificación inicial no se modificó, pero se incrementó el necesario para la clasificación final (p < 0,001), que resultó superior en pacientes con diagnóstico final de SCA (p < 0,001). CONCLUSIONES: Se observa un mayor uso de la UDT tras su creación, causado por un incremento de pacientes con DTNT de características no típicamente coronarias, disminuyendo el porcentaje de clasificados inicial y finalmente como debidos a SCA.

[Failure of a special winter programme aimed to alleviate negative effects of winter overload on an emergency department]. / Cuantificación de los efectos negativos de la sobrecarga invernal en urgencias y de la efectividad de las medidas extraordinarias invernales para paliarlos.

BACKGROUND AND OBJECTIVE: We aimed: a) to determine changes in patient flow, and in emergency department (ED) effectiveness and quality that may happen depending on the season (winter/non-winter), and b) to analyze effects on those changes when a special winter programme (SWP) of the Pla Integral d'Urgències de Catalunya (PIUC) is applied. MATERIAL AND METHOD: We studied 4 weeks of each period: non-winter period, winter control period (without SWP), winter period with SWP. Within the 3 periods, the daily census was taken as a proxy of external pressure, and the number of patients admitted to the hospital from the ED as a proxy of internal pressure. In each period, effectiveness markers--ED occupancy rate, rate of ED patients waiting for a bed, waiting time (WT) and number of patients waiting to be seen (PW), length of stay-- objective quality markers -revisit rate, rate of patients left without being seen, rate of patients left against medical advise (LAMA), and mortality rate-, and subjective quality markers -patient satisfaction with the physician, the nurse, the general ED organization, and level of complaint solution- were recorded. RESULTS: Compared to the non-winter period, in the winter period without SWP the daily census rose by 6% (p = 0.07), and the number of patients admitted 10.8% (p = 0.16). These increases went along with a worsening of almost all effectiveness and quality markers, although only PW (+63%; p < 0.01), WT (+130%; p < 0.001), length of stay (+28%; p < 0.05), rate of patients left without being seen (+97%; p < 0.001) and LAMA (+218%; p < 0.05) reached statistical significance. In the winter period with SWP, the daily census kept stable but the number of patients admitted grew by 18% (p < 0.01). The SWP improved some subjective quality markers (patient satisfaction with the physician and the nurse), but failed to improve any effectiveness or objective quality marker. Some of them got even worse within the SWP period: ED occupancy rate, +20% (p = 0.001); PW, +42% (p < 0.05), and WT, +56% (p < 0.05). CONCLUSIONS: In winter, a worsening of ED effectiveness and quality can be expected. Measures from the SWP prepared by the Administration are unable to correct such deterioration. A profound analysis of the SWP is suggested.

Triage flowchart to rule out acute coronary syndrome.

AIM: The aim of the study was to establish a triage flowchart to rule out acute coronary syndrome (ACS) among patients with chest pain (CP) arriving on an Emergency Department (ED). PATIENTS AND METHOD: This prospective observational study included 1000 consecutive patients with CP arriving on an ED CP unit. Demographic and clinical characteristics along with vital signs were recorded as independent variables. After CP unit protocol completion and 1-month follow-up, patients were classified as (dependent variable) (1) true non-ACS (all noncoronary patients at the first visit that kept this condition when called 1 month later) or (2) true ACS (all the remaining patients). Relationship among variables was assessed by multiple logistic regression analysis. A triage flowchart was obtained from significant variables and applied to patients with CP who were then grouped in "triage non-ACS" and "triage ACS." Validity indexes to exclude ACS for triage flowchart were measured. RESULTS: Variables significantly associated with non-ACS and included in the triage flowchart were age <40 years (odds ratio 3.61, 95% CI 1.63-7.99), absence of diabetes (2.74, 1.53-4.88), no previously known coronary artery disease (5.46, 3.42-8.71), nonoppressive pain (10.63, 6.04-18.70), and nonretrosternal pain (5.16, 2.82-9.42). For the triage flowchart, both specificity and positive predictive value to rule out ACS were 100%. CONCLUSIONS: The triage flowchart is able to accurately identify patients with CP not having an ACS. It may help triage nurses make quick decisions on who should be immediately seen and who could safely wait when delays in medical attention are unavoidable. Prospective validation is needed.

