REACTED – Reducing Acute Chest pain Time in the ED: A prospective pre‐/post‐interventional cohort study, stratifying risk using early cardiac multi‐markers, probably increases discharges safely

Mountain, David; Ercleve, Tor; Allely, Peter; McQuillan, Brendan; Yamen, Eric; Beilby, John; Lim, EeMun; Rogers, Jeremy R; Geelhoed, Elizabeth

doi:10.1111/1742-6723.12590

Cited by 4 publications

(3 citation statements)

References 29 publications

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“…[2][3][4]6,7 Second, LoS in the ED in our study are very short, ranging from 2.9 hours with ruleout based on a hsTnT less than LoD to 5.3 hours with the 0/3-hour diagnostic algorithm. In the literature, reported LoS vary between 4 hours, 8,26 5.3 hours, 38 5.5 hours, 39 6.4 hours 19 to 26.3 hours, 31 with the shortest observation times (median LoS 4 hours in both studies) using the dual biomarker strategy, 8 or the 0/1-hour rule-out in the TRAPID study. 26 Conversely, the longest LoS have been reported in an Australasian cohort, 31 in which LoS was associated with high utilisation rates of investigations before discharge.…”

Section: Discussionmentioning

confidence: 91%

“…Third, post-implementation discharge rates after ruleout were 62.8% and thus at the upper end of the reported range. Discharge rates in other observational or randomised studies are heterogeneous with low discharge rates among low-risk patients between 18.4% and 26%, 9,18,21 intermediate discharge rates between 42.3% and 55% 19,39,40 and high discharge rates between 67.8% and 72%. 8,38,41 Only one study 42 reported significantly longer hospitalisation stays by 35%, fewer early discharges after a negative result (7% vs. 22%, P=0.0001), more coronary angiograms (77% vs. 55%, P=0.0001) and revascularisations (45% vs. 31%, P=0.0001) after implementation of hsTn assays by 35%.…”

Section: Discussionmentioning

confidence: 98%

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RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction

Stoyanov

Hund

Biener

et al. 2019

European Heart Journal: Acute Cardiovascular Care

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Background: Although the value of fast diagnostic protocols in suspected acute coronary syndrome has been validated, there is insufficient real world evidence including patients with lower pre-test probability, atypical symptoms and confounding comorbidities. The feasibility, efficacy and safety of European Society of Cardiology (ESC) 0/1 and 0/3-hour algorithms using high-sensitivity troponin T were evaluated in a consecutive cohort with suspected acute coronary syndrome. Methods: During 12 months, 2525 eligible patients were enrolled. In a pre-implementation period of 6 months, the prevalence of protocols, disposition, lengths of emergency department stay and treatments were registered. Implementation of the 0/1-hour protocol was monitored for another 6 months. Primary endpoints comprised the change of diagnostic protocols and 30-day mortality after direct discharge from the emergency department. Results: Use of the ESC 0/1-hour algorithm increased by 270% at the cost of the standard 0/3-hour protocol. After rule-out (1588 patients), 1309 patients (76.1%) were discharged directly from the emergency department, with an all-cause mortality of 0.08% at 30 days (one death due to lung cancer). Median lengths of stay were 2.9 (1.9–3.8) and 3.2 (2.7–4.4) hours using a single high-sensitivity troponin T below the limit of detection (5 ng/L) at presentation and the ESC 0/1-hour algorithm, respectively, as compared to 5.3 (4.7–6.5) hours using the ESC 0/3-hour rule-out protocol ( P<0.001). Discharge rates increased from 53.9% to 62.8% ( P<0.001), without excessive use of diagnostic resources within 30 days. Conclusion: Implementation of the ESC 0/1-hour algorithm is feasible and safe, is associated with shorter emergency department stay than the ESC 0/3-hour protocol, and an increase in discharge rates. Trial registration: ClinicalTrials.gov , Unique identifier: NCT03111862.

