Evaluating the effectiveness of evidence-based guidelines for the use of spacer devices in children with acute asthma

OBJECTIVE: To change standard practice from using nebulisers to metered dose inhalers and holding chambers (spacers) in children presenting with mild to moderate acute asthma. DESIGN: A before-after comparison of children with acute asthma presenting to the emergency department (ED) between August and October 1999 with those presenting between June and August 1997. SETTING: A tertiary care metropolitan children's hospital. INTERVENTIONS: Evidence-based clinical practice guidelines for using spacers were developed by a local multidisciplinary consensus process. A multifaceted guideline implementation program was used in 1999. MAIN OUTCOME MEASURES: Physician prescribing practices (spacer use); clinical outcomes (need for hospitalisation, admission to intensive care unit, and length of stay [LOS]). RESULTS: 75 of 247 children (30%; 95% CI, 25%-36%) required hospital admission in 1999. This was similar to the 1997 study period, when 95 of 326 (29%; 95% CI, 24%-34%) children were admitted. Of those with mild to moderate asthma, 160 (68%) received bronchodilators in the ED; 151 (94%) were initially treated with a spacer device in 1999. In 1997, no children were initially treated with spacers in the ED. The median (range) LOS in hospital for children with asthma of all severities was 1.7 (0.5-19.8) days in 1999 and 1.7 (0.2-7.6) days in 1997 (P=0.85). CONCLUSIONS: We successfully changed standard practice from using nebulisers to spacers for bronchodilator delivery in children with mild to moderate acute asthma, with no difference in the need for or duration of hospitalisation.     

Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial

CONTEXT: Delayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality. OBJECTIVE: To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use. DESIGN AND SETTING: The Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states. PARTICIPANTS: A total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease-related diagnosis. INTERVENTION: One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801). MAIN OUTCOME MEASURES: Time from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs. RESULTS: General population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0.6%), but the change did not differ significantly from that observed in reference communities (-6. 8% per year; 95% CI, -14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly. CONCLUSIONS: In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI. JAMA. 2000;284:60-67     

Do management algorithms improve chest pain triage?

OBJECTIVE: To audit the use of management algorithms for chest pain in an emergency department. DESIGN AND SETTING: Prospective study of all patients with chest pain presenting to the emergency department of an urban teaching hospital between 12 January and 4 May 1997. Staff were asked to complete a standardised admission form that incorporated the risk stratification algorithms for managing patients with suspected acute coronary syndrome. MAIN OUTCOME MEASURES: Compliance with the use of management algorithms; concordance with a cardiologist's review of the triage grouping and admission/discharge decision; and major cardiovascular events over four months. RESULTS: Emergency department staff documented the triage group in 223 of 503 cases (45%). Concordance with the group assigned by a cardiologist was 70% (kappa = 0.73; SE kappa = 0.04). When the management algorithm was applied correctly, 92% of triage decisions were correct (95% confidence interval [CI], 87%-96%). The triage decision was less often correct when risk stratification was not done (78% [73%-83%], P < 0.001), overestimated (77% [66%-88%], P < 0.01), or underestimated (50% [18%-82%], P < 0.001). The proportion of patients free of major cardiovascular events at four-month follow-up was 50% for those with myocardial infarction with ST-segment elevation, 47% for those with a high short-term risk of an adverse cardiac event, 82% for those with intermediate risk, and 99% for those with a low risk or non-coronary chest pain (P < 0.001). CONCLUSIONS: Use of management algorithms by emergency staff was poor. When used, triage decisions were more likely to be correct. Subsequent outcome confirms that the NHMRC risk stratification algorithms are useful for prognostic stratification of patients with suspected acute coronary syndrome.     

Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia

OBJECTIVE: To estimate the appropriateness of emergency department (ED) presentations by people aged>or=65 years living in residential care facilities. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study of older residents of residential care facilities who presented to the ED of the Royal Perth Hospital, Western Australia, between January and June 2002. Data were reviewed by an expert clinical panel. MAIN OUTCOME MEASURES: Appropriateness of ED presentation, presenting complaint, involvement of a general practitioner/locum doctor prior to transfer, proportion of patients admitted to hospital from the ED, survival to discharge. RESULTS: 541 residents aged>or=65 years were transferred by ambulance to the ED, comprising 8.3% of all ED presentations of people in this age group. The mean age of the study cohort was 83.7 years (SD, 7.0 years), of which 68% were women. Of the 541 presentations, 326 (60%) resulted in hospital admission, and of these, 276 (85%) survived to hospital discharge. Musculoskeletal disorders accounted for 25% of all presentations, and 22% were falls-related; pneumonia (11% of presentations) was the single largest presenting complaint. ED attendance was deemed "inappropriate" for 71/541 cases (13.1%; 95% CI, 10.5%-16.2%); in only 25% of ED presentations was a GP/locum doctor involved prior to transfer. CONCLUSIONS: The majority of ED presentations by aged care residents were considered to be appropriate, but there was scope for improvement in coordinating care between the hospital ED and residential care institutions.     

Measurement of cardiac troponin I levels in the emergency department: predictive value for cardiac and all-cause mortality

OBJECTIVE: To assess the predictive value of cardiac troponin I levels in cardiac and all-cause mortality in patients presenting to an emergency department. DESIGN: A prospective cohort study. SETTING: The emergency department of a major tertiary teaching hospital in metropolitan Melbourne over a six-week period in 1998. PATIENTS: All patients with requests for cardiac enzyme level measurement. MAIN OUTCOME MEASURES: Cardiac and all-cause mortality within 30 days of presentation. RESULTS: 424 patients (232 men, 192 women; age range, 16-93 years) were reviewed. The 30-day mortality rate was 7.3% (31/424); in patients with raised levels of both creatine kinase (CK)-MB isoenzyme and troponin I this rate was 27% (7/26; 95% CI, 13%-44%); and in those with troponin I levels above 2 microg/L, but normal CK-MB values, it was 24% (5/21; 95% CI, 5%-43%). The mortality rate in the group with normal results of cardiac markers was 4.3% (14/328; 95% CI, 2.1%-6.5%). Patients with minor increases in troponin I levels (minimal myocardial damage) showed an intermediate 30-day mortality rate (13%, 5/39; 95% CI, 2%-24%). Other predictors of 30-day mortality included age, presentation with shortness of breath, and electrocardiography (ECG) changes diagnostic of acute myocardial infarction or consistent with ischaemia. Cardiovascular causes were responsible for most of the deaths in patients with raised troponin I levels. Multivariate logistic regression analysis showed that raised levels of troponin (> 2.0 microg/L), but not of CK-MB, predict 30-day mortality rate. CONCLUSIONS: Compared with CK-MB, cardiac troponin I more accurately predicts 30-day mortality rates in patients presenting to the emergency department. Moreover, troponin I levels identify additional groups of patients at increased risk of death not so identified by measuring CK-MB values.     

降钙素原评价急性冠脉综合征的临床研究

目的：探讨降钙素原（ PCT）评价急性冠脉综合征的临床意义。方法：通过对急诊141例缺血性胸痛患者进行心肌标志物的测定,观察患者心脏不良事件（ MACE）发生率及死亡率,并进一步比较PCT与其他心肌标志物,如肌钙蛋白T（Tn-T）、肌酸磷酸激酶同工酶（CK-MB）、肌红蛋白及超敏C反应蛋白（Hs-CRP）在评价急性冠脉综合征中的临床意义。结果：PCT诊断心肌梗死敏感性为38.3％（95％CI 28.8％～47.3％）,特异性为77.8％（95％CI 70.0％～84.4％）,阳性似然比[LR（＋）]1.725,阴性似然比[LR（-）]0.792;复测PCT敏感性、特异性、LR （＋）及LR （-）分别为90.0％（95％CI 80.9％～95.7％）、59.3％（95％CI 52.5％～63.5％）、2.2及0.16。 PCT评价MACE、住院期间死亡率及自入院后1个月内、6个月内的死亡率敏感性及特异性分别为81.3％（95％CI 54％～95％）/40.8％（95％CI 32％～49％）、66.7％（95％CI 13％～98％）/38.4％（95％CI 30％～47％）、50％（95％CI 9％～90％）/38％（95％CI 30％～47％）、60％（95％CI 17％～92％）/38.2％（95％CI 30％～47％）。结论：对以缺血性胸痛为主要表现的患者来说,PCT不是诊断急性冠脉综合征有效的标志物,且对心肌梗死预后无准确的评价意义。     

