Impact of Social-Interpersonal Factors in the ER on PTSD/Cardiac Outcomes

描述（由申请人提供）：急诊科（艾德）挽救生命，但一些可改变的艾德因素可能会对患者造成长期伤害。这项研究的目的是通过确定与艾德治疗后长期精神和医学预后不良相关的艾德因素，使数百万患者受益。大多数医疗环境是平静和可预测的，但ED往往不是。在美国，几乎每一个艾德的一天中，过度拥挤和相关因素都有很大的不同，有些时间的特点是平静和安静，而另一些时间则是过度拥挤和混乱。我们发现，当艾德拥挤时，接受急性心脏事件治疗的患者发生创伤后应激障碍（PTSD）症状的风险增加，心脏事件后的PTSD症状与随后心脏事件或死亡率的风险加倍相关。此外，过去两年进行的研究表明，在拥挤的急诊室接受治疗的急性心脏病患者住院和一年死亡率的风险增加。有可能艾德 这些因素增加了PTSD的风险，这反过来又可能导致更糟糕的心脏结果。虽然许多假设的医源性方面的ED是可以修改的，临床指南忽略了他们，很少有ED已经采取必要的步骤来解决这些问题。事实上，虽然ST段抬高型心肌梗死（STEMI）患者按照明确的临床路径进行治疗，确保他们快速通过艾德，但没有这样的指南管理美国每年住院的100多万非ST段抬高型心肌梗死（NSTEMI）或不稳定型心绞痛（UA）患者的艾德治疗。因此，这些患者经常暴露于潜在有害的艾德因素12小时或更长时间，而他们想知道他们是否有危及生命的心脏病发作。艾德因素是否会增加NSTEMI/UA患者PTSD和随后心脏事件/死亡率的风险尚未得到全面测试。我们建议观察一组NSTEMI/UA患者，从在艾德就诊到住院治疗。我们将测量三个潜在有害的艾德因素：（1）拥挤（人口普查，等待时间，和暴露于他人的重症监护）;（2）人际因素（医患沟通，社会支持的存在和有效性）;和（3）病人的反应（生理唤醒和心理唤醒）。研究协调员将首先在艾德病房内短暂地捕捉实时拥挤数据和患者的心理反应，然后在住院期间全面评估患者的反应和人际关系因素。临床医生将通过电话采访参与者，以确定基线后一个月的创伤后应激障碍状态，我们将确定基线后一年的心脏事件复发和全因死亡率（ACM）。潜在有害的艾德因素是可以改变的。这项研究将确定艾德因素是否会增加每年在美国接受ED治疗的100多万NSTEMI/UA患者的心脏复发、死亡率和PTSD风险，确定那些最重要的目标因素，并指出干预措施以抵消该风险。

DESCRIPTION (provided by applicant): Emergency departments (ED) save lives, but some modifiable ED factors may cause patients harm in the long term. The goal of the proposed research is to benefit millions of patients by identifying those ED factors that are associated wit poor long-term psychiatric and medical prognosis after ED treatment. Most medical contexts are calm and predictable, but EDs frequently are not. Overcrowding and associated factors vary substantially through the course of a single day in almost every ED in the US, with some hours characterized by calm and quiet and others by overcrowding and chaos. We have found that patients treated for acute cardiac events when the ED is crowded are at increased risk for developing posttraumatic stress disorder (PTSD) symptoms, and that PTSD symptoms after a cardiac event are associated with a doubling of risk for a subsequent cardiac event or mortality. Further, research conducted in the past two years has shown that acute cardiac patients treated in crowded EDs are at increased risk for in-hospital and one-year mortality. It is possible that ED factors increase the risk of PTSD, which in turn may lead to worse cardiac outcomes. Although many of the hypothesized iatrogenic aspects of EDs are modifiable, clinical guidelines ignore them and very few EDs have taken the steps necessary to address them. In fact, while ST-segment elevation myocardial infarction [STEMI] patients are treated in accordance with well-defined clinical pathways that ensure they are moved quickly through the ED, no such guidelines govern the ED treatment of over one million patients hospitalized annually in the United States with non-ST-segment elevation MI (NSTEMI) or unstable angina (UA). Thus, these patients are often exposed to potentially harmful ED factors for 12 hours or longer while they wonder whether they are having a life-threatening heart attack. Whether ED factors increase risk for PTSD and subsequent cardiac events/mortality in NSTEMI/UA patients have not been tested comprehensively. We propose observing a cohort of patients with NSTEMI/UA from presentation in the ED through inpatient care. We will measure three potentially harmful ED factors: (1) crowding (census, wait time, and exposure to others' critical care); (2) interpersonal factors (doctor-patient communication, presence and effectiveness of social support); and (3) patient reactions (physiological arousal and psychological arousal). Research coordinators will first capture real-time crowding data and patients' psychological reactions briefly in the ED then assess patient reactions and interpersonal factors comprehensively during inpatient stay. A clinician will interview participants by telephone to determine PTSD status one month after baseline, and we will ascertain cardiac event recurrence and all-cause mortality (ACM) one year after baseline. Potentially harmful ED factors are modifiable. This research will determine whether ED factors increase risk of cardiac recurrence, mortality, and PTSD in the more than one million NSTEMI/UA patients treated in US EDs every year, identify those factors that are most important to target, and point to interventions to offset that risk.