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Archives of cardiovascular diseases
Volume 108, n° 3
pages 181-188 (mars 2015)
Doi : 10.1016/j.acvd.2014.11.002
Received : 26 January 2014 ;  accepted : 26 November 2014
Management of non-traumatic chest pain by the French Emergency Medical System: Insights from the DOLORES registry
Étude de la douleur thoracique non traumatique prise en charge par le Samu : résultats du registre DOLORES
 

Stéphane Manzo-Silberman a, , Nathalie Assez b, Benoît Vivien c, Karim Tazarourte d, Tarak Mokni e, Vincent Bounes f, Agnès Greffet c, Vincent Bataille f, Geneviève Mulak g, Patrick Goldstein b, Jean Louis Ducassé f, Christian Spaulding h, Sandrine Charpentier f, i
a Service de cardiologie, université Paris VII, CHU Lariboisière, AP–HP, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France 
b Service d’aide médicale urgente de Lille, Lille, France 
c Service d’aide médicale urgente de Paris, université Paris Descartes–Paris V, CHU Necker-enfants malades, AP–HP, Paris, France 
d Service d’aide médicale urgente 77, urgence-réanimation, hôpital Marc-Jacquet, Melun, France 
e Service d’aide médicale urgente, hôpital Côte-Basque, Bayonne, France 
f Service d’aide médicale urgente, CHU Toulouse 3, Toulouse, France 
g Société française de cardiologie, Paris, France 
h Inserm U 970, département de cardiologie, centre d’expertise de la mort subite, université Paris-Descartes, hôpital européen Georges-Pompidou, AP–HP, Paris, France 
i Inserm UMR 1027, University Paul Sabatier Toulouse III, Toulouse, France 

Corresponding author.
Summary
Background

The early recognition of acute coronary syndromes is a priority in health care systems, to reduce revascularization delays. In France, patients are encouraged to call emergency numbers (15, 112), which are routed to a Medical Dispatch Centre where physicians conduct an interview and decide on the appropriate response. However, the effectiveness of this system has not yet been assessed.

Aim

To describe and analyse the response of emergency physicians receiving calls for chest pain in the French Emergency Medical System.

Methods

From 16 November to 13 December 2009, calls to the Medical Dispatch Centre for non-traumatic chest pain were included prospectively in a multicentre observational study. Clinical characteristics and triage decisions were collected.

Results

A total of 1647 patients were included in the study. An interview was conducted with the patient in only 30.5% of cases, and with relatives, bystanders or physicians in the other cases. A Mobile Intensive Care Unit was dispatched to 854 patients (51.9%) presenting with typical angina chest pains and a high risk of cardiovascular disease. Paramedics were sent to 516 patients (31.3%) and a general practitioner was sent to 169 patients (10.3%). Patients were given medical advice only by telephone in 108 cases (6.6%).

Conclusions

Emergency physicians in the Medical Dispatch Centre sent an effecter to the majority of patients who called the Emergency Medical System for chest pain. The response level was based on the characteristics of the chest pain and the patient's risk profile.

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Résumé
Contexte

Le diagnostic précoce des syndromes coronaires aigus est la priorité des systèmes de soins afin de réduire les délais de revascularization. En France, il est vivement recommandé aux patients d’appeler les numéros d’urgences (15, 112) qui conduisent à des centres de régulation où des médecins, en fonction de leur interrogatoire, décident de la prise en charge la plus appropriée. Cependant, l’efficacité de ce système n’a à ce jour jamais été évaluée.

Objectif

Décrire et analyser les choix de réponse des médecins lors des appels pour douleurs thoracique par le service d’aide médicale urgente (SAMU).

Méthodes

Du 16 novembre au 13 décembre 2009, l’ensemble des appels aux centres de régulation pour douleur thoracique non traumatique ont été inclus prospectivement dans une étude observationnelle multicentrique. Les caractéristiques cliniques et les décisions d’orientation ont été recueillies.