All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time

OBJECTIVE: To quantify time doctors in hospital wards spend on specific work tasks, and with health professionals and patients. DESIGN: Observational time and motion study. SETTING: 400-bed teaching hospital in Sydney. PARTICIPANTS: 19 doctors (seven registrars, five residents, seven interns) in four wards were observed between 08:30 and 19:00 for a total of 151 hours between July and December 2006. MAIN OUTCOME MEASURES: Proportions of time in categories of work; proportions of tasks performed with health professionals and patients; proportions of tasks using specific information tools; rates of multitasking and interruptions. RESULTS: The greatest proportions of doctors' time were in professional communication (33%; 95% CI, 29%-38%); social activities, such as non-work communication and meal breaks (17%; 95% CI, 13%-21%), and indirect care, such as planning care (17%; 95% CI, 15%-19%). Multitasking involved 20% of time, and on average, doctors were interrupted every 21 minutes. Most tasks were completed with another doctor (56%; 95% CI, 55%-57%), while 24% (95% CI, 23%-25%) were undertaken alone and 15% (95% CI, 15%-16%) with a patient. Interns spent more time completing documentation and administrative tasks, and less time in direct care than residents and registrars. The time interns spent documenting (22%) was almost double the time they were engaged in direct patient care. CONCLUSIONS: Two-thirds of doctors' time was consumed by three work categories: professional communication, social activities and indirect care. Doctors on wards are interrupted at considerably lower rates than those in emergency and intensive care units. The results confirm interns' previously reported dissatisfaction with their level of administrative work and documentation.     

急性非创伤性胸痛的临床研究

目的探讨急性非创伤性胸痛病因及早期诊断方法。方法总结226例以急性非创伤性胸痛为主要症状患者的临床资料,进行病因和诊断方法的统计分析。结果以急性胸痛为主要表现的非创伤性疾病中,心源性123例,占54.42%,其中稳定型心绞痛12例,占5.31%;急性冠脉综合征81例,占35.84%;非心源性胸痛103例,占45.58%,以肺炎、支气管炎最为常见（31例,占13.72%）。两者在年龄、性别、心血管危险因素构上差异有统计学意义（P〈0.05）;结论急性胸痛的病因复杂,治疗方法不尽相同,医生应思路清晰,尽快明确诊断,使高危患者得到及时救治。     

Sex differences in evaluation and outcome of unstable angina

CONTEXT: The existence of sex bias in the delivery of cardiac care is controversial, and little is known about the association between sex and delivery of care and outcomes at an early point in the diagnostic sequence, such as when patients present for the evaluation of chest pain. OBJECTIVE: To test the hypothesis that female sex is negatively associated with care delivered to and outcomes of persons diagnosed as having unstable angina. DESIGN: Inception population-based cohort study with an average of 6 years of follow-up. SETTING: Emergency departments (EDs) in Olmsted County, Minnesota. PATIENTS: A total of 2271 Olmsted County residents (1306 men and 965 women) who presented to the ED for the first time with symptoms meeting criteria for unstable angina between 1985 and 1992. MAIN OUTCOME MEASURES: Use of cardiac procedures within 90 days of ED visit, overall mortality, and cardiac events (cardiac death, nonfatal myocardial infarction, nonfatal cardiac arrest, and congestive heart failure), compared by sex and Agency for Health Care Policy and Research cardiovascular risk category (low, intermediate, or high). RESULTS: Women were older (P<.001), more likely to have a history of hypertension (P = .001), and less likely to present with typical angina (P = .004) than men. Men were more likely than women to undergo noninvasive cardiac tests (relative risk [RR], 1.27; 95% confidence interval [CI], 1.14-1.40) as well as invasive cardiac procedures (RR, 1.72; 95% CI, 1.51-1.97). After adjustment, male sex was associated with a 24% increase in the use of cardiac procedures. Survival of both men and women in the high and intermediate risk categories was significantly lower than expected per the general population (P<.001). Women had a worse outcome than men, but after multivariate adjustment, male sex was associated with a trend toward an increase in the risk of death (RR, 1.23; 95% CI, 0.99-1.54) and significantly associated with increased risk of cardiac events (RR, 1.21; 95% CI, 1.03-1.42). CONCLUSIONS: Our population-based data indicate that after an ED visit for symptoms of unstable angina, the use of cardiac procedures was lower in women, but after taking into account baseline characteristics, men experienced worse outcomes.     

