- Recognize that a significant proportion of the Unites States population receives care in rural safety net emergency departments.
- Understand that acute myocardial infarction is a high-risk, low-frequency event in the rural emergency department.
- List patient safety strategies likely to reduce acute myocardial infarction morbidity and mortality.
- Discuss the role of telehealth in rural emergency department chest pain care.
A 62-year-old man with a history of diabetes presented to a rural emergency department (ED) complaining of chest pain, hiccups, and generalized weakness. His vital signs were within normal limits, and physical examination was unremarkable. His initial electrocardiogram revealed an incomplete left bundle branch block. Laboratory results were notable for a blood sugar of 615 mg/dL, an anion gap acidosis, and a troponin of 1.8 μg/L (normal < 0.05 μg/L). The ED provider felt this presentation was consistent with a hyperosmolar hyperglycemic state from poor adherence and that the patient should be admitted to the hospital.
As this was a rural hospital with 35 inpatient beds, there was no on-site provider to admit the patient overnight. The ED physician called the internist who was covering this hospital (and another rural hospital) and discussed the admission. The internist was concerned about the elevated troponin and possible myocardial ischemia, and he ordered aspirin and a heparin drip from home. These orders were not communicated to the nurse or the physician in the ED. Due to the configuration of the electronic health record, the ED nurse did not see the orders and neither medication was given. The internist's plan was to contact the local cardiologist who would be available the next day.
The patient was transferred to an acute care bed 2 hours later. When he arrived, he was diaphoretic, somnolent, tachycardic, and borderline hypotensive. The nurse called the covering internist at home about the situation, and the internist ordered more laboratory tests (including a troponin I) and inquired about the heparin drip. The nurse realized that the drip had never been started and called the pharmacy to clarify the dosing. When she went to administer the heparin, she found the patient to be unresponsive, hypotensive, and bradycardic. She called a code blue, and resuscitation was initiated.
During the resuscitation, the repeat troponin I level returned at 42 μg/L, consistent with an acute myocardial infarction. The patient's initial presentation with chest pain and weakness was likely because of an acute myocardial infarction. Despite maximal efforts, the patient could not be resuscitated and died. An autopsy revealed an acute myocardial infarction and a rupture of the left ventricular free wall.
Commentary by A. Clinton MacKinney, MD, MS, and Nicholas M. Mohr, MD, MS
While rural Americans constitute 19% of the population, rural community hospitals comprise nearly 38% of all United States community hospitals.(1) The typical rural emergency department (ED) has a much lower case volume than nonrural EDs, with a median of 8158 ED visits per year (Table 1).(2) However, because of the large number of rural EDs, 42% of all ED visits in the US occur at EDs in rural counties.(2) As a result of the lower case volume, staff in rural EDs treat high-risk, low-frequency events (e.g., acute myocardial infarction, stroke, severe trauma, sepsis) less often than staff in higher volume hospitals. Furthermore, providers staffing rural EDs often work alone with a small nursing team that may have additional non-ED responsibilities (such as helping out on a small inpatient unit), making treatment of high-risk cases even more challenging.(3) Subspecialty physicians, such as cardiologists, are not available in many rural EDs.(4)
More than 7 million patients with chest pain are seen in US EDs each year.(5) Causes of chest pain are multiple, and many etiologies are challenging to diagnose in the ED.(6) Acute myocardial infarction (AMI), while very serious, is the ultimate diagnosis in only 8% of chest pain patients in US EDs.(7) Of patients with symptomatic acute coronary syndrome, 8% have no chest pain at the time of presentation, and up to one-third have no symptoms at all.(8,9) This heterogeneity in clinical presentations leads to both overtriage and undertriage, and the proportion of patients with AMI or unstable angina discharged from an ED to home may be as high as 2%.(7) Patients with AMI have been observed to have an estimated 43% higher mortality if treated in the lowest case volume EDs compared to the highest volume EDs (Table 2).(10) Other conditions, such as sepsis, respiratory failure, congestive heart failure, gastrointestinal hemorrhage, and renal failure exhibit similar outcome–volume relationships.(10)
