American Journal of Emergency Medicine xxx (xxxx) xxx

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Effects of emergency department boarding on mortality in patients with

ST-segment elevation myocardial infarction
Jin Hee Jeong, MD a,b,⁎, Dong Hoon Kim, MD, PhD a,b, Tae Yun Kim, MD a, Changwoo Kang, MD a,
Soo Hoon Lee, MD a, Sang Bong Lee, MD a, Seong Chun Kim, MD, PhD c, Yong Joo Park, MD c, Daesung Lim, MD c
a
Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju-si, Gyeongsangnam-do, Republic of Korea
b
Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
c
Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Gyeongsangnam, Republic of
Korea

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Patients with ST-segment elevation myocardial infarction (STEMI) are sometimes boarded in the
Received 8 May 2019 emergency department (ED) after percutaneous coronary intervention (PCI). We evaluated the effects of direct
Received in revised form 5 August 2019 and indirect admission to the CCU on mortality and the effect on length of stay (LOS) in patients with STEMI.
Accepted 18 August 2019 Method: This was a retrospective observational study of patients with STEMI between Jan 2014 and Nov 2017.
Available online xxxx
The patients were divided into the direct admission (DA) group, who were admitted into the CCU immediately
after PCI, and the indirect admission (IA) group, who were admitted after boarding in the ED. The primary end-
Keywords:
ST-segment elevation myocardial infarction
point was in-hospital mortality. Secondary endpoints were 3-month mortality, LOS in CCU and hospital, and LOS
Boarding under intensive care.
Intensive care uni Results: During the study period, 780 patients were enrolled and analyzed. The in-hospital mortality rate and 3-
month mortality rate were 5.9% (46 patients) and 8.5% (66 patients). The DA group and IA group had similar in-
hospital and 3-month mortality rates (P = .50, P = .28). The median CCU LOS and hospital LOS was similar for
both groups (P = .28, P = .46). However, LOS under in intensive care for the IA group was significantly longer
than that of the DA group (DA, 31.9 h; IA, 38.7 h; P b .001).
Conclusion: This study suggests that direct admission after PCI and indirect admission was not associated with
mortality in patients with STEMI. In addition, the stay in ED also appears to be associated with the duration of
stay under critical care.
© 2019 Published by Elsevier Inc.

1. Introduction
Ischemic heart disease is a major cause of death worldwide [1]. ST-
segment elevation myocardial infarction (STEMI) is the most severe
form of ischemic heart disease [2]. Patients with STEMI require rapid re-
perfusion therapy, such as percutaneous coronary intervention (PCI) or
fibrinolytic therapy, within 12 h of the onset of symptoms [1,3]. Patients
undergoing reperfusion therapy must be admitted for observation and
treatment, but many patients are boarded in the emergency depart-
ment (ED) due to limited availability of the coronary care unit (CCU)
or an equivalent unit bed [1,4]. Hence, the ED serves as an area for
post-reperfusion treatment as well as initial treatment for patients
with STEMI.
⁎ Corresponding author at: Department of Emergency Medicine, Gyeongsang National
University School of Medicine and Gyeongsang National University Hospital, Jinju-si,
Gyeongsangnam-do, Republic of Korea.
E-mail address: kloud144@gmail.com (J.H. Jeong).
A few studies have assessed boarding of patients with myocardial in-
farction (MI) in the ED. [5-7] They showed that boarding in the ED did
not affect mortality rates in patients with MI. One study reported similar
mortality rates in three groups of patients with MI who were admitted
to the CCU, intermediate care unit, and ward after at least 24 h of ED
boarding [5]. However, most patients who were admitted to the inter-
mediate care unit and ward after 24 h of ED boarding did not undergo
reperfusion therapy and did not show ST elevation in an electrocardio-
gram. Another study demonstrated that a length of stay (LOS) in the ED
of N8 h after reperfusion therapy was not associated with mortality in
patients with STEMI [6]. This 8 h criterion was based on a study of
non-ST-segment elevation myocardial infarction (NSTEMI) that did
not include patients who underwent PCI within 12 h of presentation
[7]. In addition, the most risky period for arrhythmia in patients with
STEMI is during and immediately after PCI [8]. As this period were in-
cluded in both study group [6], the risk of ED boarding has not been
clearly demonstrated.
In this study, we hypothesized that the clinical outcomes of patients
who are admitted directly to the CCU might be different from those of

