Clinician Variation in Management of Acute Troponin Negative Cardiac Chest Pain: A Qualitative Study

Abstract

Purpose: Infective endocarditis is a condition associated with high morbidity and mortality, despite advances in diagnosis, medical and surgical treatment options. We sought to ascertain the scope of this condition among all patients diagnosed with this condition in an Adelaide tertiary hospital, over a 5-year period.Methods: This retrospective case series identified 77 patients who had a diagnosis of confirmed infective endocarditis as per the Modified Dukes' criteria, over a 5-year period from June 2011 to June 2016 at Lyell McEwin Hospital.Results: Our cohort was predominantly male (61%). Most common age range was 51-75 years (39%). Most patients presented with fever and non-specific symptoms. Most of the patients were from the Northern Adelaide metropolitan area (74%). 79.2% presented from the community, while 20.8% had health care associated infections. 22.1% had associated intravenous drug use (IVDU). 86.7% had native cardiac valves. 13.4% had prosthetic cardiac valves. 5.2% had cardiovascular implantable electrical devices (CIEDs). Staphylococcus aureus was the most common causative organism (47.4%). Aortic and mitral valves were most commonly affected (49.4% and 40.3%). Embolic phenomena and heart failure were the most common complications (29.9% and 19.5%). Stroke was the most common embolic complication. 35.1% required surgical intervention with most of them undergoing valve replacement. In-hospital mortality was 11.7%.Conclusions: Infective endocarditis commonly presents with fever and non-specific symptoms. Our cohort demonstrated similar clinical features compared to recent studies. Although our cohort had a lower mortality compared to previous studies, in-hospital mortality due to infective endocarditis remains high.http://dx.The use of a standard chest pain pathway is mandated within the NSW Health System. Despite clear policy expectations, there are still inconsistencies in pathway implementation, with anecdotal evidence suggesting continuing variance in assessment and management processes between clinicians and institutions. This variation can lead to significant adverse events. An understanding of the key areas of variation is needed to develop improvement strategies. This study aims to provide insight into areas of clinician variation within pathway guidelines.Methods: 30 clinicians (residents, registrars and consultants) from Emergency and Cardiology Departments at the participating hospital completed a structured paper-based survey containing 5 clinical scenarios of acute chest pain.Results: In the first clinical scenario 23.3% of clinicians classified the patient as intermediate risk, 73.3% high risk and 3.3% low risk. This variance was observed in scenario two, with 80% of clinicians stratifying patients as intermediate risk, 3.3% high risk and 16.7% low risk. Similarly in scenario three, 76.7% deemed the patient intermediate risk, 13.3% high risk and 10% low risk. In clinical scenario three, of the 23 clinicians who stratified the patient as intermediate risk, 4.5% would discharge home, wh...