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Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 98%

RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction

Stoyanov

Hund

Biener

et al. 2019

European Heart Journal: Acute Cardiovascular Care

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“…To date, the reported literature on sex differences in triage categorisation in those presenting with chest pain has been inconsistent,9 13 with most focusing on its late management 14. Further, it is uncertain whether, among individuals who present with chest pain, delay in time to medical examination is associated with increased in-hospital mortality, and if so if this differs by sex.…”

Section: Introductionmentioning

confidence: 99%

Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments

Mnatzaganian

Hiller

Braitberg

et al. 2019

Heart

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ObjectiveTo determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED).MethodsAll adults (≥18 years) with non-traumatic chest pain presentations to three EDs in Melbourne, Australia between 2009 and 2013 were retrospectively analysed. Data sources included routinely collected hospital databases. Triage scoring of the urgency of presentation, time to medical examination, cardiac troponin testing, admission to specialised care units, and in-ED and in-hospital mortality were each modelled using the generalised estimating equations approach.ResultsOverall 54 138 patients (48.7% women) presented with chest pain, contributing to 76 216 presentations, of which 26 282 (34.5%) were cardiac. In multivariable analyses, compared with men, women were 18% less likely to be allocated an urgency of ‘immediate review’ or ‘within 10 min review’ (OR=0.82, 95% CI 0.79 to 0.85), 16% less likely to be examined within the first hour of arrival to the ED by an emergency physician (0.84, 0.81 to 0.87), 20% less likely to have a troponin test performed (0.80, 0.77 to 0.83), 36% less likely to be admitted to a specialised care unit (0.64, 0.61 to 0.68), and 35% (p=0.039) and 36% (p=0.002) more likely to die in the ED and in the hospital, respectively.ConclusionsIn the ED, systemic sex bias, to the detriment of women, exists in the early management and treatment of non-traumatic chest pain. Future studies that identify the drivers explaining why women presenting with chest pain are disadvantaged in terms of care, relative to men, are warranted.

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Australia's first cardiac emergency department: Patient profile, activity and performance in the initial 6 months

Cohen,

Meek,

Hayden

et al. 2024

Emerg Medicine Australasia

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ObjectiveTo profile the initial 6‐month experience at the Victorian Heart Hospital (VHH) cardiac emergency (CE). The primary objective was to describe VHH CE patient characteristics, including presenting complaint, final diagnosis and disposition. Secondary objectives were to report on patient numbers, patient source and quality indicator performance including ambulance off‐load by 40 min, waiting time and length of stay (LOS).MethodsA retrospective review included all patients who presented to the VHH CE from 9 March 2023 to 8 September 2023. Patient reports containing the relevant clinical information were generated from the CE electronic medical record system. Diagnoses of MI were checked for accuracy by full record review.ResultsThere were 3303 CE presentations in the first 6 months of operation, of which 6% were transferred from other sites. Median age was 65 years (interquartile range [IQR]: 53–77), 56% were males; the most common presenting complaints were presumed cardiac chest pain (67%) and arrhythmia (17%). The admission, discharge and transfer rates were 38%, 54% and 8%, respectively. In total, 15% were diagnosed with MI. The most common diagnoses for discharged and admitted patients were non‐specific chest pain (57%) and ST‐elevation MI (22%), respectively. Ambulance off‐load by 40 min was met for 96%. Median waiting time was 6 min (IQR: 3–10). Median CE LOS for discharged and admitted patients was 3.2 h (IQR: 2.5–4.0) and 3.7 h (IQR: 1.8–6.0), with 75% and 56% being <4 h, respectively.ConclusionsThe population predominantly had cardiovascular disease as expected. Some performance indicators, including ED LOS, were identified as requiring intervention.

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REACTED – Reducing Acute Chest pain Time in the ED: A prospective pre‐/post‐interventional cohort study, stratifying risk using early cardiac multi‐markers, probably increases discharges safely

Abstract: Paired cardiac markers performed adequately for avoidable MACE, and disposition improved significantly. A confounding system change meant the reduced EDLOS (primary outcome) was unable to be associated with the intervention.

Cited by 4 publications

References 29 publications

RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction

RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction

Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments

Australia's first cardiac emergency department: Patient profile, activity and performance in the initial 6 months

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