Feasability of a Rapid Diagnostic Protocol for an Emergency Department Chest Pain Unit,☆☆,,★★

Presented at the Society for Academic Emergency Medicine Annual Meeting, San Antonio, May 1995.
https://doi.org/10.1016/S0196-0644(97)70315-9Get rights and content

Abstract

See related editorial, p 168.

Study objective: To evaluate the applicability of a short-stay protocol for exclusion of acute ischemic heart disease without hospital admission and to analyze these results in the context of a conceptual model. Methods: An observational study of patients who presented with chest pain to the emergency department of an 886-bed inner-city municipal hospital and who needed hospital admission to rule out acute myocardial infarction (AMI). Patients were assessed by ED attending physicians to determine eligibility for an alternative, 12- hour protocol in an ED chest pain observation unit (CPOU) followed by immediate exercise testing. Outcome measures were proportion of patients eligible for the short-stay protocol, risk factor profile, and reasons for exclusion. Results: Of 500 patients screened, 446 had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% confidence interval [CI], 48.7% to 57.9%) were found to have low probability for AMI. After study exclusion criteria were applied to the patient cohort, 63 patients (14.1%; 95% CI, 10.9% to 17.3%) were eligible for the protocol. The most common reasons for exclusion were history of coronary artery disease (46%) and inability to perform an interpretable exercise tolerance test (42%). Conclusion: Although most admitted patients with chest pain (53%) were at low probability for AMI, only a minority (14%) were eligible for a short-stay protocol that required patients to be free of known coronary artery disease and able to perform an exercise tolerance test. Factors affecting the operations and efficiency of a CPOU include clinical characteristics of the target patient population, protocol tests used, and hospital occupancy and reimbursement patterns. [Zalenski RJ, Rydman RJ, McCarren M, Roberts RR, Jovanovic B, Das K, Mensah EK, Kampe LM: Feasibility of a rapid diagnostic protocol for an emergency department chest pain unit. Ann Emerg Med January 1997;29:99-108.]

Section snippets

INTRODUCTION

Suspected coronary heart disease (CHD), because of high disease prevalence and mortality, requires a very sensitive emergency department evaluation. To minimize inappropriate discharges of patients with acute cardiac ischemia, emergency physicians initiate inhospital evaluation for all patients who meet a low threshold of disease likelihood.1, 2, 3 High sensitivity is secured at the expense of specificity and considerable public resource consumption ($3 billion) in the hospitalization of 3

MATERIALS AND METHODS

This observational study examined a representative subset of all patients with chest pain suggestive of acute cardiac ischemia who needed hospital admission for further evaluation. Each patient slated for hospital admission was assigned a high or low probability of AMI, based on a valid, standardized algorithm developed by Goldman et al.1 The target group, patients with low probability of AMI needing hospital admission, were further examined for inclusion and exclusion criteria.

This study was

RESULTS

Of the 500 ED patients admitted to rule out ischemic heart disease who were examined for eligibility for the short-stay protocol, 446 (89.2%) had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% CI, 48.7% to 57.9%) were found to have low probability of AMI, and 46.7% were found to have high probability. Of the low-probability patients, 40% were so classified because they had no new ECG findings and their pain had lasted longer than 48 hours; 29% had no new ECG

DISCUSSION

Although most patients admitted for chest pain had a low probability of AMI, the short-stay protocol, as configured for this study, applied to only 27% of them, representing 14% of the total. Although this proportion was lower than anticipated, it was nonetheless large enough to provide an important part of a strategy to decrease the burden of hospital admissions.

The short-stay CPOU protocol is appropriate only for patients with low probability of AMI.9 Therefore, the upper limit of the

References (18)

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    Citation Excerpt :

    An estimated 5.6 million visits are made to EDs in the United States for chest pain at a cost of more than $5 billion each year [159]. Most of these patients are at low risk for myocardial infarction [160]. Between 85% and 90% of patients who present to the observation unit with chest pain are ruled out for myocardial infarction and other serious cardiac events [161–163].

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From the Department of Emergency Medicine*, and the Department of Medicine, Cook County Hospital; and the Center for Health Services Research§ the Division of Health Policy and Administration, and the Division of Epidemiology and Biometry, School of Public Health, University of Illinois, Chicago, Illinois.

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Supported in part by the Agency for Health Care Policy and Research, grant number R01-HS-07103.

Address for reprints: Robert J Zalenski, MD, Department of Emergency Medicine, Wayne State University, 4201 St Antoine, Detroit, Michigan 48201, E-mail [email protected]

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Reprint no. 47/1/78479

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