[Treatment of atrial fibrillation at different levels of health care]. / Tratamiento de la fibrilación auricular en los distintos niveles asistenciales de un área sanitaria.

BACKGROUND AND OBJECTIVE: Atrial fibrillation is managed in multiple settings by different specialists. We sought to analyze treatment and compliance of the prevailing guidelines of patients with atrial fibrillation attended at different levels of health care and to quantify interventions to correct treatment inadequacies. PATIENTS AND METHOD: We included all adult patients with atrial fibrillation who presented during a 14 day-period to different levels of health care of a tertiary hospital and a related primary care clinic (family physician, cardiologist, emergency department, hospitalization). In all of them, clinical and epidemiological data in relation to atrial fibrillation, and all data referring to treatment and compliance of guidelines, were recorded prospectively. RESULTS: 293 patients were included. Clinical and epidemiological data were similar in the different settings. A great diversity in atrial fibrillation treatment was observed. In 30 and 33% of the patients, antiarrhythmic and antithrombotic treatment, respectively, did not meet the recommendations of the prevailing guidelines. The adequacy was inferior in primary care. The adequacy percentages increased slightly after the medical attention (2 and 3% respectively, p non significant) with no differences in this increase between the different settings. CONCLUSIONS: There are no epidemiological differences between patients with atrial fibrillation treated at different levels of health care. An important number of patients do not follow the recommendations of the prevailing guidelines. There is a clear medical abstention in incorrectly treated cases.

Análisis individualizado por sexo de los factores asociados a la clasificación inicial errónea en urgencias del dolor torácico como no coronario / Factors associated with erroneous emergency department noncardiac chest pain classifications in men and women

Introducción. Analizar de forma independiente en mujeres y hombres la frecuencia y las características clínicas asociadas a una clasificación inicial errónea (CIE) en urgencias del dolor torácico (DT) como no coronario. Método. Se analizan todas las consultas por DT atendidas en urgencias entre 2008 y 2017 clasificadas inicialmente (historia clínica y ECG) como DT no coronario. Se consideró como CIE si el diagnóstico final fue síndrome coronario agudo (SCA). Se crearon dos modelos multivariable, uno con 10 factores de riesgo, y otro con 10 características clínicas del DT, en los que se investigó la asociación de estas variables con una CIE. Se analizaron independientemente mujeres y hombres. Resultados. Se analizaron 8.093 mujeres con DT clasificado inicialmente como no coronario (edad mediana: 54 años, RIC: 38-73), 72 con CIE (0,9%). Los factores de riesgo asociados independientemente a CIE fueron obesidad (OR = 0,40; IC 95% = 0,17-0,97) y consumo de cocaína (5,18; 1,16-23,2), y las características clínicas fueron relación con el esfuerzo (2,01; 1,21-3,33), existencia de irradiación (2,05; 1,23-3,41) y síntomas vegetativos acompañantes (1,86; 1,02-3,41). Se analizaron 9.979 hombres (edad mediana: 47 años, RIC: 33-64), 83 con CIE (0,8%). Los factores de riesgo asociados a CIE fueron edad > 40 años (1,74; 1,04-2,91) e hipertensión (0,45; 0,24-0,84). No hubo características clínicas del DT asociadas a CIE. Conclusión. En las mujeres con dolor torácico, se identifican más características asociadas al error de clasificación que en los hombres. Este estudio remarca la necesidad de análisis independiente por sexo en el SCA, en el que clásica- mente se ha considerado la clínica en las mujeres como atípica. (AU)