Risk factors for ischaemic stroke recurrence after hospitalisation

OBJECTIVE: To determine risk factors for ischaemic stroke recurrence among patients admitted to hospital for a first-ever occurrence of ischaemic stroke. DESIGN, SETTING AND PATIENTS: Retrospective study involving linked hospitalisation and death records. The cohort comprised 7816 people who were hospitalised for first-ever ischaemic stroke between July 1995 and December 1999 in Western Australia. Cox's proportional hazards model was used to identify risk factors for stroke recurrence. MAIN OUTCOME MEASURES: Time to first recurrence; cumulative recurrence risk; risk factors for recurrence. RESULTS: The median time to first stroke recurrence was 255 days. The cumulative probability of first recurrence was 5.1% (95% CI, 4.6%-5.7%) at 6 months, 8.4% (95% CI, 7.6%-9.1%) at 1 year and 19.8% (95% CI, 18.1%-21.4%) at 4 years. The risk of first recurrence was increased by advancing age (hazard ratio [HR], 1.03; 95% CI, 1.02-1.04), Aboriginality (HR, 1.50; 95% CI, 1.02-2.22), diabetes (HR, 1.27; 95% CI, 1.07-1.51), a history of cardiac conditions (HR, 1.18; 95% CI, 1.01-1.38), post-stroke urinary incontinence (HR, 1.27; 95% CI, 1.03-1.57) and transfer to another hospital on index admission (HR, 1.26; 95% CI, 1.08-1.46). Admission at first stroke occurrence to a hospital maintaining a stroke unit reduced the risk of recurrence (HR, 0.84; 95% CI, 0.72-0.99). CONCLUSION: The risk factors identified in our study have implications for planning secondary prevention strategies. In particular, Aboriginality and transfer to another hospital upon admission for first-ever ischaemic stroke were important risk factors. Research into the level of compliance and access to stroke treatment by Aboriginal patients to prevent further strokes is required.     

The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments

OBJECTIVE: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission. DESIGN: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records. SETTING: Three tertiary metropolitan hospitals between July 2000 and June 2003. PARTICIPANTS: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period. MAIN OUTCOME MEASURES: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital. RESULTS: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r=0.98; 95% CI, 0.79-1.00). An Overcrowding Hazard Scale>2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1-1.6), 1.3 (95% CI, 1.2-1.5) and 1.2 (95% CI, 1.1-1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale>2 compared with one of <3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1-1.1; P<0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1-1.3; P=0.01). CONCLUSIONS: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.     

Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department

Context  Emergency department (ED) physicians often are uncertain about wherein the hospital to triage patients with suspected acute cardiac ischemia.Many patients are triaged unnecessarily to intensive or intermediate cardiaccare units. Objective  To determine whether use of a clinical decision rule improves physicians'hospital triage decisions for patients with suspected acute cardiac ischemia. Design and Setting  Prospective before-after impact analysis conducted at a large, urban,US public hospital. Participants  Consecutive patients admitted from the ED with suspected acute cardiacischemia during 2 periods: preintervention group (n = 207 patients enrolledin March 1997) and intervention group (n = 1008 patients enrolled in August-November1999). Intervention  An adaptation of a previously validated clinical decision rule was adoptedas the standard of care in the ED after a 3-month period of pilot testingand training. The rule predicts major cardiac complications within 72 hoursafter evaluation in the ED and stratifies patients' risk of major complicationsinto 4 groups—high, moderate, low, and very low—according to electrocardiographicfindings and presence or absence of 3 clinical predictors in the ED. Main Outcome Measures  Safety of physicians' triage decisions, defined as the proportion ofpatients with major cardiac complications who were admitted to inpatient cardiaccare beds (coronary care unit or inpatient telemetry unit); efficiency ofdecisions, defined as the proportion of patients without major complicationswho were triaged to an ED observation unit or an unmonitored ward. Results  By intention-to-treat analysis, efficiency was higher in the interventiongroup (36%) than the preintervention group (21%) (difference, 15%; 95% confidenceinterval [CI], 8%-21%; P<.001). Safety was notsignificantly different (94% in the intervention group vs 89%; difference,5%; 95% CI, -11% to 39%; P = .57). Subgroupanalysis of intervention-group patients showed higher efficiency when physiciansactually used the decision rule (38% vs 27%; difference, 11%; 95% CI, 3%-18%; P = .01). Improved efficiency was explained solely by differenttriage decisions for very low-risk patients. Most surveyed physicians (16/19[84%]) believed that the decision rule improved patient care. Conclusions  Use of the clinical decision rule had a favorable impact on physicians'hospital triage decisions. Efficiency improved without compromising safety.      

A case for more year-long internships outside metropolitan areas?

OBJECTIVE: To determine whether medical graduates who spent their intern year at a non-metropolitan hospital were more likely to practise outside metropolitan areas on completion of training than were interns in metropolitan hospitals. DESIGN: Retrospective follow-up of doctors who held year-long internships at a non-metropolitan hospital and interns from metropolitan hospitals. SETTING: Ballarat Base Hospital (BBH) (Rural, Remote and Metropolitan Area [RRMA] rural zone) and hospitals in Melbourne and Geelong (RRMA metropolitan zone). PARTICIPANTS: 57/63 (90%) Victorian medical graduates completing internships at BBH between 1989 and 1997 and 126/126 (100%) sex-matched metropolitan interns, chosen at random. MAIN OUTCOME MEASURES: Practice location in 2002. RESULTS: More BBH interns were practising as GPs outside metropolitan areas (44%) than metropolitan interns (13%) (difference, 31%; 95% CI, 17%-45%). The proportion of interns in specialist practice outside metropolitan areas was small for both groups - zero and 3%, respectively (difference, - 3%; 95% CI, - 6% to 0). None of the specialist training posts held by interns were outside metropolitan areas. Of BBH interns entering general practice, 41% (95% CI, 24%-58%) did so in the local health region. CONCLUSIONS: Regional interns are a good source of non-metropolitan GPs, especially locally. Prospective studies to determine the precise influence of regional internships on eventual practice location, and whether more such posts would lead to more graduates entering non-metropolitan practice, would be worthwhile.     

Higher neonatal morbidity after routine early hospital discharge: Are we sending newborns home too early?

BACKGROUND: A growing body of evidence suggests that the trend toward earlier discharge may affect newborn morbidity. The authors assessed how hospital readmission rates were affected by a clinical guideline aimed at discharging newborns from hospital 24 hours after birth. METHOD: A retrospective before-after cohort study was conducted involving 7009 infants born by uncomplicated vaginal delivery at a large level II hospital in Toronto between Dec. 31, 1993, and Sept. 29, 1997. The primary outcome was a comparison of the rate of hospital readmission among newborns before (5936 infants) and after (1073 infants) the early-discharge policy was implemented (Apr. 1, 1997). The causes for readmission were secondary outcomes. RESULTS: Before the early-discharge guideline was implemented, the mean length of stay declined from 2.25 days (95% confidence interval [CI] 2.18-2.32) to 1.88 days (95% CI 1.84-1.92) (p < 0.001). After implementation there was a further decline, to 1.62 days (95% CI 1.56-1.67) (p < 0.001). A total of 126 infants (11.7%) in the early-discharge cohort required readmission by 1 month, as compared with 396 infants (6.7%) in the preguideline cohort (odds ratio 1.86, 95% CI 1.51-2.30). The main reason for early readmission was neonatal jaundice, with a higher rate among infants in the early-discharge cohort than among those in the preguideline cohort (8.6% v. 3.1%; odds ratio 2.96, 95% CI 2.29-3.84). INTERPRETATION: Decreases in newborn length of stay may result in substantial increases in morbidity. Careful consideration is needed to establish whether a reduction in length of stay to less than 24 to 36 hours is harmful to babies.     

Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial

Context  Observational studies of acute myocardial perfusion imaging in emergency department (ED) patients with chest pain have suggested high sensitivity and negative predictive value for acute cardiac ischemia, but use of this method has not been prospectively tested. Objective  To assess whether incorporating acute resting perfusion imaging into an ED evaluation strategy for patients with suspected acute ischemia but no initial electrocardiogram (ECG) changes diagnostic of acute ischemia improves clinical decision making for initial ED triage. Design, Setting, and Patients  Prospective, randomized controlled trial conducted at 7 academic medical centers and community hospitals between July 1997 and May 1999 among 2475 adult ED patients with chest pain or other symptoms suggestive of acute cardiac ischemia and with normal or nondiagnostic initial ECG results. Intervention  Patients were randomly assigned to receive either the usual ED evaluation strategy (n = 1260) or the usual strategy supplemented with results from acute resting myocardial perfusion imaging using single-photon emission computed tomography with injection of 20 to 30 mCi of Tc-99m sestamibi (n = 1215), interpreted in real time by local staff physicians and with results provided to the ED physician for incorporation into clinical decision making. Main Outcome Measure  Appropriateness of triage decision either to admit to hospital/observation or to discharge directly home from the ED. Results  Among patients with acute cardiac ischemia (ie, acute myocardial infarction [MI] or unstable angina; n = 329), there were no differences in ED triage decisions between those receiving standard evaluation and those whose evaluation was supplemented by a sestamibi scan. Among patients with acute MI (n = 56), 97% vs 96% were hospitalized (relative risk [RR], 1.00; 95% confidence interval [CI], 0.89-1.12), and among those with unstable angina (n = 273), 83% vs 81% were hospitalized (RR, 0.98; 95% CI, 0.87-1.10). However, among patients without acute cardiac ischemia (n = 2146), hospitalization was 52% with usual care vs 42% with sestamibi imaging (RR, 0.84; 95% CI, 0.77-0.92). Conclusions  Sestamibi perfusion imaging improves ED triage decision making for patients with symptoms suggestive of acute cardiac ischemia without obvious abnormalities on initial ECG. In this study, unnecessary hospitalizations were reduced among patients without acute ischemia, without reducing appropriate admission for patients with acute ischemia.      

Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program

OBJECTIVES: To determine if an integrated clinical risk management program that detects adverse patient events in a hospital, analyses their risk and takes action can alter the rate of adverse events. DESIGN: Longitudinal survey of adverse patient events over eight years of progressive implementation of the risk management program. PARTICIPANTS AND SETTING: 49,834 inpatients (July 1991 to September 1999) and 20,050 emergency department patients (October 1997 to September 1999) at a rural base hospital in the Wimmera region of Victoria. MAIN OUTCOME MEASURES: Rates of adverse events detected by medical record review and clinical incident and general practitioner reporting. RESULTS: The annual rate of inpatient adverse events decreased between the first and eighth years of the study from 1.35% of all patient discharges (69 events) to 0.74% (49 events) (P<0.001). Absolute risk reduction was 0.61% (95% CI, 0.23%-0.99%), and relative risk reduction was 44.9% (95% CI, 16.9%-72.9%). The quarterly rate of emergency department adverse events decreased between the first and eighth quarters of monitoring from 3.26% of all attendances (84 events) to 0.48% (12 events) (P< 0.001). Absolute risk reduction was 2.78% (95% CI, 2.04%-3.52%), and relative risk reduction was 85.3% (95% CI, 62.7%-100%). CONCLUSIONS: Adverse patient events can be detected, and their frequency reduced, using multiple detection methods and clinical improvement strategies as part of an integrated clinical risk management program.