Implementation of a pre-hospital decision rule in general practice: Triage of patients with suspected myocardial infarction
Why the study?
Does a pre-hospital decision rule using clinical characteristics and electrocardiography safely reduce unnecessary hospital admissions in patients with suspected acute cardiac pathology?
Population
1,982 patients with symptoms suggestive of acute cardiac pathology, seen by a general practitioner, for whom…
Design
Cohort
Authors
Discussion
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Member takes
Implication
May support reduced CCU admissions via pre-hospital triage; leaves open need for randomized confirmation before practice change.
Key Points
- To develop and prospectively validate a pre-hospital clinical decision rule to improve the triage and hospital referral of patients presenting with suspected acute cardiac disease.
- Phase 1 derived a predictive decision rule using clinical characteristics and ambulance-recorded electrocardiograms in 1,005 patients with suspected acute cardiac pathology.
- Phase 2 prospectively validated the rule in 977 patients using a standardized symptom questionnaire administered by general practitioners and computerized pre-hospital electrocardiograms recorded at home by ambulance nurses.
- The decision rule recommended no hospitalization in 227 of 977 patients (23%), and general practitioners adhered to this recommendation in 44% of cases with no observed complications, despite 7 patients developing non-Q wave myocardial infarction.
- Implementation of pre-hospital triage reduced Coronary Care Unit admissions by 12% (118 of 977 patients), while general practitioners withheld admission in only 19 of 750 patients (2%) where admission was recommended.
Structured PICO
Does a pre-hospital decision rule using clinical characteristics and electrocardiography safely reduce unnecessary hospital admissions in patients with suspected acute cardiac pathology?
P
Population
1,982 patients (1,005 in derivation phase, 977 in validation phase) with symptoms suggestive of acute cardiac pathology, seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.
I
Intervention
Pre-hospital decision rule based on clinical characteristics (standardized questionnaire) and computerized pre-hospital electrocardiogram to guide hospitalization decisions.
O
Outcome
Identification of patients at low and high probability of acute cardiac pathology and reduction in Coronary Care Unit admissions.
A pre-hospital decision rule combining clinical characteristics and ECG findings can safely reduce unnecessary Coronary Care Unit admissions for patients with suspected acute cardiac pathology.
Cite This Study
Grijseels et al. (1996) studied this question.