Implementation of a Risk Stratification and Management Pathway for Acute Chest Pain in the Emergency Department

Abstract

Objectives Chest pain is a common complaint in the emergency department, and a small but important minority represents an acute coronary syndrome (ACS). Variation in diagnostic workup, risk stratification, and management may result in underuse, misuse, and/or overuse of resources. Methods From July to October 2014, we conducted a prospective cohort study in an academic medical center by implementing a Standardized Clinical Assessment and Management Plan (SCAMP) for chest pain based on the HEART score. In addition to capturing adherence to the SCAMP algorithm and reasons for any deviations, we measured troponin sample timing; rates of stress test utilization; length of stay (LOS); and 30-day rates of revascularization, ACS, and death. Results We identified 239 patients during the enrollment period who were eligible to enter the SCAMP, of whom 97 patients were entered into the pathway. Patients were risk stratified into one of 3 risk tiers: high (n = 3), intermediate (n = 40), and low (n = 54). Among low-risk patients, recommendations for troponin testing were not followed in 56%, and 11% received stress tests contrary to the SCAMP recommendation. None of the low-risk patients had elevated troponin measurements, and none had an abnormal stress test. Mean LOS in low-risk patients managed with discordant plans was 22:26 h/min, compared with 9:13 h/min in concordant patients (P < 0.001). Mean LOS in intermediate-risk patients with stress testing was 25:53 h/min, compared with 7:55 h/min for those without (P < 0.001). At 30 days, 10% of intermediate-risk patients and 0% of low-risk patients experienced an ACS event (risk difference 10% [0.7%–19%]); none experienced revascularization or death. The most frequently cited reason for deviation from the SCAMP was lack of confidence in the tool. Conclusions Compliance with SCAMP recommendations for low- and intermediate-risk patients was poor, largely due to lack of confidence in the tool. However, in our study population, outcomes suggest that deviation from the SCAMP yielded no additional clinical benefit while significantly prolonging emergency department LOS.

Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta‐analysis

“…Our search identified 778 citations (Figure ) and following removal of duplicates, we screened 557 studies, from which 62 studies underwent full‐text review. We included 29 distinct cohorts from 30 studies in the meta‐analysis . All included studies evaluated the prognostic accuracy of the HEART score using a low‐risk threshold (score between 0 and 3).…”

“…Sixteen studies evaluated the HEART score for 30‐day incidence of MACE, while 13 evaluated the HEART score for 6‐week incidence of MACE . Most studies included only patients presenting with chest pain, while five studies included patients presenting with “suspected ACS.” In 14 studies, the ECG was interpreted by an ED physician, while in seven studies the ECG was specifically interpreted by a cardiologist . Four studies computed the HEART score using high‐sensitivity troponin assays, while the remaining studies used conventional troponin T or I assays (as used in the original study) …”

Implementation of an Opioid Detoxification Management Pathway Reduces Emergency Department Length of Stay

“…This indicates that there was nonadherence to the pathway, consistent with contemporary studies of pathway implementation. 4,5 Using multiple linear regression, a social work consult was associated with a 221.1 (95% CI; 116.4 – 325.8) minute increased EDLOS, indicating that nonadherence attenuated the maximum possible impact of the intervention on EDLOS.…”

Nurse-Initiated Protocols for Chest Pain in the Emergency Department

“…When NIP processes are initiated, diagnostic results are finished sooner and disposition changes are improved (Hwang et al, 2016). Using a standardized NIP for CP can decrease LOS for CP patients in the ED (Baugh et al, 2016).…”

“…Early completion of an EKG is essential for diagnosing ST-segment elevation myocardial infarction (STEMI), and EKG findings within 10 minutes of ED arrival are critical for positive outcomes (Yiadom, et al, 2017). EKG acquisition times found in the HEART study showed expedited patient care among intermediate and low risk CP patient populations while decreasing LOS (Baugh et al, 2016;Hwang et al, 2016). Safely determining the acuity of CP patients can also lead to early discharge among low-risk populations (Douma, et al, 2016;Mahler et al,…”