Prehospital management of patients with chest pain by 3 mobile intensive care units

Objectives: Few studies have examined management by of patients with chest pain mobile intensive care units in rural areas. We sought to establish the characteristics of patients attended; analyze the ability of mobile intensive care units to resolve the emergency; and assess the application of recommendations, appropriateness of transfer destinations, and agreement with diagnoses made in the hospital emergency department. Methods: Retrospective observational study of chest pain emergencies attended by the mobile intensive care units of the Guadalquivir health care district in Cordoba, Spain, between June 2009 and June 2010. We reviewed emergency care reports from the mobile units and the computerized medical history for each patient, collecting general patient data and cardiovascular risk factors. The following emergency care variables were collected: time until arrival on the scene of the emergency and time from the emergency scene until arrival at the hospital, probability of ischemic heart disease, diagnosis, treatments, referrals and transfer decisions, and unit providing transport. The following information regarding resolution of the emergency was also recorded: destination after evaluation in the hospital emergency department, diagnostic agreement, application of fibrinolysis, and subsequent events in patients not referred for further care. Results: A total of 278 cases were attended; the mean age was 72.12 years, and 55% were men. Women were older, the prevalence of arterial hypertension was higher in women, and fewer were smokers. Time until provision of emergency care was 9.7 minutes and time until arrival at a hospital emergency department was 93.1 minutes. Low probability of ischemic heart disease was recorded for 59.7%; 83.2% were resolved in the home, and 3.6% of these patients later experienced a coronary event. High probability of ischemic heart disease was recorded for 40.3%; this evaluation was associated with younger age, diabetes, smoking, and number of cardiovascular risk factors. General measures were implemented in over 90% of the cases; nitroglycerin was administered in 83.9%, morphine in 27.7%, and acetylsalicylic acid in 74.1%. Fewer patients received clopidogrel (23.9%) or heparin (17.4%), although use of these drugs improved during the study period. Chest pain unrelated to ischemic heart disease was diagnosed in 47.1%, nonspecific chest pain in 26%, and ischemic chest pain in 26.7%. The mobile unit's diagnosis and the hospital emergency department's were in agreement in 75.3% overall, and in 100% of cases of acute coronary syndrome with ST-segment elevation and high-risk acute myocardial infarction. Hospital admission was ordered in 71.2%. Fibrinolysis was initiated in 40.6% of cases of acute coronary syndrome with ST-segment elevation. Conclusions: In spite of the wide geographic distribution of cases and advanced age of these rural patients, the mobile intensive care units provided quality care in responding to reports of chest pain. The mobile units were able to resolve many cases and provide a diagnosis. They followed treatment guidelines, but areas for improvement have been identified. [Emergencias 2013;25:13-22]