https://doi.org/10.1016/j.ajem.2019.158400
0735-6757/© 2019 Published by Elsevier Inc.
2 J.H. Jeong et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
patients who board in the ED immediately following PCI. We also won-
dered whether the stay in the ED during the period immediately after
PCI might affect the LOS in the CCU and hospital.
The aim of this study was the effects of direct and indirect admission
to the CCU on mortality and on LOS in patients with STEMI who
underwent PCI.
2. Methods
2.1. Study setting and participants
This was a retrospective observational study based on prospectively
recorded MI registry data from a tertiary university hospital. The study
period was from Jan 2014 to Nov 2017.
Regional cardiocerebrovascular centers supported by the Ministry of
Health and Welfare operate nationwide. In December 2012, our hospital
was designated the regional cardiocerebrovascular center. Our center
acts as a final referral center in this region because the nearest similar
center is N100 km away. Our center provides emergent PCI for 24 h.
The research coordinator of the center collected and managed the regis-
try data for patients with MI.
The inclusion criterion was patients with STEMI who underwent pri-
mary PCI in the ED. The exclusion criteria were patients with NSTEMI,
patients with cardiac arrest before presentation with or without return
of spontaneous circulation, patients who opted against PCI as the pri-
mary reperfusion therapy, and patients who were not admitted to the
CCU or intensive care unit (ICU).
There was no care system related to STEMI in the pre-hospital stage
during the study period. When patients arrived to the ED, they were ex-
amined by emergency physicians as soon as possible and electrocardi-
ography was performed. After consulting the cardiologists, text
messages were sent to alert the catheterization laboratory (physicians,
technicians, and nurses) of the patient's arrival. When the patient and
catheterization laboratory were ready for PCI, the patients were trans-
ferred to the laboratory. Heparin, NG, aspirin, PLT inhibitors, and lipitor
were used and the goal for door to balloon (DTB) was 90 min. After PCI,
if there was availability in the CCU or ICU, the patients were admitted di-
rectly next to the catheterization laboratory. If there was no room, the
patients were returned to the ED and boarded until a room was avail-
able. There was no special room for patients with MI in the ED, but
these patients were closely monitored by nurses. This study was ap-
proved by the Institutional Review Board of Gyeongsang National Uni-
versity Hospital.
2.2. Data and outcome
We reviewed the collected database and medical records and
charted the data into a standardized form. The demographics included
age, sex, presence of diabetes mellitus, hyperlipidemia, hypertension,
alcohol use within 1 yr, smoking status, previous MI, the Charlson co-
morbidity index, and body mass index. The clinical data included sys-
tolic and diastolic blood pressure; heart rate on presentation; whether
the patient presented in off-hours; hypoxia, hypotension and ED cardio-
pulmonary resuscitation before PCI; pre-PCI ED LOS, DTB; TIMI risk
score; and Killip class. Laboratory values included the white blood cell
count, triglycerides, low-density lipoprotein, HbA1c, highest CK-MB,
and highest troponin I.
Off-hour presentation was defined as patient presentation from
18:00 to 07:59 or on weekends and holidays. Hypoxia and hypotension
before PCI were defined by the use of oxygen and vasopressors to keep
saturation above 92% and systolic blood pressure over 90 mm Hg. ED
cardiopulmonary resuscitation before PCI described patients who ar-
rived to the ED without cardiac arrest but suffered cardiac arrest before
PCI.
The time data were calculated based on EMR records. Pre-PCI ED LOS
was defined as the LOS from ED arrival to departure to the
catheterization laboratory. Post-PCI ED LOS was defined as the LOS