While responsible for the minority of chest pain presentations, AMI is one of the highest risk causes of chest pain. In this case, the diagnosis was complicated by coexisting hyperosmolar hyperglycemic state, an emergency that may have distracted the ED physician from the appropriate diagnosis of AMI (given new left bundle branch block and elevated troponin). The ECRI Institute lists diagnostic errors as the Number 1 patient safety concern in 2018, affecting up to 5% of US adults annually (Table 3), and cognitive error can be an important contribution to misdiagnosis.(11-13) Complex patients with multiple coexisting abnormalities can predispose clinicians to premature closure and diagnosis momentum, where clinically relevant abnormalities are misattributed to a single diagnosis previously identified.(12) This bias can also be exacerbated in a busy ED with clinicians distracted by competing patients and priorities.(14)
For low-frequency, high-risk clinical issues like an AMI, rural hospitals may benefit from efforts to standardize care. A standard chest pain protocol might prompt ED staff to perform an electrocardiogram (ECG) immediately upon arrival for all patients with chest pain, prompt providers to consider repeating the ECG periodically, notify the clinician of the elevated troponin, and recommend transfer to a center with a cardiac catheterization laboratory for patients meeting criteria for AMI. A similar approach to standardizing care should be applied to other low-frequency, high-risk clinical issues, such as sepsis, for which protocolized care and electronic health record–based prompts have been shown to improve adherence with international guidelines.(15)
In addition to standardization of care and developing care pathways, rural hospitals may also benefit from improving teamwork and coordination of care. Such coordination can be particularly important given the limited staffing and that nursing staff may be engaged in other activities (such as helping care for an inpatient or assisting at a delivery) and not always easily available. Multiple programs have been developed harnessing crew resource management (CRM) techniques. These programs can reduce diagnostic errors by engaging diverse perspectives from within the entire care team. Morey and colleagues found that a CRM program applied to an ED staff in clinical teams reduced the clinical error rate significantly from 30.9% to 4.4% (p = .039).(16)
Another option to improve care in rural EDs is ED-based consultation. Involving consultants from large-volume urban enters early with complex patients in rural hospitals can enhance the detection of subtle abnormalities and can improve early treatment and triage. One strategy that has been used successfully in stroke, trauma, and for undifferentiated ED patients is ED-based telehealth, which has been shown to improve the timeliness and quality of care.(17-20) Using ED-based systems, a rural provider can use a single button to connect with a tertiary physician–nurse team using a high-definition video connection, and this team can help with medical decision-making, documentation, and transfer planning.
In this case, an off-site internist ordered aspirin and a heparin drip while the patient was awaiting admission. However, neither medication was given in the ED, and this medication error did not surface until 2 hours later when the patient arrived in the acute care unit. Delays from the admission decision to arrival on the inpatient unit are problematic. The median time from ED provider decision to admit to patient arrival on the inpatient unit in the US is more than 2 hours. Such a delay in the present case was enough time for the patient's condition to deteriorate significantly. The admitting internist attempted to manage the patient from home with orders that were not completed.
In the hospital described in this case, there may have been confusion about which physician (ED or off-site internist) had responsibility for this patient before he was transferred to the inpatient unit. In most cases, patients physically present in the ED are the responsibility of the ED provider. Internal care coordination is the ECRI Institute's Number 3 patient safety concern in 2018.(11) Ideally, a patient care transfer from one clinician to another should be a warm handoff, where a person-to-person handoff occurs in front of the patient and family.(21) In the absence of a warm handoff, formal communication techniques should be used, such as Situation-Background-Assessment-Recommendation (SBAR) (22) and communication read-back, to reduce communication errors. Rural hospitals should consider standardizing communication between ED and admitting providers and also between the admitting provider and nursing staff. Both strategies might have ensured that this patient received the ordered medications and might have provided the internist an opportunity to intervene when the patient's condition deteriorated.