Résultats

Un total de 1647 patients a été inclus dans l’étude. L’entretien téléphonique n’a été réalisé avec le patient que dans seulement 30,5 % des cas, avec des parents, des témoins ou des médecins dans les autres cas. Un service mobile d’urgence et de réanimation a été envoyé pour 854 patients (51,9 %) qui souffraient de douleurs thoraciques typiques avec un risque élevé de maladie cardiovasculaire. Une ambulance a été envoyée pour 516 patients (31,3 %), et un médecin généraliste pour 169 (10,3 %). Les patients ne recevaient qu’un avis médical par téléphone dans 108 cas (6,6 %).

Conclusion

Les médecins d’urgence dans les centres de régulation médicale envoient un effecteur pour la majorité des appels pour douleur thoracique. Le type d’effecteur est défini par les caractéristiques de la douleur et le profil de risque du patient.

The full text of this article is available in PDF format.

Keywords : Chest pain, Acute coronary syndrome, Triage, Hotline, Emergency

Mots clés : Douleur thoracique, Syndrome coronaire aigu, Triage, Centre d’appel, Urgences

Abbreviations : ACS, CAD, ED, MICU, STEMI


Background

The incidence of acute coronary syndromes (ACS) in France is 280 per 100,000 in men and 60 per 100,000 in women [1]. Myocardial infarction accounts for 10–12% of the global annual mortality rate. Prompt intervention with appropriate care can significantly improve mortality, with associated cost savings. Data from French registries show a huge decrease in the 30-day mortality rate from 1995 to 2010 (11.3–4.4%), mainly due to decreased delays and enhanced access to reperfusion strategies [2]. Prehospital management of chest pain remains challenging. International guidelines highlight the need for shorter delays to improve prognosis, particularly in the acute setting of ST-segment elevation myocardial infarction (STEMI) [3]. Dedicated regional protocols are recommended to accelerate and improve ACS diagnosis in the emergency department (ED) [4] or by the prehospital ambulance service, with or without medical staff on board [5, 6, 7]. Accurate prehospital patient orientation allows the initiation of effective therapy, such as fibrinolysis, transfer for primary angioplasty or admission to a coronary care unit for early coronary angiography [8]. Avoiding admissions to such units for patients with chest pain not due to ACS increases the unit's performance, limiting unnecessary and expensive hospital stays.

In France, patients with chest pain call a Medical Dispatch Centre (service d’aide médicale urgente [SAMU]) and emergency physicians assess the probability of an ACS; if an ACS is suspected, they dispatch a Mobile Intensive Care Unit (MICU) with a physician on board. In the other cases, paramedics or a general practitioner can be sent on site, or the physician can simply advise the patient by telephone [7].

The emergency physician in charge of the telephone triage can only rely on the clinical data gathered during the telephone call. Calls for ACS represent about 15% of all calls for chest pain at the Medical Dispatch Centre, which is similar to the incidence of patients with ACS presenting to EDs [9]. Until now, no decision-making algorithm has been validated. Effective identification of ACS has failed using Advanced Medical Priority Dispatch call prioritization [10]. To date, no study has been published analysing the variables that influence the decision to send a medical team to the patient at the time of telephone triage.

We performed a multicentre observational study in various Medical Dispatch Centres in France, to assess emergency call triage for chest pain by describing the population according to the type of strategy chosen. In particular we analysed the characteristics of patients to whom an MICU was sent.

Methods
Study

We conducted a multicentre observational study, supported by the French Society of Cardiology (SFC) and the French Society of Emergency Medicine (SFMU), with an educational grant from Eli Lilly. Between 16 November and 13 December 2009, all emergency calls for non-traumatic chest pain received by the Medical Dispatch Centres in Bayonne, Lille, Melun, Paris and Toulouse were included prospectively in the study. Exclusion criteria were age<18 years and traumatic chest pain.

