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Management of non-ST-segment elevation acute coronary syndromes in emergency departments according to hospital size: cases from the Emergency Management of Acute Coronary Syndrome (MUSICA) registry

Sánchez M, Bauset JL, Cuervo R, Carbajosa J, Cristina Oria M, Povar J, Santaló M

Àrea d’Urgències. Hospital Clínic de Barcelona. Grupo de Investigación “Urgencias: procesos y patologias”, IDIBAPS, Barcelona, Spain. Servicio de Urgencias. Hospital Reina Sofía de Murcia, Spain. Servicio de Urgencias. Hospital Clínico San Carlos de Madri

Objective: To determine whether hospital emergency department management of acute
coronary syndrome (ACS) without ST-segment elevation differs by type of hospital.
Methods: In the MUSICA registry (Emergency Management of Acute Coronary
Syndrome) we identified 920 patients with non-ST-elevation ACS. The patients’ most
recent episodes had been treated at 97 hospital emergency departments. The outcome
variables were emergency care times and emergency treatments classified as IA measures
in the 2007 guidelines of the European Society of Cardiology. The variables were
compared between 3 levels of hospital: fewer than 200 beds (Level 1), more than 200
and fewer than 500 beds (Level 2), and more than 500 beds (Level 3).
Results: Of the 920 patients, 340 (37%) attended a Level 1 hospital, 243 (26.4%) a
Level 2 hospital, and 337 (36.7%) a Level 3 hospital. Analysis of patient characteristics at
baseline and during the ACS episode revealed no clinically important differences
between hospital categories. Delay of emergency department treatment was
significantly longer (45 minutes) at Level 3 than at Level 1 (29 minutes) or Level 2 (30
minutes). Aspirin was given to a significantly higher percentage of Level 3 patients
(84%) than Level 2 (75.3%) or Level 1 (74.7%) patients. More patients received
clopidogrel at Level 2 (46.5%) and Level 1 (57.4%) hospitals than at Level 3 facilities
(42.4%); the same pattern was seen for the administration of anticoagulants (79.8% and
78.8% of patients at Level 2 and Level 1 facilities, respectively, but 70.9% at Level 3).
Conclusions: Non-ST-elevation ACS is managed differently at smaller and larger
hospitals. We detected considerable room for improving the standards of emergency
care in this clinical setting.

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