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Effects of Trauma Cases on the Care of Patients Who Have Chest Pain in an Emergency Department

Boutros, Farid MD; Redelmeier, Donald A. MD, MSc(HSR)

Journal of Trauma-Injury Infection & Critical Care: April 2000 - Volume 48 - Issue 4 - pp 649-653
Article Titles

Background: Trauma victims sometimes take priority over other patients because their injuries require immediate treatment. We examined whether such demands might compromise the care of patients with acute chest pain in an emergency department.

Methods: Case patients were patients with chest pain who arrived immediately after a major trauma victim. Control patients were patients with chest pain who arrived on a preceding day when no trauma patient was in the emergency department.

Results: Case and control patients were similar in mean age (60 vs. 60 years, p = not significant), percentage male (47 vs. 53%, p = not significant) and percentage ultimately diagnosed as cardiac (29 vs. 33%, p = not significant). Case patients spent an average of 81 minutes longer in the emergency department (297 vs. 216 minutes, p = 0.009). Similar delays were observed in the subgroup of patients ultimately diagnosed as cardiac (309 vs. 217 minutes, p = 0.029). Case patients had generally worse scores on the American College of Emergency Physicians Quality Assurance Index (75.6 vs. 84.4, p = 0.027), particularly those ultimately diagnosed as cardiac (60.3 vs. 85.1, p = 0.002). The common failures were failure to administer aspirin, undertreatment of ongoing pain, and failure to provide instructions regarding treatment and need to return.

Conclusion: Trauma victims can decrease the timeliness and quality of care for other patients who have potentially life-threatening conditions in an emergency department.

Chest pain is one of the most common and serious patient presentations in emergency medicine. Approximately 10% of emergency department patients have chest pain as their chief complaint and approximately 20% of patients admitted to the hospital through an emergency department have chest pain as the admitting diagnosis. 1–3 Myocardial infarction, for example, each year affects approximately 500,000 Americans, causes approximately 200,000 deaths, and creates approximately $7 billion of direct medical costs. 4,5 Chest pain is also a difficult patient presentation to manage correctly. 6 For example, approximately 1 in 20 patients with acute myocardial infarction is mistakenly sent home from the emergency department. 7–9 Additional errors can occur in the care of patients with pulmonary emboli, aortic dissection, or other noncardiac causes of chest pain. 10

Traumatic injury is another leading cause of mortality and morbidity that frequently requires emergency medical treatment. During a typical year, approximately one in seven Americans will have at least one serious injury requiring a visit to an emergency department, amounting to approximately $3 billion of direct medical costs and $11 billion of indirect societal costs. 11,12 The causes of injury tend to be related to motor vehicle crashes (approximately one third), recreational adventures (approximately one fourth), work activities (approximately one fifth), home exertion (approximately one seventh), or miscellaneous behaviors (approximately one fifteenth). 13 The emergency management of trauma patients is complicated because of the potential for multiple concurrent injuries, the need for acute resuscitation in some patients, and the resources required for complicated interventions.

There is widespread recognition that patients with chest pain merit prompt attention. However, demands from other patients may sometimes contribute to occasions for which medical personnel might be unavailable to attend to chest pain patients. 14,15 In this study, we focus on emergency department care because of the remarkable fluctuations in workloads with some particularly intense moments. We address one cause of increased workloads, the arrival of a major trauma patient, because such events are easily classified, usually unscheduled, often demanding, and sometimes loaded with emotion (especially if many are injured in one event). 16–18 Our primary research question was whether trauma cases alter the timeliness and quality of care in the emergency department for patients who have chest pain.

From the University of Toronto Departments of Medicine (F.B., D.A.R.) and Health Administration (D.A.R.); the University of Toronto Program in Clinical Epidemiology and Health Care Research (D.A.R.); and the Sunnybrook and Women’s College Health Sciences Centre Trauma Program (D.A.R.), Toronto Ontario, Canada.

Address for reprints: Donald A. Redelmeier, MD, MSc(HSR), Sunnybrook and Women’s Hospital, G-151, 2075 Bayview Avenue, Toronto Ontario, Canada M4 N 3M5; email:

Submitted for publication June 17, 1999.

Accepted for publication January 4, 2000.

Dr. Redelmeier is supported by a career scientist award from the Ontario Ministry of Health and the de Souza Chair of the University of Toronto. This project was partially funded by a grant from the Physician’s Services Incorporated Foundation of Ontario.

© 2000 Lippincott Williams & Wilkins, Inc.