Predicting the clinical course in critically ill patients can be challenging and determining whether a rural hospital has the capacity to care for a patient can be difficult with evolving clinical conditions. Many patients want to remain local for hospital care when possible, but physicians may overestimate the value of local care in patients' perceptions of care quality.(23) Most ED-based triage tools have been developed to predict patient acuity and resource needs, but none have been devoted to rural issues in matching patient needs to facility resources explicitly.(24)
Triaging patients from rural hospitals to hospitals with greater capacity is one strategy for providing care to complex critically ill patients. Elaborate triage systems have been developed for trauma and cardiac care, and some have proposed similar systems for other critically ill patients.(24) The National Academy of Medicine has recommended a coordinated regionalized emergency system as one strategy for improving outcomes from emergency care.(25) Coordinated implies seamless care from the patient's point of view; various components of the system must communicate continuously and coordinate their activities. Regionalized implies that hospitals, emergency medical services, and other agencies provide emergency care to everyone in that region. Ideally, patients should be taken to the optimal facility within the region based on their condition and the distances involved.(26) Caring for complex patients requires physician resources, nursing resources, and technical resources. Transfer protocols can help to articulate these thresholds. There is evidence that delaying transfer when a transfer is appropriate can worsen patient outcomes.(27,28)
Standardizing care pathways, improving teamwork, using ED-based consultation or telemedicine consults, standardizing handoffs, and building triage protocols all can help prevent adverse events.
- Emergency department clinical care protocols and enhanced teamwork may improve care for high-risk, low-frequency events such as acute myocardial infarction, stroke, trauma, and sepsis.
- Emergency department telehealth consultation can aid local providers and prevent diagnostic errors.
- Providers should include warm handoffs (when possible) and standardized communication (including SBAR and read-back) to reduce errors from miscommunication.
- Standardized transfer protocols may make transfer-versus-admit decision making less challenging.
A. Clinton MacKinney, MD, MS Clinical Associate Professor and Deputy Director Rural Telehealth Research Center Department of Health Management and Policy College of Public Health, University of Iowa Iowa City, Iowa
Nicholas M. Mohr, MD, MS Associate Professor of Emergency Medicine and Anesthesia Critical Care University of Iowa Carver College of Medicine Iowa City, Iowa
Faculty Disclosure: Dr. Mohr has received research funding from the Federal Office of Rural Health Policy, US Department of Health and Human Services. The commentary does not include information regarding investigational or off-label use of products or devices. All conflicts of interest have been resolved in accordance with the ACCME Updated Standards for commercial support.
