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BackgroundThe History Electrocardiogram Age Risk factor Troponin (HEART) Pathway and Emergency Department Assessment of Chest pain Score (EDACS) are validated accelerated diagnostic pathways designed to risk stratify patients presenting to the emergency department with chest pain. Data from large multisite prospective studies comparing these accelerated diagnostic pathways are limited.MethodsThe HEART Pathway Implementation is a prospective three-site cohort study, which accrued adults with symptoms concerning for acute coronary syndrome. Physicians completed electronic health record HEART Pathway and EDACS risk assessments on participants. Major adverse cardiac events (death, myocardial infarction and coronary revascularisation) at 30 days were determined using electronic health record, insurance claims and death index data. Test characteristics for detection of major adverse cardiac events were calculated for both accelerated diagnostic pathways and McNemar’s tests were used for comparisons.Results5799 patients presenting to the emergency department were accrued, of which HEART Pathway and EDACS assessments were completed on 4399. Major adverse cardiac events at 30 days occurred in 449/4399 (10.2%). The HEART Pathway identified 38.4% (95% CI 37.0% to 39.9%) of patients as low-risk compared with 58.1% (95% CI 56.6% to 59.6%) identified as low-risk by EDACS (p<0.001). Major adverse cardiac events occurred in 0.4% (95% CI 0.2% to 0.9%) of patients classified as low-risk by the HEART Pathway compared with 1.0% (95% CI 0.7% to 1.5%) of patients identified as low-risk by EDACS (p<0.001). Thus, the HEART Pathway had a negative predictive value of 99.6% (95% CI 99.1% to 99.8%) for major adverse cardiac events compared with a negative predictive value of 99.0% (95% CI 98.5% to 99.3%) for EDACS.ConclusionsEDACS identifies a larger proportion of patients as low-risk than the HEART Pathway, but has a higher missed major adverse cardiac events rate at 30 days. Physicians will need to consider their risk tolerance when deciding whether to adopt the HEART Pathway or EDACS accelerated diagnostic pathway.Trial registration numberNCT02056964.

The HEART Pathway is a validated risk stratification protocol for Emergency Department patients with chest pain that has yet to be tested in the prehospital setting. This study seeks to test the performance of a prehospital modified HEART Pathway (PMHP). A prospective cohort study of adults with chest pain without ST-segment elevation myocardial infarction was conducted at three EMS agencies between 12/2016-1/2018. To complete a PMHP assessment, paramedics drew blood, measured point-of-care (POC) troponin (i-STAT; Abbott Point of Care) and calculated a HEAR score. Patients were stratified into three groups: high-risk based on an elevated troponin, low-risk based on a HEAR score <4 with a negative troponin, or moderate risk for a HEAR score �4 with a negative troponin. Sensitivity, specificity, negative and positive predictive values of the PMHP for detection of major adverse cardiac events (MACE: cardiac death, MI, or coronary revascularization) at 30days were calculated. A total of 506 patients were accrued, with PMHP completed in 78.1% (395/506). MACE at 30-days occurred in 18.7% (74/395). Among these patients, 7.1% (28/ 395) were high risk yielding a specificity and PPV for 30-day MACE of 96.6% (95%CI: 94.0-98.3%) and 60.7% (95%CI: 40.6-78.6%) respectively. Low-risk assessments occurred in 31.4% (124/395), which were 90.5% (95%CI: 81.5-96.1%) sensitive for 30-day MACE with a NPV of 94.4% (95%CI: 88.7-97.7%). Moderate-risk assessments occurred in 61.5% (243/395), of which 20.6% had 30-day MACE. The PMHP is able to identify high-risk and low-risk groups with high specificity and negative predictive value for 30-day MACE.

Introduction: Increased out-of-hospital time is associated with worse outcomes in trauma. Sparse literature exists comparing prehospital scene and transport time management intervals between adult and pediatric trauma patients. National Emergency Medical Services guidelines recommend that trauma scene time be less than 10 minutes. The objective of this study was to examine prehospital time intervals in adult and pediatric trauma patients. Methods: We performed a retrospective cohort study of blunt and penetrating trauma patients in a fivecounty region in North Carolina using prehospital records. We included patients who were transported emergency traffic directly from the scene by ground ambulance to a Level I or Level II trauma center between 2013-2018. We defined pediatric patients as those less than 16 years old. Urbanicity was controlled for using the Centers for Medicare and Medicaid's Ambulance Fee Schedule. We performed descriptive statistics and linear mixed-effects regression modeling. Results: A total of 2179 records met the study criteria, of which 2077 were used in the analysis. Mean scene time was 14.2 minutes (95% confidence interval [CI], 13.9-14.5) and 35.3% (n = 733) of encounters had a scene time of 10 minutes or less. Mean transport time was 17.5 minutes (95% CI, 17.0-17.9). Linear mixed-effects regression revealed that scene times were shorter for pediatric patients (p<0.0001), males (p=0.0016), penetrating injury (p<0.0001), and patients with blunt trauma in rural settings (p=0.005), and that transport times were shorter for males (p = 0.02), non-White patients (p<0.0001), and patients in urban areas (p<0.0001). Conclusion: This study population largely missed the 10-minute scene time goal. Demographic and patient factors were associated with scene and transport times. Shorter scene times occurred with pediatric patients, males, and among those with penetrating trauma. Additionally, suffering blunt trauma while in a rural environment was associated with shorter scene time. Males, non-White patients, and patients in urban environments tended to have shorter transport times. Future studies with outcomes data are needed to identify factors that prolong out-of-hospital time and to assess the impact of out-of-hospital time on patient outcomes. [West J Emerg Med. 2020;21(2)455-462.]

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