Elsevier

Australian Critical Care

Volume 27, Issue 1, February 2014, Pages 11-16
Australian Critical Care

Management of the acute cardiac patient in the Australian rural setting: A 12 month retrospective study

https://doi.org/10.1016/j.aucc.2013.03.002Get rights and content

Abstract

Background

Rural cardiac patients may require transfer to tertiary health services for ongoing acute cardiac management. The time required to transfer is a consideration in determining appropriate clinical care. There is little published data reporting acute cardiac management in the Australian regional setting that reviews factors determining transfer to a tertiary centre.

Purpose

This paper reports the findings of a quantitative, retrospective study conducted to identify demographic differences and potential predictors to urban transfer for ongoing acute cardiac management for patients presenting to a regional hospital with suspected acute myocardial infarction.

Methods

Using a purpose designed tool an audit of 204 files from June 2009 to July 2010 was conducted for all patients admitted to a regional hospital having a discharge diagnosis of acute myocardial infarction or angina. Patient demographics, clinical outcomes, concordance with treatment guidelines, and possible predictors of treatment decisions were investigated.

Findings

Patients younger than 65 years (p < 0.001), unemployed (p < 0.01) and with acute electrocardiograph changes (p < 0.01) were more likely to be transferred to a tertiary centre. Treatment guidelines concordance for acute cardiac care ranged from 70% to 79% for all patients.

Conclusions

Although presenting patients were treated in a timely manner consistent with national guidelines, to be younger, unemployed or have electrocardiograph changes was a greater predictor to urban transfer. It is unknown if these differences in transferring or not to a tertiary centre contribute to poorer long-term cardiac outcomes for rural patients. Further evaluations are warranted.

Introduction

Cardiovascular disease (CVD) has been the major cause of death in Australia for many decades. Over three million Australians have a long term CVD.1 However, the mortality rate attributed to CVD varies by the recorded prevalence of risk factors and with this, geographic location. A 2007 publication outlined that cardiovascular death rates are 20–40% higher in regional and remote Australia and seen in younger patients when compared to urban areas.2 This is in addition to the reported differences between men and women in regional areas.3

Acute Coronary Syndrome (ACS) is one of the largest subsets of CVD and can be further subdivided into angina and acute myocardial infarction (AMI). An AMI is classified as a ST-segment Elevation Myocardial Infarction (STEMI) or Non ST-segment Elevation Myocardial Infarction (NSTEMI). The distinction influences clinical management. Despite the technology to treat coronary heart disease, research demonstrates the critical determinant on health outcomes for patients following an AMI is ‘time to treatment’.4

Treatment of a STEMI typically involves rapid re-establishment of blood flow either by means of Percutaneous Coronary Intervention (PCI) to the affected vessel or fibrinolytic therapy (FT) to relieve obstruction and re-establish coronary blood flow.5, 6 The choice of revascularisation therapy is time dependant. Both local and international treatment guidelines recommend immediate PCI in the presence of a STEMI.7 Greater than 12 h from symptom onset indicates treatment with PCI can be deferred and FT is recommended.7, 8, 9 A PCI is performed in tertiary referral centres, which are predominantly located in the metropolitan centres in Australia. Given the geographical distances regional Australians are faced with to access tertiary centres, optimal health outcomes are affected. Travel time is often greater than 2 h by road or fixed wing aircraft. This is in addition to time taken to find and secure a monitored bed in an appropriate facility as well as patient handover for transfer. The total time taken to transfer as a consequence is significant in the Australian rural context for health outcomes.

The aim of this study was to describe health and transfer outcomes for people presenting to a regional hospital having a discharge diagnosis of AMI. The socio-demographic and transfer destinations of a regional cohort were examined to identify potential differences between transferred and non-transferred patients experiencing a STEMI, and to identify possible predictors to transfer.

Section snippets

Methods

A quantitative retrospective study was conducted. Prospective Human Research Ethics Committee (HREC) approval was obtained from the university and hospitals committees (approval numbers: FHEC10/138 and JHEC/354/10/14, respectively). A ‘waiver of consent’ was applied for in the HREC applications based on the requirements outlined in the ‘National Statement on Ethical Conduct in Human Research’.10 A waiver of consent is applicable when the study fulfils the criteria of a low risk study and there

Results

Patient files of those admitted to the study site in the study period coded with an ICD-10 discharge diagnosis of I21 (AMI) and its’ subsets were evaluated. A flow diagram was constructed to assist in the scrutiny of this study's design (see Fig. 1). This approach is consistent with the ‘strengthening the reporting of observational studies in epidemiology’ (STROBE) statement.12

Of the 204 medical files that satisfied the study criteria, 139 patients (68%) arrived at the regional hospital's

Discussion

The primary aim of this study was to investigate acute coronary care management in the Australian rural setting; including those factors that influence the transfer of patients to a tertiary referral centre. The annual number of transfers for tertiary intervention (n = 99, 48%) for the study hospital is reflective of similar regional institutions.13 Despite the study setting being a major rural city, the number of transfers during this 12 month period is recognised as small when compared to the

Conclusions

This investigation reported statistically significant demographic and clinical differences between those patients transferred and those not transferred for ongoing management following their AMI. Patients transferred were younger in years when compared to those not transferred. Further, there was a considerable delay in days to transfer to a tertiary centre. Interestingly, no relationship was noted between time and day of presentation transfer. Whilst distance is a major barrier to accessing

Conflict of interest statement

The authors declare that there are no conflicts of interest.

Acknowledgements

The authors would like to thank the staff of the regional hospital for their support with this study. The authors would like to thank Professor Jeni Warburton for her review of the manuscript. Thank you to the anonymous reviewers for their considered comments and guidance.

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