Table 1. Emergency Department Visits by County Type.(2)
Table 2. Acute Myocardial Infarction Mortality by Emergency Department Case Volume.(10)
||ED Case Volume
|AMI Adjusted Mortality Rate, %, (CI)
*CI: confidence interval
Table 3. ECRI Institute's Top 10 Patient Safety Concerns for 2018.(11)
| 1 Diagnostic Errors
| 2 Opioid safety across the continuum of care
| 3 Internal care coordination
| 4 Workarounds
| 5 Incorporating health IT into patient safety programs
| 6 Management of behavioral health needs in acute care settings
| 7 All-hazards emergency preparedness
| 8 Device cleaning, disinfection, and sterilization
| 9 Patient engagement and health literacy
|10 Leadership engagement in patient safety
1. American Hospital Association. Fast Facts on US Hospitals, 2018. [Available at]
2. Muelleman RL, Sullivan AF, Espinola JA, Ginde AA, Wadman MC, Camargo CA Jr. Distribution of emergency departments according to annual visit volume and urban-rural status: implications for access and staffing. Acad Emerg Med. 2010;17:1390-1397. [go to PubMed]
3. Casey MM, Wholey D, Moscovice IS. Rural emergency department staffing and participation in emergency certification and training programs. J Rural Health. 2008;24:253-262. [go to PubMed]
4. Rao MB, Lerro C, Gross CP. The shortage of on-call surgical specialist coverage: a national survey of emergency department directors. Acad Emerg Med. 2010;17:1374-1382. [go to PubMed]
5. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables. Atlanta, Georgia: Centers for Disease Control and Prevention; 2015. [Available at]
6. Cayley WE Jr. Diagnosing the cause of chest pain. Am Fam Physician. 2005;72:2012-2021. [go to PubMed]
7. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-1170. [go to PubMed]
8. Brieger D, Eagle KA, Goodman SG, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. Chest. 2004;126:461-469. [go to PubMed]
9. Burgess DC, Hunt D, Li L, et al. Incidence and predictors of silent myocardial infarction in type 2 diabetes and the effect of fenofibrate: an analysis from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. Eur Heart J. 2010;31:92-99. [go to PubMed]
10. Kocher KE, Haggins AN, Sabbatini AK, Sauser K, Sharp AL. Emergency department hospitalization volume and mortality in the United States. Ann Emerg Med. 2014;64:446-457.e446. [go to PubMed]
11. ECRI Institute. Top 10 Patient Safety Concerns for Healthcare Organizations for 2018.
12. Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf. 2014;23:727-731. [go to PubMed]
13. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775-780. [go to PubMed]
14. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"? Acad Emerg Med. 2000;7:1239-1243. [go to PubMed]
15. Levy MM, Rhodes A, Phillips GS, et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Intensive Care Medicine. 2014;40:1623-1633. [Available at]
16. Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, Berns SD. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002;37:1553-1581. [go to PubMed]
17. Müller-Barna P, Hubert GJ, Boy S, et al. TeleStroke Units serving as a model of care in rural areas: 10-year experience of the TeleMedical Project for integrative Stroke Care. Stroke. 2014;45:2739-2744. [go to PubMed]
18. Mohr NM, Vakkalanka JP, Harland KK, et al. Telemedicine use decreases rural emergency department length of stay for transferred North Dakota trauma patients. Telemed J E Health. 2018;24:194-202 [go to PubMed]
19. Mohr NM, Young T, Harland KK, et al. Emergency department telemedicine shortens rural time-to-provider and emergency department transfer times. Telemed J E Health. 2018;24:582-593. [go to PubMed]
20. Dharmar M, Romano PS, Kuppermann N, et al. Impact of critical care telemedicine consultations on children in rural emergency departments. Crit Care Med. 2013;41:2388-2395. [go to PubMed]
21. Warm Handoff: Intervention. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. [Available at]
22. SBAR Tool: Situation-Background-Assessment-Recommendation. Cambridge, MA: Institute for Healthcare Improvement. [Available at]
23. Mohr NM, Wong TS, Faine B, Schlichting A, Noack J, Ahmed A. Discordance between patient and clinician experiences and priorities in rural interhospital transfer: a mixed methods study. J Rural Health. 2016;32:25-34. [go to PubMed]
24. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care. Rockville, MD: Agency for Healthcare Research and Quality; 2018. AHRQ Publication No. 12-0014. [Available at]
25. Institute of Medicine. IOM report: the future of emergency care in the United States health system. Acad Emerg Med. 2006;13:1081-1085. [go to PubMed]
26. Feazel L, Schlichting AB, Bell GR, et al. Achieving regionalization through rural interhospital transfer. Am J Emerg Med. 2015;33:1288-1296. [go to PubMed]
27. Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477-1483. [go to PubMed]
28. Rincon F, Morino T, Behrens D, et al. Association between out-of-hospital emergency department transfer and poor hospital outcome in critically ill stroke patients. J Crit Care. 2011;26:620-625. [go to PubMed]