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Background Protocols utilizing high-sensitivity cardiac troponin (hs-cTn) assays for the evaluation of suspected acute coronary syndrome (ACS) in the emergency department (ED) have been gaining popularity across the US and the world. These protocols more rapidly rule-out ACS and more accurately identify the presence of acute myocardial injury. At this time, few randomized trials have evaluated the safety and operational impact of these assays, resulting in limited evidence to guide the use and implementation of hs-cTn in the ED. Objective The main study objective is to test the effectiveness of a rapid ACS rule-out pathway using hs-cTnI in safely discharging patients from the ED for whom clinical suspicion for ACS exists. Design This prospective, implementation trial (n = 11,070) will utilize a stepped wedge cluster randomized trial design. The design will allow for all participating sites to capture benefit from the implementation of the hs-cTnI pathway while providing data evaluating the effectiveness in providing safe and rapid evaluation of patients with clinical suspicion for ACS. Summary Demonstrating that clinical pathways using hs-cTnI can be effectively implemented to rapidly rule-out ACS while conserving costly hospital resources has significant implications for the care of patients with possible acute cardiac conditions in EDs across the US. Clinicaltrials.gov identifier NCT04488913.

Background The COVID‐19 pandemic affected the volume and epidemiology of pediatric emergency department (ED) visits. We aimed to determine the rate of associated complications for 16 high‐risk conditions in a Michigan statewide network of academic and community EDs during the pandemic. Methods We conducted a cross‐sectional study of pediatric ED visits among a network of 5 Michigan health systems during the pre‐pandemic (March 1, 2019–March 10, 2020) and pandemic (March 11, 2020–March 31, 2021) periods. Data were collected from the medical record and included patient demographics, ED visit characteristics, procedure codes, and final International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. Selection of codes for 16 high‐risk conditions and diagnostic complications were identified using previously described methods. Characteristics of ED visits were compared before versus during the pandemic using χ 2 and Fisher's exact tests. We used multilevel logistic regression to analyze covariates and potential confounders for being diagnosed with a high‐risk condition or a complication of a high‐risk condition. Results A total of 417,038 pediatric ED visits were analyzed. The proportion of patients presenting with 10 of 16 high‐risk conditions (including appendicitis, sepsis, and stroke) was higher in the pandemic period compared with pre‐pandemic ( P < 0.01). Despite this, there was no significant increase in the frequency of complications for any of the 16 high‐risk conditions during the pandemic. The adjusted odds of being diagnosed with appendicitis (pre‐pandemic 0.23% vs pandemic 0.52%; odds ratio [OR], 1.19 [95% confidence interval, CI, 1.00–1.41]), diabetic ketoacidosis (pre‐pandemic 0.16% vs pandemic 0.52%; OR, 2.40 [95% CI, 2.07–2.78]), intussusception (pre‐pandemic 0.05% vs pandemic 0.07%; OR, 1.64 [95% CI, 1.22–2.21)], and testicular torsion (pre‐pandemic 0.10% vs pandemic 0.14%; OR, 1.64 [95% CI, 1.18–2.28]) was higher during the pandemic. Conclusions Despite a higher proportion of ED visits attributed to high‐risk conditions, there was no increase in complications, suggesting minimal impact of the pandemic on outcomes of pediatric ED visits.

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