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Cardiovascular emergencies rarely unrecognized in ED

Opportunities to diagnose patients presenting to the ED for cardiovascular emergencies are missed less than one in 20 times, according to research published in JAMA Internal Medicine.

“Accurate and timely diagnosis is a cornerstone of high-quality care,” Daniel A.Waxman, MD, PhD, department of emergency medicine at the University of California, Los Angeles, and colleagues wrote. “A report by the Institute of Medicine, Improving Diagnosis in Health Care, calls diagnostic error an underappreciated source of patient harm and ‘a blind spot’ in the patient safety movement.”

Waxman and colleagues investigated how often diagnostic opportunities were missed in patients discharged from the ED without diagnosis who demonstrated symptoms of underlying acute cardiovascular pathology.

The researchers assessed the Medicare claims of all fee-for-service Medicare patients (n = 1,561,940; mean age, 77.9 years; 54.1% female) who were hospitalized between 2007 and 2014 for symptoms of imminent ruptured abdominal aortic aneurysm (n= 17,963), acute myocardial infarction (n = 304,980), stroke (n = 1,181,648), aortic dissection (n = 19,675) and subarachnoid hemorrhage (n = 37,674).

Results showed that 3.4% of ruptured abdominal aortic aneurysm diagnostic opportunities were missed in the ED, as were 2.3% of acute MI cases, 4.1% of stroke cases, 4.5% of aortic dissection cases and 3.5% of subarachnoid hemorrhage cases. Longitudinal trends of missed diagnostic opportunities were rising for ruptured abdominal aortic aneurysm, stroke and subarachnoid hemorrhage and nonsignificant for acute MI and aortic dissection.

Unrecognized emergencies were more likely in females, those aged younger than 65 years, those with dual eligibility for Medicare and Medicaid coverage and those with chronic conditions, including end-stage renal disease, dementia, depression, diabetes, cerebrovascular disease, hypertension, coronary artery disease and COPD.

“Among Medicare patients, opportunities to diagnose ruptured [abdominal aortic aneurysm], [acute] MI, stroke, aortic dissection, and [subarachnoid hemorrhage] are missed in less than one in 20 ED presentations,” Waxman and colleagues concluded. “Further improvement may prove difficult.” – by Alaina Tedesco

Disclosure: Waxman reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.