title: Performance of Emergency Department Screening Criteria for an Early ECG to Identify ST-Segment Elevation Myocardial Infarction.
abstract: BACKGROUND
  Timely diagnosis of ST-segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. Obtaining this test within 10 minutes of ED arrival is critical to achieving the best outcomes. We investigated variability in the timely identification of STEMI across institutions and whether performance variation was associated with the ED characteristics, the comprehensiveness of screening criteria, and the STEMI screening processes.
  
  
  RESULTS
  We examined STEMI screening performance in 7 EDs, with the missed case rate (MCR) as our primary end point. The MCR is the proportion of primarily screened ED patients diagnosed with STEMI who did not receive an ECG within 15 minutes of ED arrival. STEMI was defined by hospital discharge diagnosis. Relationships between the MCR and ED characteristics, screening criteria, and STEMI screening processes were assessed, along with differences in door-to-ECG times for captured versus missed patients. The overall MCR for all 7 EDs was 12.8%. The lowest and highest MCRs were 3.4% and 32.6%, respectively. The mean difference in door-to-ECG times for captured and missed patients was 31 minutes, with a range of 14 to 80 minutes of additional myocardial ischemia time for missed cases. The prevalence of primarily screened ED STEMIs was 0.09%. EDs with the greatestinformedness(sensitivity+specificity-1) demonstrated superior performance across all other screening measures.
  
  
  CONCLUSIONS
  The 29.2% difference in MCRs between the highest and lowest performing EDs demonstrates room for improving timely STEMI identification among primarily screened ED patients. The MCR and informedness can be used to compare screening across EDs and to understand variable performance.
authors.affiliation: Vanderbilt University, Nashville, TN maya.yiadom@vanderbilt.edu.
authors.forename: Maame Yaa A B
authors.initials: MY
authors.lastname: Yiadom
authors.affiliation: Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Baugh
authors.affiliation: Vanderbilt University, Nashville, TN.
authors.forename: Conor M
authors.initials: CM
authors.lastname: McWade
authors.affiliation: Vanderbilt University, Nashville, TN.
authors.forename: Xulei
authors.initials: X
authors.lastname: Liu
authors.affiliation: Department of Emergency Medicine, University of California at Davis, Sacramento, CA.
authors.forename: Kyoung Jun
authors.initials: KJ
authors.lastname: Song
authors.affiliation: Department of Emergency Medicine, University of Wisconsin at Madison, WI.
authors.forename: Brian W
authors.initials: BW
authors.lastname: Patterson
authors.affiliation: Vanderbilt University, Nashville, TN.
authors.forename: Cathy A
authors.initials: CA
authors.lastname: Jenkins
authors.affiliation: Department of Emergency Medicine, Oregon Health & Sciences University, Portland, OR.
authors.forename: Mary
authors.initials: M
authors.lastname: Tanski
authors.affiliation: Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Angela M
authors.initials: AM
authors.lastname: Mills
authors.affiliation: Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX.
authors.forename: Gilberto
authors.initials: G
authors.lastname: Salazar
authors.affiliation: Vanderbilt University, Nashville, TN.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Wang
authors.affiliation: Vanderbilt University, Nashville, TN.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Dittus
authors.affiliation: Vanderbilt University, Nashville, TN.
authors.forename: Dandan
authors.initials: D
authors.lastname: Liu
authors.affiliation: Vanderbilt University, Nashville, TN.
authors.forename: Alan B
authors.initials: AB
authors.lastname: Storrow
mesh_terms: D000368:Aged; D042241:Early Diagnosis; D004562:Electrocardiography / Q000379:methods*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D000072657:ST Elevation Myocardial Infarction / Q000175:diagnosis* / Q000453:epidemiology / Q000503:physiopathology; D013997:Time Factors; D014218:Triage; D014481:United States / Q000453:epidemiology
keywords: ST‐segment elevation myocardial infarction; emergency department; false‐negative rate; informedness; missed case rate; screening; timely care