Quality indicators and non-ischemic myocardial injury in emergency medicine

Abstract

Erakorraline meditsiin on oluline osa tervishoiust, mille funktsioonideks on ennekõike kriitiliste seisundite esmane käsitlus, elundipuudulikkuste diagnoosimine ja ennetamine ning seeläbi suremuse ja invaliidistumise vähendamine. Eestis saavutas erakorraline meditsiin iseseisva arstliku eriala staatuse 2000. aastal. Järgnevatel aastatel on loodud erakorralise meditsiiniabi võrgustik, haigete triaažisüsteem, eriala residentuuriprogramm ning astutud on esimesed sammud ravikvaliteedi hindamise poole. Sarnaselt muu maailmaga on ka Eestis järjest suurenenud nõudlus erakorralise meditsiini järele. See on kaasa toonud osakondade ülerahvastuse, mis põhjustab potentsiaalselt tervist kahjustavaid viivitusi inimese raviteekonnal. Antud uurimistöö keskendus kahele haigete grupile erakorralise meditsiini osakonnas (EMO) – ägeda kõhuvaluga raskes seisundis ning tõsise rindkere traumaga patsientidele. Kõhuvalu on sage pöördumise põhjus, mille taga võib olla kiiret sekkumist vajav haigus ning trauma on oluline rahva tervise probleem. Töö fookuses olid ravikvaliteedi indikaatorid ja südamelihase kahjustus. Kvaliteediindikaatorite juures hindasime valu ravimist ning patsiendi viibitud aega EMO-s. Leidsime olulisi puudujääke praeguses praktikas. Esiteks, valu tugevus, mis on adekvaatse ravi aluseks, on sageli dokumenteerimata ning aeg valuravini on liiga pikk. Teiseks, ägeda kõhuvaluga haiged, kes peaksid pärast esmast diagnostikat ja ravi liikuma haiglasse või minema koju, viibivad EMO-s oluliselt kauem kui on sätestatud Tervisekassa poolt kinnitatud kvaliteedi nõuetes. See viitab kitsaskohtadele erakorralise patsiendi raviteekonnal. Pikem aeg EMO-s on seotud halvema prognoosiga. Troponiin on vereseerumist määratav biomarker, mida kasutatakse südamelihase infarkti diagnoosimiseks. Täpsemate testide kasutuselevõtuga on südamelihase kahjustus määratav ka teiste haiguste ja seisundite, näiteks sepsise, raske trauma ja šoki korral. Leidsime, et nii rindkere raske traumaga patsientidel kui ka ägeda kõhuvaluga patsientidel, kellel ei määrata rutiinselt troponiini, esineb sageli varjatud südamelihase kahjustus, mis on seotud oluliselt halvemate ravitulemustega.Emergency medicine plays a crucial role in healthcare, encompassing functions such as the initial treatment of critical conditions, the diagnosis and prevention of organ failures, and the subsequent reduction of mortality and disability rates. In Estonia, emergency medicine was established as an independent medical specialty in the year 2000. Over the years, the country has developed an emergency medical care network, implemented a triage system for patients, introduced a specialty residency program, and taken steps to assess quality of care. However, like healthcare systems around the world, Estonia's emergency medicine system faces growing demand and department overcrowding, potentially resulting in harmful delays for patients. Current research has focused on two patient groups at the emergency department (ED): those presenting with acute abdominal pain and those with serious chest trauma. Acute abdominal pain is a common reason for seeking emergency medical attention, often requiring prompt intervention, while trauma remains a significant public health concern. This study has particularly concentrated on quality indicators and myocardial injury. In terms of quality indicators, we have examined two crucial aspects: the management of pain and the length of stay in the ED. We have identified significant shortcomings in current practices. Firstly, the intensity of pain, a fundamental basis for adequate treatment, is often undocumented, and the time to pain relief is too lengthy. Secondly, patients with acute abdominal pain, who should ideally be hospitalized or discharged after initial diagnostics and treatment, often spend considerably more time in the ED than stipulated in the quality indicators approved by the Health Insurance Fund. This points to deficiencies in the treatment of emergency patients, as a longer ED stay is associated with a poorer prognosis. Troponin is a biomarker used to diagnose myocardial infarction. With the introduction of more specific tests, injury can be identified in patients with different profile e.g sepsis, major trauma, shock patients. We found that patients with severe chest trauma, and patients with acute abdominal pain who are not routinely tested for troponin often have occult myocardial injury which is associated with significantly worse outcomes of these patients.