AEM: Race, ethnicity may play role in ED decisions

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African-Americans and Hispanics who presented to the emergency room with chest pain were less likely than whites to be referred for immediate care, despite having similar symptoms, according to the results of a study published Sept. 24 in Academic Emergency Medicine.

According to the researchers, these practices violate the American College of Cardiology and American Heart Association guidelines that outline that patients who present with chest pain should undergo an immediate electrocardiogram (ECG).

"Emergency room triage is the critical step that determines the whole cascade of clinical decisions and testing that happens next, so if patients are misclassified on arrival, they won't receive the care they need when they need it," according to the guidelines

To better assess ED triage decisions, Lenny Lopez, MD, MPH, of the Massachusetts General Hospital in Boston, and colleagues assessed data from 1997 to 2006 that was reported in the National Hospital Ambulatory Medical Care Survey of Emergency Departments (NHAMCS-ED) to evaluate whether first ED triage decisions and disparities of care are affected by racial, ethnic and gender-based differences.

The NHAHCS-ED database includes age, gender, race and ethnicity and insurance status of almost 22,000 patients presenting with chest pain and who were examined by a hospitals ED. Additionally, the database was broken down into four triage categories: emergent patients who should be seen immediately, urgent for patients who can wait 15 to 60 minutes, semi-urgent for those who can wait one to two hours and non-urgent for patients who can wait two hours or longer.

During the study, patients in the first two aforementioned categories were considered emergent and those in the later two, non-emergent.

Among patients who received an ED diagnosis of probable MI, there were no significant differences in initial symptoms between racial or ethnic groups,” the authors wrote. However, Lopez and colleagues reported that African-American and Hispanic patients were less likely than whites to be triaged as emergent.

Additionally, the authors reported that in addition to African-Americans and Hispanics, uninsured patients or those covered by Medicaid were less likely to receive cardiac testing procedures such as ECG, cardiac monitoring or measurement of cardiac enzymes.

The authors noted that the day of the week of admission or whether patients arrived by ambulance did not affect outcomes of the study.

"These differences in ED triage may be important drivers of disparities in testing, procedures and eventual outcomes," said Lopez. "If you are misclassified at this first step, you're less likely to get the ECG because your condition is not considered urgent. In the long term, you may have an even more severe heart attack that could have been prevented if intervention had occurred earlier. This is not an area of medicine where there is a lack of clarity about what we are supposed to do, so quality improvement strategies need to focus on 100 percent guideline-driven triage management for every single patient."