from re-arrival to the ED after PCI to admission to the CCU or ICU. CCU
LOS was defined as the LOS from admission to discharge from the CCU
or ICU. Hospital LOS was defined as LOS from arrival to ED to discharge
from hospital. The LOS under intensive care was defined as from arrival
to the CCU or ICU or re-arrival to the ED from PCI to discharge from the
CCU or ICU, which meant the sum of post-PCI ED LOS and CCU LOS.
The patients were divided into two groups. The direct admission
(DA) group was immediately admitted from the catheterization labora-
tory to the CCU. The indirect admission (IA) group was admitted to the
CCU after boarding in the ED.
Mortality after 3 months was identified via phone interviews. The
primary endpoint was in-hospital mortality. Secondary endpoints
were 3-month mortality, CCU LOS, LOS under intensive care, and hospi-
tal LOS.
2.3. Statistics
Because data skew was observed, continuous variables were
expressed as median (interquartile range; IQR) and categorical vari-
ables were expressed as numbers (percentages). The Mann-Whitney
U test for continuous variables and X2 test for categorical variables
were used to compare baseline characteristics and clinical data. Mortal-
ity rate and the LOS were compared used these tests as well. A P-value
b.05 was considered clinically significant. The SPSS 21.0 statistical soft-
ware (SPSS Inc., Chicago, IL, USA) was used for statistical analyses.
3. Results
During the study period, 1924 patients with MI arrived at our ED, but
1144 patients were excluded from the analyses: 1042 patients with
NSTEMI, 59 patients who went into cardiac arrest before presentation,
19 patients who did not choose PCI as primary reperfusion therapy,
and 24 patients who were not admitted to the CCU, hence 780 patients
were enrolled and analyzed in this study (Fig. 1).
Median (IQR) age was 65.0 (55.0–76.0) years old and males
accounted for 53.5% (417 patients) of the sample. Diabetes mellitus
was present in 183 patients (23.5%) and hypertension was found in
340 patients (43.6%). Off-hours presentation was observed in 485 pa-
tients(62.2%). The median pre-PCI ED LOS was 20.0 min (16.0–26.0)
and the median DTB was 43.0 (36.0–51.0). The median TIMI risk score
was 4.0 (2.0–6.0). The median CCU LOS was 30.4 h (22.2–47.2), LOS
under intensive care was 34.4 h (22.9–48.1), and hospital LOS was
101.0 h (80.3–143.4).
There were 651 patients in the DA group and 129 patients in the IA
group. The median post PCI ED LOS of the IA group was 4.4 (1.7–13.7) h.
The baseline characteristics of the groups did not significantly differ re-
garding age, sex, diabetes mellitus, hypertension, alcohol use within
1 yr, current smoker, hyperlipidemia, previous MI, Charlson comorbid-
ity index, or body mass index (all P N .05) (Table 1). The clinical data
of the groups were not significantly different: vital signs on presenta-
tion, off-hours presentation, hypoxia, hypotension and ED cardiopulmo-
nary resuscitation before PCI, pre-PCI ED LOS, DTB, TIMI risk score, Killip
score, and laboratory values (all of them, P N .05) (Table 2).
The in-hospital mortality rate and 3-month mortality rate were 5.9%
(46 patients) and 8.5% (66 patients). Only four patients were lost to fol-
low up at 3 months. The two groups had non-significantly different in-
hospital mortality rates (DA, 39 patients, 6.0%; IA, 7 patients, 5.4%; P =
.50) and 3-month mortality rate did not significantly differ between the
groups (DA, 53 patients, 8.1%; IA 13, 10.1%; P = .28).
The median CCU LOS was not significantly different between the
groups (DA, 31.9 [22.4–47.2]; IA, 26.1 [21.1–47.4]; P = .28). But the
LOS under intensive care was significantly longer for the IA group than
the DA group (DA, 31.9 h [22.4–47.2]; IA, 38.7 h [26.7–55.0]; P b .001).
The hospital LOS was not different between both groups (DA, 101.2 h
[79.6–141.4]; IA, 101.0 h [82.3–149.4]; P = .46).
 J.H. Jeong et al. / American Journal of Emergency Medicine xxx (xxxx) xxx 3

