SummaryBackground: The use of protocols for patients with ST-elevation myocardial infarction (MI) is growing, but no definite conclusion regarding the value of critical pathways in Europe has been drawn.Hypothesis: The aim of this study was to investigate the impact of critical pathway on processes of care and outcome for patients presenting to the emergency department (ED) of a large urban European hospital because of possible ST-elevation MI.Methods: Critical pathways for management of acute chest pain at our ED were developed in 1998 and have been revised every year. Accordingly, the records of all patients referred in 1997 to the ED because of chest pain (before pathway implementation) and in 2001 (after last pathway revision) were reviewed. An ST-elevation MI was diagnosed at ED in 520 of 5,066 (10.3%) patients with chest pain in 1997, and in 452 of 4,843 (9.3%) patients with chest pain in 2001. Patients were managed according to the ED cardiologists' decisions in 1997, whereas they entered the pathways for ST-elevation MI in 2001, with predefined criteria for diagnosis, thrombolysis, percutaneous coronary intervention, and admission to the coronary care unit.Results: Comparison of treatment modalities disclosed that more patients were given thrombolysis in 1997 (49 vs. 16%,

Abstract. The level of commitment in the analysis of clinical errors made in the emergency department (ED) is currently focused on organization and processes rather than on individual action. Four major cases of clinical errors made in the ED of a teaching hospital were investigated. Analysis suggested that the process of clinical decision making and the overreliance on the use of patterns during the cognitive process had a major role in causing the errors, rather than factors related to procedures or organization. It appears hard to design system changes and tactics to significantly reduce the probability of making errors associated with the cognitive process involved in clinical decision making. The authors have initiated a systematic analysis of errors made during the diagnostic workup in their ED, and the rate of clinically significant errors is tracked. A file is being created with the purpose to use it for teaching and orientation of all new staff. Key words: error; emergency medicine; procedures; cognitive process. ACADEMIC EMERGENCY MEDICINE 2000; 7:1278-1281 T HE DEBATE about clinical errors and the best way to analyze errors and to minimize their impact on adverse outcomes is increasing, even in the field of emergency medicine (EM). The level of commitment is currently focused on organizational systems and processes rather than on individual actions.1,2 The use of formal protocols and guidelines for diagnosis and treatment appears to ensure a systematic, comprehensive, and efficient approach to the process of clinical decision making, reducing to a minimum the probability of errors.We investigated whether major cases of clinical errors occurred at the emergency department (ED) of our teaching hospital during a one-year period. Cases were identified through reviewing the charts of patients who died in the ED or who were transferred to the intensive care unit (ICU) within 24 hours of their admission to the ED. Errors were defined as actions or missed actions that would have resulted in a change in the patient's care, actions that caused harm or death to the patient, or actions with the potential to do so. The goal of our investigation was to test the hypothesis that sub- CASE REPORTSStudy Setting. The ED of San Camillo Hospital, Rome, Italy, is a high-specialty-level department with units of EM, emergency and trauma surgery, intensive care, neurosurgery, and heart surgery. The institution of a stroke unit and a chest pain unit is planned. A mean of 110,000 people are seen each year at our department.Residents training in endocrinology, internal medicine, EM, general and emergency surgery, anesthesiology, and intensive care work in our hospital and, specifically, in the ED. Courses of basic life support (BLS) and advanced cardiac life support (ACLS) are offered on behalf of the Italian Resuscitation Council.Case Finding. For purpose of this study, cases were identified using very restrictive criteria. Members of the staff carefully reviewed the charts of all patients who died in the ED or who were transf...

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A 54-year-old female from Brazil with a 2-month history of anterior chest pain episodes was referred to our hospital. Before admission she underwent an ECG stress test that showed significant ST-segment depression in leads V4 -V6 together with anginal symptoms. The patient had a family history of sudden cardiac death (2 sisters died at 36 and 54 years of age) and a past history of hypertension. She had never suffered from syncope or palpitations.Biochemical blood parameters and urinalysis were in the normal range. Twelve-lead ECG presented ST-T nonspecific abnormalities ( Figure 1) and chest x-ray was normal but showed a mild increase in the second right arch (Figure 2).Echocardiogram revealed thickened left ventricular walls, mostly in the lateral and inferior midventricular and distal segments, and a brightly speckled endocardium during systole without clear trabeculations (Figure 3 Coronary angiography confirmed residual fetal sinusoidal circulation with wide communication between both coronary arteries and left ventricle; left and right coronary arteries were enlarged and tortuous, but free from atherosclerotic obstructions ( Figure 6 and Data Supplement Movies IV and V).To support the presence of cardiomyopathy, cardiac magnetic resonance with a 1.5-T cardiovascular magnetic resonance system (SignA CV/i, General Electric, Milwaukee, Wis) and sequenced fast imaging employing steady-state acquisition cine imaging acquisition was performed. These imaging techniques showed normal myocardium thickness but reduced thickness in the apical area, with small fine trabeculae of left midventricular and apical endocardium. This pattern was neither conclusive for the diagnosis of noncompaction of the ventricular myocardium nor of hypertrophic cardiomyopathy, whereas it suggested the presence of spongy myocardial tissue (Figures 7 and 8 and Data Supplement Movies VI and VII).Finally, no ventricular arrhythmias were detected on 48-hour Holter recording performed before patient discharge on angiotensin-converting enzyme inhibitors, ␤-blockers, and aspirin therapy. The lady was free of cardiovascular event during a 6-month period of follow-up.Multiple coronary artery-left ventricle microfistulae are quite uncommon and are presumed to originate from an arrest in the fetal coronary circulation development with the persistence of embryonic myocardial sinusoids. 1 In this embryogenic phase, myocardium is still a spongy meshwork of fibers, and, in parallel with the development of coronary arteries, it gradually became compact and thus reduced the intertrabecular recesses to capillaries. 2 We hypothesize that both coronary artery-left ventricle microfistulae and spongy endocardium detected in the present case derive from a concurrent arrest in the embryogenic development.Rarely, multiple coronary-left ventricle microfistulae have been diagnosed in cases of apical hypertrophic cardiomyopathy, 3 and only 1 postmortem report described an association with spongy myocardium. 4 To our knowledge, the present case is the first case diagn...

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