In accordance with French law, our local ethics committee considered that patient consent could be waived for participation in this observational study. Data file collection and storage were approved by the ‘Comité consultatif sur le traitement de l’information en matière de recherche’ (CCTIRS) and the ‘Commission nationale informatique et liberté’ (CNIL).

Patients

The emergency system in France is based on the early intervention of physicians. Emergency call numbers (15 or 112) are routed to the closest Medical Dispatch Centre. These calls are first received by the auxiliary medical triage staff members, whose role is to open a file containing the telephone number of the caller and the geographical location of the patient, and to assess the degree of emergency; the call is then transmitted to an emergency physician.

After analysing the situation, the emergency physician chooses the type of response: medical advice by telephone; consultation by a general practitioner; dispatch of a paramedic team for hospitalization without a medical evaluation; or dispatch of an ambulance (MICU) staffed with at least one emergency physician.

All patients included in the study were identified by a study number. Five files were planned and completed according to the care process. For each patient there was a file for the telephone triage and a file for the 30-day follow-up; there were also files for the MICU medical staff, the ED and the cardiology department. Patient demographics and clinical data were recorded, as well as the estimation of the probability of ACS by the clinician on site and the decisions taken at each step.

Statistical analysis

Statistical analyses were conducted using Stata Statistical Software, release 10 (StataCorp LP, College Station, TX, USA). Statistics are reported as means with standard deviations, and medians with interquartile ranges for delays. Means were compared using Student's t test for normally distributed data or the non-parametric two-sample Mann-Whitney rank-sum test for data not fitting the assumption of parametric testing. Percentages were compared using Pearson's Chi2 test and Fisher's exact test. Univariate analyses were performed to identify factors associated with the dispatch of the MICU.

Results

During the study, a total of 1647 emergency calls for non-traumatic chest pain were regulated by the Medical Dispatch Centres of Bayonne (n =94; 5.7%), Lille (n =588; 35.7%), Melun (n =68; 4.1%), Paris (n =521; 31.6%) and Toulouse (n =376; 22.8%).

First decision by regulation triage

An MICU was sent to the patient in 51.9% of cases (Figure 1), paramedics were sent in 31.3% of cases, and a general practitioner was sent in 10.3% of cases; patients were only given medical advice by telephone, with no dispatch, in 6.6% of cases.



Figure 1


Figure 1. 

First decision of the Medical Dispatch Centre and final destination of the patient. ED: emergency department; MICU: Mobile Intensive Care Unit.

Zoom

The patient was admitted directly to a cardiology ward or a coronary care unit in 33.3% of cases handled by the MICU emergency physician and in fewer than 3% of cases when a paramedic or general practitioner was dispatched.

A total of 942 patients (61% of total calls) were admitted to an ED, while 303 patients (20%) were admitted to a cardiology department. In 5% of all calls that resulted in a staff carer (general practitioner, paramedics or MICU) being sent, the final decision was to leave the patient at home.

Call characteristics

During the study period, 68.9% of calls occurred on a weekday; an MICU was more frequently sent as a result of these calls. A total of 43.1% of calls were received during office hours (between 08.00 and 20.00); an MICU was less frequently dispatched as a result of these calls (Table 1).

The patient called the Medical Dispatch Centre directly in only 30.5% of all cases. In the other cases, the telephone call was made by a paramedic, a relative, a bystander or a general practitioner. An MICU was sent more frequently when the call came from a paramedic or a general practitioner rather than from the patient, a relative or a bystander (P <0.00001).

The physician in charge of the triage was able to question the patient in fewer than 40% of cases. Interestingly, speaking directly with the patient was not associated with a statistical difference in terms of MICU dispatch.