Fig. 1. Study patients.

4. Discussion equivalent units with continuous monitoring and specialized care

after reperfusion therapy [1]. The American Heart Association also rec-
The mortality rates were similar for direct admission to the CCU and ommends that patients with low-risk STEMI be directly admitted to
indirect admission to the CCU after ED boarding in patients with STEMI the step-down unit after successful PCI, and the most recent update
who underwent PCI. However, the LOS under intensive care was signif- did not mention the admission site [18-20]. In one previous study, no
icantly longer in the patients with indirect admission to the CCU. unresolvable adverse events occurred in patients with STEMI in Killip
To the best of our knowledge, this is the first study to compare out- class I after successful PCI in the step-down unit [21].
comes between direct and indirect admission to the CCU after PCI. Many The results of the present study support these previous findings.
previous studies have focused on the admission of STEMI patients, and Some STEMI patients may be treatable outside of the CCU. This might
direct admission has been defined in various ways. For example, direct be the result of reduced mortality rates due to improvements in treat-
admission has been defined as immediate admission to the catheteriza- ment methods, equipment, and management in other wards outside
tion laboratory bypassing the ED, or as direct admission to a PCI center the CCU [13,21,22]. The ED has equipment and specialized care similar
bypassing a non-PCI-capable facility [2,9-11]. The present study to that of the step-down unit. Several studies have suggested that long
adopted a different definition of direct transmission. Previous studies boarding of critically ill patients in the ED is associated with a high mor-
have also focused on treatment before PCI. The current study focused tality rate [4,23-26]. Rapid diagnosis and critical care are required for
on direct admission to the CCU and admission after PCI. critically ill patients; however, these might be delayed in an over-
After the concept of the CCU was developed in the 1960s, it became crowded ED. [4,27] Studies that have addressed the ED boarding of
well known that the care in CCU is important [12]. The advantages of STEMI patients have reported different results than studies of other crit-
care in the CCU came from continuous ECG monitoring, the rapid re- ical diseases [6,28,29]. We also found that ED boarding is not associated
sponses of trained physicians and nurses to arrhythmia, and the use of with mortality. Previous studies have shown that the time to PCI for
defibrillation and closed-chest cardiopulmonary resuscitation [12-15]. STEMI patients is not affected by ED crowding [28,29]. STEMI patients
These interventions are most commonly required during immediate pe- can easily be diagnosed based on their medical history and ECG, in con-
riod after PCI due to arrhythmia, which is more common during the trast with other critical diseases that require further examination. In ad-
early hours [8,16,17]. Direct admission to the CCU after PCI might en- dition, the patients were boarded after PCI, which was the most critical
hance these advantages. However, it seems that the practice of admis- treatment. We believe that this difference may be related to the similar
sion after PCI in patients with STEMI has changed. The European mortality rates observed in patients indirectly admitted after boarding
Society of Cardiology guidelines for patients with STEMI does not rec- in the ED compared to those who were directly admitted.
ommend CCU as the only admission site [1]. They also recommend Admission after boarding in the ED was not associated with in-
creased mortality; however, it would not be safe for all patients with
STEMI to stay in the ED after PCI. A previous study showed that MI re-
Table 1 currence rates were higher for STEMI patients with TIMI risk scores ≥4
The Baseline characteristics of study patients.
who had a prolonged stay in the ED than for those who had a short ED
Total DA group IA group (n P stay [6]. High-risk patients with significant arrhythmia, shock, need
patients (n = 129) value for mechanical support, or high TIMI scores should be admitted to the
(n = 780) = 651)
CCU for critical care [13]. Otherwise, patients who are stable after PCI
Age, median (IQR) 65.0 64.0 66.0 0.75 may be admitted to the step-down unit directly or after boarding in
(55.0–76.0) (55.0–76.0) (53.5–78.0) the ED. This approach would allow physicians to save space in the
Sex, male, n (%) 417 (53.5) 345 (53.0) 72 (55.8) 0.31
Diabetes mellitus, n (%) 183 (23.5) 154 (23.7) 29 (22.5) 0.44
CCU for higher-risk patients.
Hypertension, n (%) 340 (43.6) 282 (43.3) 58 (45.0) 0.40 LOS under critical care was significantly higher in the IA group. De-
Alcohol use within 1 yr, n (%) 299 (38.3) 251 (38.6) 48 (37.2) 0.43 spite the care provided during the ED stay, CCU LOS did not decrease.
Current smoker, n (%) 331 (42.4) 283 (43.5) 48 (37.2) 0.11 There are two possible reasons for this result. First, ICU stay may not
Hyperlipidemia, n (%) 45 (5.8) 35 (5.4) 10 (7.8) 0.19
have decreased in the IA group because of the clinicians' belief that a
Previous myocardial infarction, n 46 (5.9) 41 (6.3) 5 (3.9) 0.20
(%) certain period of CCU care was required regardless of the post-PCI care
The Charlson comorbidity index, 0 (0.0–1.0) 0 (0.0–1.0) 0 (0.0–1.0) 0.90 during boarding time in the ED. The European Society of Cardiology rec-
median (IQR) ommends monitoring patients with STEMI for at least 24 h after symp-
Body mass index (kg/m2), 23.9 24.0 24.0 0.43 tom onset [1]. This may affect the physicians' practice of keeping
median (IQR) (21.8–25.9) (21.7–26.0) (22.3–25.9)
patients in the CCU for a certain period of time. The second explanation
4 J.H. Jeong et al. / American Journal of Emergency Medicine xxx (xxxx) xxx

