Abstract 13600: Patients Identified as Low Risk May Be Safely Discharged From the Emergency Department After Presentation With Chest Pain

Abstract

Background: Chest pain accounts for over 8 million visits to the emergency department (ED) annually in the United States. However, only a minority of these patients are eventually diagnosed with acute myocardial infarction. Hypothesis: A protocol may be safely utilized to identify and evaluate low risk patients upon presentation to the ED with chest pain. Methods: A prospective study at a large academic medical center evaluated the safety of a protocol to schedule outpatient stress testing and follow-up for low risk patients discharged from the ED after presenting with chest pain. Patients were low risk if they were pain-free in the ED, had negative cardiac enzymes, non-ischemic electrocardiogram and TIMI risk score < 1, or if a cardiologist deemed patient low risk for acute myocardial infarction. Selected patients were discharged from the ED and scheduled for stress testing within 1-3 business days. Patients with positive test results were evaluated by a cardiologist for medical management or coronary angiography as needed. Results: A total of 1,735 patients were enrolled in the protocol. Of the 1,036 patients completing a follow-up stress test, only 6.4% (66/1,036) had an abnormal result. Forty-two of these 66 patients (63.6%) were either determined to be false positive by the cardiologist or underwent medical management. The remaining 24 (36.4%) had coronary angiography, of which only 20.8% (5/24) had significant coronary artery disease requiring percutaneous coronary intervention. All patients were followed for 30 days after their ED visit. During this period, 1.9% (33/1735) of patients returned to the ED per protocol, and 1% (18/1735) were admitted to the hospital for chest pain or other cardiovascular presentation. Only 3 patients (0.2%) had myocardial infarction. No mortality was recorded during this period. With this protocol, patients and insurers avoided over $16 million in professional and facility charges and over $3 million in payments. Estimated cost savings from reducing hospitalization in our patient population was about $3.77 million. Conclusions: Our data support that an outpatient evaluation protocol for low risk patients presenting to the ED with chest pain is safe, avoids unnecessary hospitalization and reduces healthcare cost.