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

描述(申请人提供)：急诊科(ED)挽救生命，但一些可改变的ED因素可能会长期对患者造成伤害。这项拟议的研究的目的是通过确定那些与ED治疗后长期精神和医学预后不良相关的ED因素，使数百万患者受益。大多数医疗环境都是平静和可预测的，但急诊室往往不是这样。在美国，几乎每个急诊室在一天的过程中，过度拥挤和相关因素都有很大不同，有些时间是平静和安静的，而另一些时间则是过度拥挤和混乱。我们发现，在急诊室拥挤时因急性心脏事件接受治疗的患者患创伤后应激障碍(PTSD)症状的风险增加，并且心脏事件后的PTSD症状与随后发生心脏事件或死亡的风险加倍相关。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内死亡的风险增加。有可能埃德 这些因素会增加患创伤后应激障碍的风险，进而可能导致更糟糕的心脏结局。尽管EDS的许多假想的医源性方面是可以修改的，但临床指南忽略了它们，很少有EDS采取必要的步骤来解决这些问题。事实上，虽然ST段抬高心肌梗死[STEMI]患者按照明确的临床路径进行治疗，确保他们快速通过急诊室，但没有这样的指南管理每年在美国住院的100多万非ST段抬高性心肌梗死(NSTEMI)或不稳定心绞痛(UA)患者的ED治疗。因此，这些患者经常在怀疑自己是否患有危及生命的心脏病发作时，暴露在潜在有害的ED因素中12小时或更长时间。在NSTEMI/UA患者中，ED因素是否会增加PTSD和随后的心脏事件/死亡率的风险还没有得到全面的测试。我们建议通过住院治疗观察一组NSTEMI/UA患者在急诊室的表现。我们将衡量三个潜在有害的ED因素：(1)拥挤(人口普查、等待时间和接触他人的危重护理)；(2)人际因素(医患沟通、社会支持的存在和有效性)；以及(3)患者反应(生理唤醒和心理唤醒)。研究协调员将首先在急诊室捕获实时拥挤数据和患者的简单心理反应，然后全面评估患者在住院期间的反应和人际因素。临床医生将在基线后一个月通过电话采访参与者以确定创伤后应激障碍状态，我们将在基线一年后确定心脏事件复发和全因死亡率(ACM)。潜在有害的勃起功能障碍因素是可以改变的。这项研究将确定每年在美国急诊室接受治疗的100多万NSTEMI/UA患者中，ED因素是否会增加心脏复发、死亡率和创伤后应激障碍的风险，找出最重要的目标因素，并指出抵消这一风险的干预措施。

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.