Characteristics of the patients

The mean age was 56.1 years; patients who were sent an MICU were older (61.2 vs 50.5 years; P <0.00001) and were more frequently men (61.8% vs 50.2% for women; P <0.00001). Patients with previous coronary artery disease (CAD) were sent an MICU more frequently (66.8%; P <0.00001), especially if they had a history of myocardial infarction (77.5%; P <0.00001) (Table 2).

The decision to dispatch an MICU was associated with the existence of risk factors. Absence of risk factors was found in 15.3% of all patients; an MICU was dispatched to 54 (28.1%) of these patients, who represent 6% of all the patients to whom an MICU was dispatched.

Diabetes, dyslipidaemia, active smoking, high blood pressure or family history of CAD were all related to the decision to send an MICU. The probability of sending a medical emergency team was multiplied by two in these cases.

Finally, pre-existing treatments with aspirin, clopidogrel and statins were each significantly associated with MICU dispatch.

Characteristics of the pain and associated symptoms

Persistence of chest discomfort and exacerbation at exertion were statistically associated with the dispatch of an MICU. An MICU was sent to patients with persistent chest pain in 55.3% of cases. Moreover, typical (retrosternal) location of the pain and its radiations without associated symptoms influenced the decision of the emergency physician to send an MICU. In contrast, atypical chest pain increased by breathing or associated symptoms reassured the emergency physician and made them choose an alternative strategy (Table 3).

Discussion

This prospective multicentre study is the first to assess the characteristics of patients who called the Medical Dispatch Centre for non-traumatic chest pain, and to analyse the factors associated with the decision to send an ambulance staffed by at least one emergency physician.

Patients who called the Medical Dispatch Centre had a high-risk profile, with 40% having previous CAD; this rate is higher than those reported in series of patients admitted to EDs [11, 12]. A total of 85% had at least one risk factor for CAD, which is similar to previous reports on patients admitted to EDs [13, 14].

Most patients (70%) had persistent chest pain during the telephone interview, which is higher than that reported in ED patients [13]. Half of the patients had a typical presentation, with retrosternal chest pain described as pressure or heaviness, and 34% reported radiation to the left arm, similar to that described in patients presenting to an ED [14].

The person calling the Medical Dispatch Centre was the patient in only 30% of cases, regardless of medical history of CAD. The interview was conducted with the patient directly in fewer than 40% of cases, making the decision-making process even more difficult.

In almost 10% of cases a general practitioner called the Medical Dispatch Centre. The patient therefore consulted a general practitioner for chest pain instead of calling an emergency number. Consulting a general practitioner for STEMI increases reperfusion delays. Lapostolle et al. demonstrated that only 29% of patients previously managed for STEMI knew the emergency numbers to call in case of chest pain [15]. Public awareness programmes encouraging patients to call the emergency numbers are necessary to reduce delays. Patient education needs to be improved, especially in those with a history of CAD.

An MICU was sent to patients with a high-risk profile; most had a history of CAD and risk factors. Previous studies performed in the ED have suggested poor accuracy for risk factors [16]. Chest pain due to ACS is typically retrosternal and oppressive, with radiation to the left arm for more than 20minutes, without modification by breathing [17, 18]. Several studies have shown chest pain characteristics to be highly predictive of stable angina and ACS [19, 20]. In our study, these clinical features were associated with the dispatch of an MICU.

Simple medical advice with no dispatch was chosen rarely by the emergency physicians, who preferred to confirm the diagnosis by sending either paramedics or a general practitioner, and, in most cases, an MICU. Several studies have shown that emergency physicians send an MICU too frequently if an ACS is suspected [21, 22]. Discharge from an ED with a missed diagnosis of ACS increases mortality [23]. In a recent publication on the risk of error in the ED, the use of current diagnostic protocols reduces the risk of discharging a patient with ACS to<2% [24].

