Background: Chest pain is a common chief complaint among adult patients presenting to emergency departments. An assessment of chest pain management at the institution noted significant variability in provider treatment patterns for chest pain. While a NSTE-ACS protocol existed, there was varied use and inconsistent adoption. Review of pre-intervention data demonstrated that some emergency medicine providers discharged 95% of this patient population home while others admitted over 60% to observation status. Barriers to ideal care were identified: variation in decision making based on who was on call (hospitalist and cardiology), inconsistent use of a risk stratification tool, unclear imaging guidelines, and an unclear disposition plan.
Purpose: With the introduction of the high sensitivity troponin (HST-I) assay, the institution embarked on a mission to develop a care standard for the management of chest pain patients. In addition, we strove to better align to American College of Cardiology (ACC) recommendations for observation rates, length of stay, and testing benchmarks.
Description: A multidisciplinary team of physicians was formed including representatives from Cardiology, Emergency Medicine, Internal Medicine, Family Medicine, Anesthesia and Laboratory Medicine. An extensive literature search along with clinical expertise and ongoing dialogue enabled the team to come to consensus by considering diverse perspectives. A phased approach included: (1) the development of a risk stratification algorithm; (2) conversion to high sensitivity troponin testing; (3) standard application of the HEART score; and (4) adoption of an outpatient “fast track” cardiology consultation. According to the algorithm, patients were stratified to inpatient cardiology evaluation, cardiac observation with or without cardiac imaging, or discharge home. Data was tracked by physician in order to understand opportunities to better understand educational gaps or potential revisions to the algorithm. Patient outcomes were tracked including those patients enrolled in the cardiology fast track program. Major adverse cardiac events and readmissions were reviewed monthly. A total of 5941 encounters for chest pain were studied (2032 pre-intervention and 4723 post- intervention). Prior to intervention, 80.7% (1641) of patients were discharged home, 16.9% (343) were admitted to cardiac observation, and 2.4% (48) were admitted for inpatient care; post-intervention, 94.8% (4477) were discharged home, 3.9% (179) were admitted to cardiac observation, and 1.4% (67) were admitted for inpatient care. Of the 343 patients admitted to observation prior to intervention, 78.4% (269) underwent stress testing; post-intervention, 49.7% (89) underwent stress testing. A cumulative 674 observation bed days and 114 inpatient bed days were saved. MACE rates were 0.26% pre- intervention and 0.23% post-intervention. 1050 stress tests were avoided, and cost savings are estimated to be $1,175,875 in 11 months of the program.
Conclusions: Introduction of a new chest pain management pathway utilizing HST-I and HEART score in combination with stress testing and management recommendations reduced variation in ED disposition and dramatically reduced stress testing volumes, while also reducing observation and inpatient bed days. These results were achieved while maintaining lower MACE rates than the previous year, demonstrating that patients are receiving better, more cost-effective care, in the correct setting at the optimal time.
