Reasons Patients With Chest Pain Delay or Do Not Call 911,☆☆,,★★

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Abstract

Study objective: To determine the reasons patients with suspected acute myocardial infarction (AMI) delay seeking medical care or do not call 911.

Design: Telephone interview of patients hospitalized with suspected AMI. Setting: Nine hospitals in King County, Washington. Participants: Patients admitted to a CCU or ICU between October 1, 1986, and December 31, 1987, with suspected AMI occurring out-of-hospital. Spouses of patients who met criteria but died during the hospitalization also participated. Interventions: Hospital records were reviewed, and a 20-minute telephone interview was conducted of patients who reside in King County but do not live in an extended care facility. Measurements: Patient demographics, cardiac history, symptoms, time of acute symptom onset, time of emergency department arrival, method of transportation, discharge diagnosis, and hospital outcome were abstracted from hospital records. Circumstances leading to the hospitalization, reasons for delay in seeking care, and reasons for not calling 911 were determined in the telephone interview. Results: In a 15-month period, 5,207 patients were hospitalized for suspected AMI in King County, Washington. Twenty-seven percent had AMI. Median patient delay between symptom onset and hospital arrival was 2 hours. Paramedics transported 45% of all patients. A representative subset of patients (2,316) were interviewed. The main reasons for delay were because the patient thought that the symptoms would go away, because the symptoms were not severe enough, and because the patient thought that the symptoms were caused by another illness. The main reasons for not calling 911 were because the symptoms were not severe enough, because the patient did not think of calling 911, and because the patient thought that self-transport would be faster because of his or her close location to the hospital. Conclusion: Maximal benefit from thrombolytic therapy is not realized in a substantial proportion of patients with AMI because of delays in seeking medical care. Knowledge of the reasons patients delay or do not call 911 can help focus efforts on achieving more rapid treatment of patients with AMI. [Meischke H, Ho MT, Eisenberg MS, Schaeffer SM, Larsen MP: Reasons patients with chest pain delay or do not call 911. Ann Emerg Med February 1995;25:193-197.]

Section snippets

INTRODUCTION

The use of thrombolytic therapy in patients with suspected acute coronary thrombosis substantially reduces mortality after acute myocardial infarction (AMI).1There is a general consensus that the sooner thrombolytic therapy can be administered after the onset of symptoms, the greater will be the reduction in myocardial damage. Thus a critical component in successful treatment is shortening the interval between the onset of symptoms and arrival at the hospital.

Patient delay (ie, the interval

MATERIALS AND METHODS

An ongoing myocardial infarction surveillance system began on October 1, 1986, in all eight King County, Washington, hospitals with ICU beds. A ninth hospital began operation in May 1987 and was included in the surveillance system at the time. These same hospitals (plus seven Seattle hospitals) took part in the myocardial infarction triage and intervention (MITI) study.4Patients admitted to the cardiac care unit or ICU with a diagnosis of rule-out AMI, chest pain, or angina were identified from

RESULTS

There were 5,206 patients admitted for possible AMI during the 15-month study period, and 2,317 (45%) were interviewed. Of those not interviewed, 25% refused, and the remainder lived outside of King County, lived in nursing homes, or otherwise could not be reached.

Sample Characteristics The average age for the overall patient sample was 62 years, with a range of 21 to 98 years. Fifty-eight percent of the patients interviewed were male, and 42% were female. The ethnic distribution based on

DISCUSSION

To improve chances for survival after an AMI, it is critical that patients respond quickly and appropriately to symptoms. Our study shows that the main obstacle in patient delay appears to be uncertainty about the symptomatology of an AMI. Most patients delayed seeking care because they were confused about how to interpret the symptoms they were experiencing. Perceived barriers to seeking care quickly (eg, cost, inconveniencing the caregiver, embarrassment, etc) appeared to be much less

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From the Department of Health Services, School of Public Health and Community Medicine, University of Washington*; the Center for Evaluation of Emergency Medical Services, Emergency Medical Services Division, Seattle-King County, Department of Public Health; and the Department of Medicine, University of Washington§, Seattle.

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Support for this study was provided in part by a grant from Genentech, Inc, San Francisco, California.

Address for reprints: Hendrika Meischke, PhD, Center for Evaluation of Emergency Medical Services, Emergency Medical Services Division, Seattle-King County Department of Public Health, 900 Fourth Avenue, Suite 850, Seattle, Washington 98164

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Reprint no. 47/1/61923

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