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  • It was imperative to make patients a first

    2019-05-15

    It was imperative to make patients a first priority who had a definitive diagnosis needing immediate, timely, and effective interventions, including primary coronary intervention (PCI), permanent PI3K Akt mTOR Compound Library implantation, and were most likely to be admitted to CCU postprocedurally (Table 1). In this study, one of the most important indicators to review and confirm timely and effective quality of care would be management of patients with STEMI. For STEMI patients, the recommendation of PCI as the preferred reperfusion strategy should be made in a timely fashion to improve outcomes. In this study, of all the STEMI patients, 85.9% (146/170) patients were treated using PCI, with subsequent admission to the CCU. Those patients who did not undergo PCI were mainly personally reluctant, or declined due to old age. Among those who underwent primary PCI, 87.7% (128/146) patients had a door-to-balloon time of < 90 minutes during the study period. About 5.9% of patients (10/170) admitted to the EICU initially did not appear to fit the clinical diagnostic criteria of STEMI, which was diagnosed after sequential electrocardiogram changes and elevation of cardiac enzymes. By using the Taiwan National Health Insurance Research Database (1999–2008), Lee et al demonstrated that the in-hospital mortality rate of patients with acute myocardial infarction decreased from 15.9% in 1999 to 12.3% in 2008. The overall mortality of acute myocardial infarction patients in this study was 13.2% (66/501), which was slightly higher than the value in 2008. In detailed analysis, an objective measurement in our study patients\' mean age of 74.1 years was significant higher than the 66.3 years in that study\'s patients pool. After adjusting for an average age of 66 years, we generated a mortality rate 9.8%, lower than the 12.3% found in the previous article. Furthermore, our study found that there was no association with increased mortality between non-STEMI patients admitted to EICU or CCU. In scrutinizing univariate analysis of clinical characteristics comparing survival to mortality among patients admitted to each EICU or CCU, respectively, in this study (Tables 2 and 3), we found that old age, PI3K Akt mTOR Compound Library poor GCS, higher APACHE II scores and Charlson comorbidity index, CHF with acute pulmonary edema, pneumonia, and acute respiratory failure were common predictors associated with in-hospital mortality. Besides, patient admissions to CCU had more specific predictors of mortality, including STEMI, out-of-hospital cardiac arrest, lower mean blood pressure, and acute renal failure, which were related to poor prognosis. It can be speculated that out of hospital cardiac arrest or STEMI patients with cardiogenic shock and poor perfusion resulting in acute renal failure would be admitted to the CCU with first priority. By comparison, there was also evidence of clinical characteristics in survivals between groups (Table 4), which supports the proposition that patients with STEMI, arrhythmia, or complete atrial–ventricular block would be likely to be admitted to CCU (p < 0.05). We found old age, more complicated clinical diagnoses, and multiple comorbidity features for survival among those admitted to the EICU (Table 5), in comparison to those survivals admitted to CCU similar to those patients with significant characteristics (Table 1). The phenomenon could be explained by our ED treating nontrauma patients with an average age of 54.1 ± 25.8 years, and around 51% of these patients were older than 65 years. In the meantime, the average occupancy rate of CCU was around 93%, which could dramatically delay admission time and increase ED length of stay. In addition, our EICU had a lower occupancy rate of 74%, an average of 34-hour short-term LOS (Table 2), and greater flexibility for critical patient admissions. It is very intriguing to find that undifferentiated elderly patients with multiple comorbidity and organic dysfunction required more dedicated and complex diagnostic procedures or management, including specialist consultations. This might account for Testcross study\'s finding of both longer ED and hospital LOS for EICU patients rather than CCU patients (Table 1). In this study, the EICU care model can continuously provide an effective diagnostic process and monitor therapeutic effects, for patients without leaving the ED, to mitigate possible complications for patients with older age, multiple organic insufficiency, and comorbidities.