Table 2
The Clinical data of study patients.

Total patients (n = 780) DA group (n = 651) IA group (n = 129) P value

Systolic blood pressure on ED presentation (mm Hg), median (IQR) 120.0 (100.0–140.0) 120.0 (106.0–140.0) 120.0 (100.0–140.0) 0.94
Diastolic blood pressure (mm Hg), on ED presentation, median (IQR) 80.0 (60.0–90.0) 80.0 (60.0–90.0) 80.0 (60.0–90.0) 0.56
Heart rate on ED presentation (/min), median (IQR) 76.0 (64.0–87.0) 76.0 (64.0–88.0) 75.0 (60.0–84.0) 0.23
Off-hour presentation, n (%) 485 (62.2) 397 (61.0) 88 (68.2) 0.07
Hypoxia before PCI, n (%) 61 (7.8) 47 (7.2) 14 (10.9) 0.11
Hypotension before PCI, n (%) 73 (9.4) 62 (9.5) 11 (8.5) 0.44
ED CPR before PCI, n (%) 15 (1.9) 13 (2.0) 2 (1.6) 0.54
Pre-PCI ED LOS (min), median (IQR) 20.0 (16.0–26.0) 20.0 (16.0–26.0) 20.0 (15.0–26.0) 0.63
Door to balloon time (min), median (IQR) 43.0 (36.0–51.0) 43.0 (36.0–50.0) 43.0 (37.5–52.0) 0.30
TIMI risk score, median (IQR) 4.0 (2.0–6.0) 4.0 (2.0–6.0) 5.0 (2.3–7.0) 0.34
Killip score, median (IQR) 1.0 (1.0–1.0) 1.0 (1.0–2.0) 1.0 (1.0–2.0) 0.80
WBC count (∗103/dL), median (IQR) 10.7 (8.9–13.6) 10.7 (8.9–13.6) 10.6 (9.2–13.4) 0.95
Triglycerides (mg/dl), median (IQR) 142.0 (94.8–206.0) 139.0 (93.0–206.0) 148.5 (107.3–206.0) 0.16
Low-density lipoprotein cholesterol (mg/dl), median (IQR) 125.0 (98.0–156.0) 125.0 (98.8–155.3) 127.5 (98.0–162.5) 0.56
HbA1c (%), median (IQR) 5.9 (5.6–6.6) 5.9 (5.6–6.6) 6.0 (5.6–6.5) 0.45
CK-MB peak (ng/ml), median (IQR) 202.2 (87.3–300.0) 203.1 (84.8–300.0) 200.1 (97.5–300.0) 0.62
Troponin-I peak (ng/ml), median (IQR) 23.0 (23.0–23.0) 23.0 (23.0–23.0) 23.0 (23.0–23.0) 0.64

