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Heart attack patients not being prioritized properly in the E.R. causing delays in critical treatment


Inappropriate initial patient assessment in hospital emergency rooms is common and leads to delays in critical tests and life-saving clot-busting treatment for heart attack patients, according to a study by the Institute for Clinical Evaluative Sciences (ICES).

Patients who go to an emergency room in Canada are first seen by a triage nurse who performs a brief evaluation and assigns each patient a triage score based on how soon they should be seen by a physician.

A score of 1 or 2 means the patient’s condition is serious and the patient should be seen by a physician very quickly. Scores of 3, 4 or 5, on the other hand, indicate a less urgent condition. Patients suspected of having a heart attack are supposed to be given a score of 1 or 2.

“In our study we found that half (50.3%) of patients who were ultimately found to be having a heart attack were given a lower priority triage score of 3, 4 or 5 when they first arrived at an Ontario emergency department. What’s most worrisome is that we found that these patients were more likely to suffer delays in the diagnosis of their heart attack, and delays in receiving clot-busting drugs,” says principal investigator and ICES scientist Dr. Clare Atzema.

The study of 3,088 heart attack patients who presented to an emergency room in Ontario between July, 2000 and March, 2001 found:

  • Half of patients who were ultimately found to be suffering a heart attack were given a low acuity triage score when they presented to an emergency department.
  • Heart attack patients who were assigned a lower priority triage score waited longer to receive an electrocardiogram, the most important diagnostic test for a heart attack.
  • Lower priority triage scores waited 15 minutes longer, on average, to get time-sensitive clot-busting drug therapy. Delays of this magnitude are known to be associated with increased mortality for heart attack patients.
  • An estimated 11/1,000 heart attack patients treated die because of a low triage. That’s about 100 Ontarians a year.

“This is an important problem, but it can be addressed. Better training and better triage could reduce these delays and mean better care and outcomes for heart attack patients” says Atzema.

Author affiliations: ICES (Atzema, Austin, Tu, Schull); The Division of Emergency Medicine (Atzema, Schull); Cardiology and General Internal Medicine (Tu); The Department of Medicine, U of T, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

The study “Emergency department triage of acute myocardial infarction patients and the effect on outcomes” is in the June 15, 2009 issue of Annals of Emergency Medicine.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.



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