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Accelerated chest pain diagnostic protocol improved early ED discharge rates
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A 2-hour diagnostic protocol for patients with chest pain nearly doubled the rate of successful early discharge in an ED setting in a recent study.
The single-center clinical trial enrolled consecutively consenting adult patients who presented to the ED of the Christchurch Hospital in New Zealand between Oct. 11, 2010, and July 4, 2012, with acute chest pain consistent with ACS. Patients were randomly assigned to an experimental diagnostic pathway (n=270) or to the hospital’s standard-of-care chest pain pathway (n=272).
Experimental pathway patients underwent an ECG and blood work for troponin I upon arrival, and their modified TIMI score was determined. If the initial ECG revealed no new ischemia, the troponin I test result was normal and the TIMI score was 0, patients were transferred to an ED observation bed. Two hours after these initial tests, patients underwent secondary ECG and troponin I blood tests. Those with negative results from the second tests were deemed low risk and discharged, with outpatient exercise stress testing conducted within 72 hours.
Upon arrival, those in the standard care group underwent an ECG and blood work for troponin I, with a subsequent troponin I test timed to occur 6 to 12 hours after the onset of symptoms of possible ACS. In keeping with standard protocol, these patients were usually admitted and observed, with follow-up procedures at the discretion of the senior clinician.
The main outcome was successful discharge, defined as discharge within 6 hours of arrival without major adverse cardiac event within the subsequent 30 days.
A significantly higher proportion of patients in the experimental group were successfully discharged within 6 hours of arrival (19.3%) than in the control group (11%). In the standard care group, 20 hours was needed to reach the same proportion of discharges as achieved in the experimental group within 6 hours. The two groups did not differ significantly according to incidence of major adverse cardiac event, and no patients in either group experienced adverse events between discharge and follow-up exercise stress testing.
“This strategy can easily be replicated,” the study researchers wrote. “Use in the clinical setting would allow discharge of more patients with chest pain to outpatient follow-up within 6 hours of presentation. The reduction in time required to assess some patients could have significant benefits in terms of reduced consumption of health resources, costs and patient anxiety and inconvenience.”
Disclosure: See the full study for a list of relevant financial disclosures.
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