ED; emergency department, PCI; percutaneous coronary intervention,CPR; cardiopulmonary resuscitation, LOS; length of stay, WBC; white blood cell.

is that complications may have occurred in the ED that required a
prolonged stay in the CCU. Such complications may result when pa-
tients in crowded EDs are overlooked. One study revealed an association
between prolonged ED stay and reduced adherence to guideline treat-
ment in patients with NSTEMI [7]. However, hospital LOS and mortality
was similar in both groups. Therefore, the cause of the similarity in ICU
LOS was more likely to be the former explanation. When determining
the time of discharge from the CCU, patient conditions and length of
stay in the ED should be taken into account.
This study had several limitations. First, it was conducted using
registry-based data, which could have introduced unmeasured bias.
Second, more severe patients are likely to be admitted to the CCU di-
rectly after PCI for intensive care. However, we compared the baseline
characteristics and clinical data, which showed a similar severity be-
tween the two study groups. Third, this study was conducted in a single
ED and CCU; therefore, the results may not be applicable to other insti-
tutions. Future multicenter prospective studies are warranted.
Changwoo Kang: Dr. Kang interpreted data, critically reviewed the
manuscript, approved the final manuscript as submitted, and agreed
to be accountable for all aspects of the work.
Soo Hoon Lee: Dr. Lee interpreted data, critically reviewed the man-
uscript, approved the final manuscript as submitted, and agreed to be
accountable for all aspects of the work.
Sang Bong Lee: Dr. Lee interpreted data, critically reviewed the man-
uscript, approved the final manuscript as submitted, and agreed to be
accountable for all aspects of the work.
Seong Chun Kim: Dr. Kim interpreted data, critically reviewed the
manuscript, approved the final manuscript as submitted, and agreed
to be accountable for all aspects of the work.
Yong Joo Park: Dr. Park interpreted data, critically reviewed the
manuscript, approved the final manuscript as submitted, and agreed
to be accountable for all aspects of the work.
Daesung Lim: Dr. Lim interpreted data, critically reviewed the man-
uscript, approved the final manuscript as submitted, and agreed to be
accountable for all aspects of the work.

5. Conclusion
This study suggests that direct admission from the catheterization
lab after PCI and indirect admission with ED boarding after PCI were
not associated with mortality in patients with STEMI. The stay in the
ED also appears to be associated with the duration of stay under critical
care.
Funding source
The authors have no financial relationships relevant to this article to
disclose.
Authors' contributions
Jin Hee Jeong: Dr. Jeong conceptualized and designed the study, an-
alyzed the data, drafted the initial manuscript, approved the final man-
uscript as submitted, and agreed to be accountable for all aspects of the
work.
Dong Hoon Kim: Dr. Kim conceptualized and designed the study, an-
alyzed the data, drafted the initial manuscript, critically reviewed the
manuscript, approved the final manuscript as submitted, and agreed
to be accountable for all aspects of the work.
Tae Yun Kim MD: Dr. Kim interpreted data, critically reviewed the
manuscript, approved the final manuscript as submitted, and agreed
to be accountable for all aspects of the work.
Declaration of competing interest
The authors have no conflicts of interest to disclose.
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