Background: Chest pain and related symptoms are the number two reason patients visit emergency departments in the United States, often leading to routine hospitalization or observation. Improving utilization management of patients presenting to the emergency department with chest pain is an important goal for hospitals. Use of 5th generation troponins and risk stratifying tools can aid in this as 5th generation troponin provides the benefit of being able to repeat the test after 3 hours instead of 6 hours, as with the traditional 4th generation troponin. The aim of our study was to identify very low risk chest pain patients with the use of a best practice advisory tool combining 5th generation troponins and HEART score to determine potentially avoidable admission rates and estimate cost savings impact over a year.
Methods: This retrospective study was divided into two phases. During Phase 1, a random sample of 100 patients admitted with chest pain from the emergency department who underwent 4th and 5th generation troponin testing were reviewed and a HEART score calculated. Low risk patients were defined as a 4th generation troponin < 0.01 and ECG without ischemic changes. Very low risk patients identified as having 5th generation troponin level less than gender specific cut offs, a delta between first and second troponin < 3 and HEART score < 3. Potentially avoidable admission rate (PAAR) calculated as very low risk patients/low risk patients and applied to total number of low risk chest pain patients admitted from the emergency department in 2018. Phase 2 of the study involved implementing a Best Practice Advisory (BPA) tool to require providers to calculate HEART score for very low risk chest pain patients and provide emergency physicians with an algorithm to aid with disposition over a period of 4 weeks. Average cost of 1-day admission was used to calculate potential annual avoidable cost.
Results: Phase 1 identified 16 very low risk patients out of 20 low risk patients which resulted in a PAAR of 80%. 30 day MACE rate was 0% for very low risk patients. Applying this PAAR to our annual number of low risk chest pain patients admitted from the emergency department in 2018 could have resulted in 400 very low risk patients who could have been rapidly discharged leading to a cost avoidance of $1.6 million dollars. Phase 2 of the study identified 46 very low risk patients that were discharged from the emergency room using 5th generation troponin and HEART score BPA, making PAAR 0%.
Conclusions: Combining 5th generation troponin and HEART score in a best practice advisory tool decreases admission rates for very low-risk acute chest pain patients, leading to lower resource utilization and significant savings over a year. A larger prospective study would be useful to continue validating this process.