EFFECTS OF EMERGENCY

BOARDING ON MORTALITY IN
PATIENS WITH ST-SEGMENT
ELEVATION MYOCARDIAL
INFARCTION
By : Isnaini Nurul F
4151171424
LV-B
 INTRODUCTION

■ Ischemic heart disease is a major cause of death worldwide.

■ ST-segment elevation myocardial infarction (STEMI) is the most severe form of ischemic
heart disease. Patients with STEMI require rapid reperfusion therapy, such as
percutaneous coronary intervention (PCI) or fibrinolytic therapy, within 12h of the onset
of symptoms.
■ Patients undergoing reperfusion therapy must be admitted for observation and
treatment, but many patients are boarded in the emergency department (ED) due to
limited availability of the coronary care unit (CCU) or an equivalent unit bed.
■ The most risky period for arrhythmia in patients with STEMI is during and immediately
after PCI.
■ The aim of this study was the effects of direct and indirect admission to the CCU on
mortality and on length of stay (LOS) in patients with STEMI who underwent PCI.
 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.
■ The inclusion criterion was patients with STEMI who underwent primary 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 primary reperfusion therapy, and patients who were not admitted
to the CCU or intensive care unit (ICU).
 METHODS

■ When patients arrived to the ED, they were examined by emergency physicians as
soon as possible and electrocardiography was performed. After consulting the
cardiologists, text messages were sent to alert the catheterization laboratory
(physicians, technicians, and nurses) of the patient's arrival.
■ After PCI, if there was availability in the CCU or ICU, the patients were admitted
directly next to the catheterization laboratory. If there was no room, the patients
were returned to the ED and boarded until a room was available .
 METHODS

2.2. Data and outcome

■ We reviewed the collected database and medical records and charted the data into
a standardized form.
■ The patients were divided into two groups. The direct admission (DA) group was
immediately admitted from the catheterization laboratory 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.
 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).
■ The median pre-PCI ED LOS was 20.0 min (16.0–26.0) and the median door to
balloon (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).
■ 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 follow 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).
 DISCUSSION

■ The mortality rates were similar for direct admission to the CCU and indirect
admission to the CCU after ED boarding in patients with STEMI who underwent PCI.
However, the LOS under intensive care was significantly longer in the patients with
indirect admission to the CCU.
■ The advantages of care in the CCU came from continuous ECG monitoring, the rapid
responses of trained physicians and nurses to arrhythmia, and the use of
defibrillation and closed-chest cardiopulmonary resuscitation
 DISCUSSION

■ The European Society of Cardiology guidelines for patients with STEMI does not
recommend CCU as the only admission site. They also recommend equivalent units
with continuous monitoring and specialized care after reperfusion therapy.
■ The American Heart Association also recommends that patients with low-risk STEMI
be directly admitted to the step-down unit after successful PCI, and the most recent
update did not mention the admission site.
■ In one previous study, no unresolvable adverse events occurred in patients with
STEMI in Killip class I after successful PCI in the step-down unit.
 DISCUSSION

■ Admission after boarding in the ED was not associated with increased 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 recurrence rates were higher for STEMI patients with
TIMI risk scores ≥4 who had a prolonged stay in the ED than for those who had a short
ED stay.
■ High-risk patients with significant arrhythmia and shock need for mechanical support, or
high TIMI scores should be admitted to the CCU for critical care.
■ Otherwise, patients who are stable after PCI may be admitted to the step-down unit
directly or after boarding in the ED. This approach would allow physicians to save space
in the CCU for higher-risk patients.
■ The European Society of Cardiology recommends monitoring patients with STEMI for at
least 24 h after symptom onset
 LIMITATIONS

1. It was conducted using registry-based data, which could have introduced

unmeasured bias.
2. More severe patients are likely to be admitted to the CCU directly after PCI for
intensive care. However, we compared the baseline characteristics and clinical
data, which showed a similar severity between the two study groups.
3. This study was conducted in a single ED and CCU; therefore, the results may not be
applicable to other institutions.
 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.