Objective. To analyze the frequency and clinical characteristics associated with erroneous initial classifications of noncardiac chest pain (NCP) in men and women. Methods. We analyzed all case records in which chest pain was initially classified as noncardiac in origin according to clinical signs and electrocardiograms evaluated in our emergency department between 2008 and 2017. We considered the initial evaluation of NCP to be in error if the final diagnosis was acute coronary syndrome. A risk model for an erroneous initial classification of NCP was developed based on multivariable analysis of our patient data. We also used multivariable analysis to explore associations between 10 clinical signs of chest pain and an erroneous initial NCP classification. The data for men and women were analyzed separately. Results. NCP was the initial classification for 8093 women; their median (interquartile range) age was 54 (38-73) years. The classification was in error for 72 women (0.9%). Odds ratios (ORs) showed that patient risk factors associated with an erroneous NCP classification in the women in our series were obesity (OR, 0.40; 95% CI, 0.17- 0.97) and cocaine consumption (OR, 5.18; 95% CI, 1.16-23.2). Clinical risk factors associated with erroneous NCP classification in women were recent physical exertion (OR, 2.01; 95% CI, 1.21-3.33), radiation exposure (OR, 2.05; 95% CI, 1.23-3.41), and vegetative symptoms (OR, 1.86; 95% CI, 1.02-3.41). For 9979 men with a median age of 47 (33-64) years, NCP was the initial classification; in 83 of the men (0.8%) the classification was erroneous. Patient factors associated with erroneous NCP classification in men were age over 40 years (OR, 1.74; 95% CI, 1.04-2.91) and hypertension (OR, 0.45; 95% CI, 0.24-0.84). No clinical signs of chest pain in men were associated with error. Conclusions. More clinical characteristics are associated with an erroneous classification of NCP in women. [...] (AU)

[Lack of inhospital beds: impact on emergency department performance]. / Repercusión de la falta de camas de hospitalización en la actividad de un servicio de urgencias hospitalario.

BACKGROUND AND OBJECTIVE: To determine the effect that the lack of inhospital beds exerts on emergency department performance. MATERIAL AND METHOD: Two different time periods with comparable daily census, but significantly different bed availability. Variables assessed were general emergency department performance markers, emergency department effectiveness markers and objective and subjective quality markers. RESULTS: All variables got worse within lower bed availability period, and reached a change magnitude between 0% and 300% when compared with control period. However, a statistical difference was only achieved in emergency department occupation rate (+14%; p < 0.001), rate of patients waiting to be admitted (+100%; p < 0.001), patients waiting to be seen (+60%; p < 0.01), waiting time to be seen (+83%; p < 0.001), time to employed for first medical assessment and treatment (+44%; p < 0.01), and patients left without being seen (+90%; p < 0.05). CONCLUSIONS: The lack of inhospital beds for patients admitted from the emergency department leads to a remarkable worsening in its function and performance.

[Estimation of emergency department activity and its relationship with inhospital bed disposition]. / Estimación de la actividad en urgencias y su relación con la provisión de camas de hospitalización.

BACKGROUND AND OBJECTIVE: To find out if the daily emergency department (ED) census and daily ED admittances can accurately be foreseen based on the number of visits arrived on ED within the first shift hours. PATIENTS AND METHOD: For 6 consecutively months, the number of ED visits from 6 AM to 10 AM (early visits), and from 10 AM to next day 6 AM (daily ED census) was recorded, along with the number of both daily hospital and ED admittances from 6 AM to 6 AM. The analysis was performed for the ED as a whole, and for each one of its sections. RESULTS: A significant direct correlation was seen between the early visits and daily ED census. This relationship was even greater as considered the ED as a whole (R2 = 0.25; p < 0.001). A direct correlation was also found between daily ED census and daily admittances (R2 = 0.19; p < 0.001). CONCLUSIONS: The number of early ED visits is an important tool to accurately predict the daily ED census and the number of in-hospital beds needed for ED patients.