Emergency physicians in the Medical Dispatch Centre do not have the same diagnostic tools that are available in the ED to rule out an ACS diagnosis; they send an MICU if the probability of ACS is high, and paramedics or a general practitioner in the other cases. If an ACS is suspected by paramedics or a general practitioner, patients are sent to hospital for further investigations. The option of giving medical advice by telephone with no dispatch was only chosen if the probability of an ACS seemed very low. This strategy enables selection of patients with a high risk of ACS, including STEMI, which requires prompt management and revascularization [7]. However, overestimation of the risk of ACS will also induce costs related to the dispatch of the MICU. Scores are therefore necessary to improve prehospital triage of patients with chest pain [25].

It is noteworthy that during office hours an MICU was sent less readily, highlighting the effort of the physician in the Medical Dispatch Centre not to overuse the MICU, but to lean towards less expensive methods, when available, in very-low-risk cases.

Study limitations

The emergency physicians in charge of the triage by telephone did not record all the items required by the registry. Firstly, this may be explained by a high rate of calls by relatives or bystanders; secondly, for some patients presenting by telephone with a high risk of ACS (e.g. typical chest pain and a personal history of CAD), the Medical Dispatch Centre emergency physician generally decided to shorten the telephone interview quickly, and sent an MICU without completing the registry.

The study was initially planned to follow the patient from the initial telephone call to hospital discharge. Unfortunately, in some regions (such as Paris), the high number of hospitals impeded the collection of data by dedicated clinical research technicians. Validation of the initial diagnosis by the Medical Dispatch Centre physician with the final diagnosis (ACS or no ACS) was therefore not possible. Furthermore, there are no data on long-term outcome and the characteristics of the physician receiving the call. The limited data collected precluded extensive analysis of the patient population. Nevertheless, the main objective of the study was to assess the variables used by Medical Dispatch Centre physicians when deciding to send an MICU, paramedics or a general practitioner. The DOREMI registry (NCT02042209) is currently on-going in three French regions. Prehospital and hospital data will be collected from the call to the Medical Dispatch Centre for chest pain to hospital discharge. A predictive score for ACS will be derived from the data and tested prospectively.

Conclusion

Emergency physicians in the Medical Dispatch Centre send an effecter (e.g. an MICU with a physician on board, paramedics or a general practitioner) to the majority of patients calling with chest pain. The decision to upscale to an MICU was based solely on clinical data gathered during the telephone interview; clinical risk factors for ACS were key predictors. Unfortunately, despite extensive public information campaigns, 10% of patients experiencing chest pain consult a general practitioner as a first step, including patients with previous CAD. Public awareness of the emergency numbers must be increased to improve the process of care and reduce delays in ACS.

Disclosure of interest

S. Manzo-Silberman has received research support from Abiomed and (minimal) fees as a speaker for AstraZeneca, Daiichi Sankyo, Eli Lilly and Servier; and has been an advisory board member for Eli Lilly. C. Spaulding has received (minimal) honoraria for presentations for Eli Lilly, AstraZeneca, Cordis, Iroko Pharmaceuticals and Servier; and has been an advisory board member for Medtronic and Abiomed. S. Charpentier has received honoraria for presentations for Eli Lilly, Daiichi Sankyo, AstraZeneca, The Medicines Company, BRAHMS Thermo Fisher and Sanofi; and has been an advisory board member for Eli Lilly, Novartis and Roche Diagnostics. Other authors declare that they have no conflicts of interest concerning this article.


Acknowledgments

The DOLORES registry is a registry from the French Society of Cardiology and the French Society of Emergency Medicine (SFMU) supported by unrestricted grants from Eli Lilly.

We would like to thank particularly Nicolas Danchin, M.D., Geneviève Mulak, Pharm.D. and the personnel of the registry committee of the French Society of Cardiology, without whom this work would not have been possible.

The authors are deeply indebted to all the physicians at the participating institutions, and to the devoted personnel of the URC-EST (Professor Tabassome Simon, Assistance publique des hôpitaux de Paris and University Paris 6), under the leadership of Elodie Drouet, and Inserm U 1027 (Toulouse).

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