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Source: Boutros F, Redelmeier DA. Effects of trauma cases on the care of patients who have chest pain in an emergency department. J Trauma 2000;48:649-653.
This retrospective study from Toronto examined whether trauma cases alter the length of stay and quality of care of emergency department (ED) patients with chest pain. The authors identified all trauma cases (Injury Severity Score > 16) presenting over a two-year period. The ED logs were screened to identify a patient entering the ED immediately after a trauma patient had arrived. If the chief complaint was chest pain, the patient was included as a case patient. For each case patient, a control patient was selected whose chief complaint also was chest pain, and who arrived in the ED during the same shift on a preceding day when no concurrent trauma case was in the ED. Seventy case and an equal number of control patients were identified. This sample had an 80% power to detect a one-third or greater difference in the average length of stay for case patients relative to controls.
Patient characteristics of the two groups were similar, including mean age and gender. Almost all of the trauma patients and their matched controls arrived within two hours of each other. The number of patients registered in the hour preceding arrival and the number of total patients in the ED at the time of arrival did not differ between the two groups. There was no significant difference between the two groups in the number of cardiac risk factors or in the number of patients ultimately diagnosed with a cardiac cause of chest pain.
Case patients spent an average of 81 minutes longer in the ED than controls (297 vs 216, P < 0.01). No significant interactions were noted during sub-analysis based on age, gender, or final disposition. There were no statistically significant differences in door-to-nurse, door-to-ECG, door-to-IV, or door-to-first medication times.
Using the American College of Emergency Physicians (ACEP) Chest Pain Guidelines, a score between zero and 100 can be calculated to yield a summary quality assurance index for each patient (higher numbers equal greater adherence to guidelines). A score was calculated for each case and control patient by reviewing the physician chart and nursing notes. On average, case patients had lower scores than control patients (75.6 vs 84.4, P = 0.027). Analyzing only those patients who ultimately were diagnosed with cardiac chest pain yielded a greater difference (60.3 vs 85.1, P = 0.002). There were non-significant trends toward an increased number of failures to administer aspirin, treat ongoing pain, and provide adequate instructions regarding treatment and need to return.
This is a well-done study with several valid conclusions. The authors show conclusively that major trauma influences the length of stay and the quality of care (as per the ACEP guidelines) of ED patients with chest pain. However, we must be careful not to jump to any conclusions that lack supporting data. The study shows an increased overall length of stay for case patients. However, our major concerns in the initial management of the patient with chest pain are the door-to-ECG and door-to-medication times, which did not differ significantly between the two groups. Thrombolytics were used only once, and no patients required urgent percutaneous transluminal coronary angioplasty (PTCA) during this study, so we cannot make any conclusions about possible delays for these treatment modalities.
According to the ACEP guidelines, quality of care suffered for case patients. What is unclear, however, is how this statistically significant difference in scores applies to clinical outcomes. It is still unclear whether the ACEP guidelines are a clinically significant marker of quality of care. As with most studies of patients with chest pain, the majority of patients did not have acute coronary ischemia. The low percentage of patients with actual coronary syndromes, in addition to a relatively small sample size, renders this study incapable of assessing the clinical difference (i.e., difference in short- and long-term morbidity and mortality) between the two groups.
Despite these limitations, this study makes an important point. With chest pain patients spending an average of 81 minutes longer in the ED due to concurrent trauma cases, it is likely that other patients in the ED with less priority are experiencing even longer delays. This study took place in a major trauma center with a team of physicians dedicated only to trauma. Low-volume EDs may find greater delays in the care of other patients, as the smaller number of physicians and nurses may be-come "stuck" with the trauma patient. Emergency physicians working with trauma patients must "multi-task" in order to maintain patient flow and quality of care.