Cardiology/original researchEmergency Department Triage of Acute Myocardial Infarction Patients and the Effect on Outcomes
Introduction
Acute myocardial infarction remains a leading cause of mortality in the US1 despite numerous therapies known to increase survival.2, 3, 4, 5, 6 Given that 6 million patients with chest pain are evaluated in US emergency departments (EDs) each year,7 a key challenge is ensuring that acute myocardial infarction patients are appropriately identified and that time-sensitive treatments are rapidly administered. Currently, performance on key acute myocardial infarction quality measures,8, 9 such as time to reperfusion, exceeds the recommended benchmark time in more than half of all acute myocardial infarction patients.10, 11, 12, 13, 14, 15
The influence of ED systems factors on these acute myocardial infarction quality measures is not well understood. Virtually all patients who present to an ED are initially assessed by a trained triage nurse; despite potentially determining such crucial factors as the timing and the location of subsequent ED care,16 the effect of the ED triage score on acute myocardial infarction quality of care has not been studied, to our knowledge. In Canada, virtually all EDs17 use the Canadian Triage and Acuity Scale18 to perform ED triage. This uniformity provides an opportunity to study the effect of triage across a population level. Australia uses a similar tool,19 whereas in the United States several triage tools are used.20
Triage assessments may be an important modifiable factor influencing treatment delays for acute myocardial infarction patients. We hypothesized that a relatively small proportion of acute myocardial infarction patients are assigned a low-acuity triage score and that this would be associated with subsequent diagnostic and treatment delays. Because the ED is a complex environment, however, a low triage score may not automatically result in fixed delays: a previous study on ED triage found that patients who are given a triage score of III actually wait longer to see a physician than those who receive a IV or V.21 Nor is it known to what extent triage delays acute myocardial infarction management, if it does. Our objectives in this study were to establish the frequency of low triage scores among acute myocardial infarction patients presenting to EDs in Ontario, Canada, and to determine the magnitude of the effect of a low ED triage score on time to ECG and time to reperfusion.
Section snippets
Study Design
This retrospective cohort study linked a population-based sample of acute myocardial infarction patients to an administrative database of all ED records in the province of Ontario, Canada, from July 2000 to March 2001, the period during which the 2 data sets overlapped. We obtained ethics approval from Sunnybrook Health Sciences Centre.
Setting
The Enhanced Feedback For Effective Cardiac Treatment (EFFECT) study contains a population-based sample of acute myocardial infarction patients from the province
Results
We linked inhospital records to ED visits for 3,088 (73.4%) of 4,210 acute myocardial infarction patients in EFFECT. Baseline characteristics of the entire study cohort are provided in Table 1. Of the 3,088 acute myocardial infarction patients, 1,552 (50.3%) were assigned a low acuity triage score. Almost half of the cohort had criteria for a STEMI (47.9%). The median door-to-ECG time for the cohort was 12.0 minutes (interquartile range [IQR] 5.0 to 24.0), and the median door-to-needle time for
Limitations
One limitation of this study was the use of only admitted acute myocardial infarction patients. This probably results in a conservative bias because we did not capture the patients who were discharged home from the ED (ie, their acute myocardial infarction was missed entirely), which might occur more frequently in acute myocardial infarction patients who are given a low-acuity triage score. Another limitation was retrospective data collection, with some of the inherent limitations of chart
Discussion
This population-based study of acute myocardial infarction patients in the province of Ontario found that half of all acute myocardial infarction patients, including 44% who had criteria for a STEMI, were assigned an inappropriately low triage score when they arrived in an ED. Low acuity triage score assignment was associated with substantial independent increases in median and 90th percentile door-to-ECG and door-to-needle times, including a 15-minute increase in median door-to-needle time and
References (54)
- et al.
ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarctionA report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina)
J Am Coll Cardiol
(2000) - et al.
Emergency department crowding and thrombolysis delays in acute myocardial infarction
Ann Emerg Med
(2004) - et al.
Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction
Am J Cardiol
(2007) - et al.
Hospital improvement in time to reperfusion in patients with acute myocardial infarction, 1999 to 2002
J Am Coll Cardiol
(2006) - et al.
Achieving rapid reperfusion with primary percutaneous coronary intervention remains a challenge: insights from American Heart Association's Get With the Guidelines program
Am Heart J
(2008) - et al.
Comparing hospital performance in door-to-balloon time between the Hospital Quality Alliance and the National Cardiovascular Data Registry
J Am Coll Cardiol
(2007) - et al.
Inconsistency of emergency department triageEmergency Department Operations Research Working Group
Ann Emerg Med
(1998) - et al.
Triage in medicine, part I: concept, history, and types
Ann Emerg Med
(2007) - et al.
Chart reviews in emergency medicine research: where are the methods?
Ann Emerg Med
(1996) - et al.
Door-to-drug and door-to-balloon times: where can we improve?time to reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI)
Am Heart J
(2006)
Treatment delay in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a key process analysis of patient and program factors
Am Heart J
Door-to-ECG time in patients with chest pain presenting to the ED
Am J Emerg Med
Quantification of the benefit of earlier thrombolytic therapy: five-year results of the Grampian Region Early Anistreplase Trial (GREAT)
J Am Coll Cardiol
Factors influencing the time to administration of thrombolytic therapy with recombinant tissue plasminogen activator (data from the National Registry of Myocardial Infarction)Participants in the National Registry of Myocardial Infarction
Am J Cardiol
Hospital delays and problems with thrombolytic administration in patients receiving thrombolytic therapy: a multicenter prospective assessmentVirginia Thrombolytic Study Group
Ann Emerg Med
Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options
J Am Coll Cardiol
Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction
J Am Coll Cardiol
Triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints
Ann Emerg Med
Expediting the early hospital care of the adult patient with nontraumatic chest pain: impact of a modified ED triage protocol
Am J Emerg Med
ED overcrowding in Taiwan: facts and strategies
Am J Emerg Med
Heart Disease and Stroke Statistics—2008 Update
ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both, or neither
BMJ
Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts
Circulation
Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients
Lancet
Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2
Lancet
Beta blockade after myocardial infarction: systematic review and meta regression analysis
BMJ
ED utilization and hospital discharge data; National Hospital Ambulatory Medical Care Survey
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Supervising editor: Judd E. Hollander, MD
Author contributions: CLA had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. CLA, PCA, JVT, and MJS concieved the study and design. JVT acquired and managed the data, and CLA and PCA performed the statistical analysis. CLA, PCA, and MJS interpreted the data. CLA and MJS drafted the article, and and all authors contributed substantially to its revision. CLA, JVT, and MJS obtained funding for the project. CLA takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This project was supported in part by a Canadian Insitutes of Health Research (CIHR) Team Grant in Cardiovascular Outcomes Research and by an operating grant from the Heart and Stroke Foundation of Ontario (NA5703). Dr. Atzema was supported by a Fellowship Award from CIHR, and Dr. Schull was supported by a New Investigator Award from CIHR. Dr. Tu was supported by a Canada Research Chair in Health Services Research and by a Career Investigator award from the Heart and Stroke Foundation of Ontario. The Canadian Insitutes of Health Research and the Heart and Stroke Foundation of Ontario had no involvement in the design or conduct of the study, data management or analysis, or article preparation, review, or authorization for submission.
Publication date: Available online January 21, 2009.
Reprints not available from the authors.