PMID- 33033102 OWN - NLM STAT- MEDLINE DCOM- 20210329 LR - 20210329 IS - 2044-6055 (Electronic) IS - 2044-6055 (Linking) VI - 10 IP - 10 DP - 2020 Oct 8 TI - Effects of crowding in the emergency department on the diagnosis and management of suspected acute coronary syndrome using rapid algorithms: an observational study. PG - e041757 LID - 10.1136/bmjopen-2020-041757 [doi] LID - e041757 AB - OBJECTIVES: Fast diagnostic algorithms using high-sensitivity troponin (hsTn) in suspected acute coronary syndrome (ACS) are regarded as beneficial to expedite diagnosis and safe discharge of patients in crowded emergency departments (ED). This study investigates the effects of crowding on process times related to the diagnostic protocol itself or other time delays, and outcomes. DESIGN: Prospective single-centre observational study. SETTING: ED (Germany). PARTICIPANTS: Final study population of 2525 consecutive patients with suspected ACS within 12 months, after exclusion of patients with ST-elevation myocardial infarction, missing blood samples, referral from other hospitals or repeated visits. INTERVENTIONS: Use of fast algorithms as per 2015 European Society of Cardiology guidelines. MAIN OUTCOME MEASURES: Crowding was defined as mismatch between patient numbers and monitoring capacities, or mean physician time per case, categorised as normal, high and very high crowding. Outcome measures were length of ED stay, direct discharge from ED, laboratory turn around times (TAT), utilisation of fast algorithms, absolute and relative non-laboratory time, as well as mortality. RESULTS: Crowding was associated with increased length of ED stay (3.75-4.89 hours, p<0.001). While median TAT of the first hsTnT increased (53-57 min, p<0.001), total TAT of serial hsTnT did not increase significantly with higher crowding (p=0.170). Lower utilisation of fast algorithms (p=0.009) and increase of additional hsTnT measurements after diagnosis (p=0.001) were observed in higher crowding. Most importantly, crowding was significantly associated with prolonged absolute (p<0.001), and particularly relative non-laboratory time (63.3%-71.3%, p<0.001). However, there was no significant effect of crowding on mortality, even after adjustment for relevant clinical variables. CONCLUSIONS: Process times, and particularly non-laboratory times, are prolonged in a crowded ED diminishing some positive effects of fast diagnostic algorithms in suspected ACS. Higher crowding levels were not significantly associated with higher all-cause mortality rates. TRIAL REGISTRATION NUMBER: NCT03111862. CI - (c) Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. FAU - Stoyanov, Kiril M AU - Stoyanov KM AD - Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany. FAU - Biener, Moritz AU - Biener M AD - Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany. FAU - Hund, Hauke AU - Hund H AD - Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany. AD - Faculty of Informatics, Heilbronn University of Applied Sciences, Heilbronn, Germany. FAU - Mueller-Hennessen, Matthias AU - Mueller-Hennessen M AD - Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany. FAU - Vafaie, Mehrshad AU - Vafaie M AD - Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany. FAU - Katus, Hugo A AU - Katus HA AD - Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany. FAU - Giannitsis, Evangelos AU - Giannitsis E AUID- ORCID: 0000-0002-1025-2872 AD - Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany Evangelos.Giannitsis@med.uni-heidelberg.de. LA - eng SI - ClinicalTrials.gov/NCT03111862 PT - Journal Article PT - Observational Study PT - Research Support, Non-U.S. Gov't DEP - 20201008 PL - England TA - BMJ Open JT - BMJ open JID - 101552874 SB - IM MH - *Acute Coronary Syndrome/diagnosis/therapy MH - Adolescent MH - Adult MH - Aged MH - Aged, 80 and over MH - Algorithms MH - Crowding MH - *Emergency Service, Hospital MH - Female MH - Germany MH - Humans MH - Length of Stay MH - Male MH - Middle Aged MH - Prospective Studies MH - Stroke Volume MH - Ventricular Function, Left MH - Young Adult PMC - PMC7545662 OTO - NOTNLM OT - accident & emergency medicine OT - coronary heart disease OT - myocardial infarction OT - protocols & guidelines COIS- Competing interests: MB reports grants and non-financial support from AstraZeneca, non-financial support from Thermo Fisher. MM-H reports grants and speaker honoraria from Roche Diagnostics; grants and non-financial support from BRAHMS Thermo Scientific. HAK received honoraria for lecturers from Roche Diagnostics, AstraZeneca, Bayer Vital, Daiichi-Sankyo, and held a patent on cTnT that has expired. EG received honoraria for lectures from Roche Diagnostics, AstraZeneca, Bayer Vital, Daiichi-Sankyo, Eli Lilly Deutschland. He serves as a consultant for Roche Diagnostics, BRAHMS Thermo Fisher, Boehringer Ingelheim, and has received research funding from BRAHMS Thermo Fisher, Roche Diagnostics, Bayer Vital and Daiichi Sankyo. EDAT- 2020/10/10 06:00 MHDA- 2021/03/30 06:00 PMCR- 2020/10/08 CRDT- 2020/10/09 05:31 PHST- 2020/10/09 05:31 [entrez] PHST- 2020/10/10 06:00 [pubmed] PHST- 2021/03/30 06:00 [medline] PHST- 2020/10/08 00:00 [pmc-release] AID - bmjopen-2020-041757 [pii] AID - 10.1136/bmjopen-2020-041757 [doi] PST - epublish SO - BMJ Open. 2020 Oct 8;10(10):e041757. doi: 10.1136/bmjopen-2020-041757.