Abstract
High-sensitivity cardiac troponin T (hs-cTnT) protocols for the evaluation of chest pain in the emergency department (ED) may reduce unnecessary resource use and overcrowding. To determine whether the implementation of a novel hs-cTnT protocol, which incorporated troponin values drawn at 0, 1, and 3 hours after ED presentation and the modified HEART score (history, electrocardiogram, age, risk factors), was associated with improvements in resource use while maintaining safety. This retrospective cohort study from Parkland Health and Hospital System, a large safety net hospital in Dallas, Texas, included data on 31 543 unique ED encounters in which patients underwent electrocardiographic and troponin testing from January 1, 2017, to October 16, 2018. The hs-cTnT protocol was implemented in December 2017. Resource use outcomes included trends in ED dwell time, troponin to disposition decision time (the difference between the first troponin draw time and the time an order was placed for inpatient admission, admission to observation, or discharge), and final patient disposition. Safety outcomes included readmission for myocardial infarction and death. In 31 543 encounters, mean (SD) patient age was 54 (14.4) years and 14 675 patients (48%) were female. Department dwell time decreased by a mean of -1.09 (95% CI, -2.81 to 0.64) minutes per month in the preintervention period. The decline was steeper after the intervention (-4.69 [95% CI, -9.05 to -0.33] minutes per month) (P for interaction = .007). The troponin to disposition time was increasing in the preintervention period by 1.72 (95% CI, 1.08 to 2.36) minutes per month; postintervention, the mean difference increased more slowly (0.37 [95% CI, -1.25 to 1.99 minutes per month; P value for interaction = .007]). The proportion of patients discharged from the ED increased after the intervention (48% vs 54%, P < .001). Thirty-day major adverse cardiac event rates were low and did not differ before and after the intervention. Implementation of a novel protocol incorporating serial hs-cTnT measurements over 3 hours with the Modified HEART Score was associated with reduction in ED dwell times and attenuation of temporal increases in time from troponin measurement to disposition. This or similar protocols to rule out myocardial infarction have the potential to reduce ED overcrowding and improve health care quality while maintaining safety.
Highlights
Emergency department (ED) overcrowding is a major public health problem in the United States and has been associated with poor outcomes, increased resource use, and restricted access to care.[1,2,3] Chest pain is the second most common concern for patients presenting to the ED in the US, accounting for more than 7 million visits annually.[4]
The decline was steeper after the intervention (−4.69 [95% CI, −9.05 to −0.33] minutes per month) (P for interaction = .007)
The troponin to disposition time was increasing in the preintervention period by 1.72 minutes per month; postintervention, the mean difference increased more slowly (0.37 [95% CI, −1.25 to 1.99 minutes per month; P value for interaction = .007])
Summary
Emergency department (ED) overcrowding is a major public health problem in the United States and has been associated with poor outcomes, increased resource use, and restricted access to care.[1,2,3] Chest pain is the second most common concern for patients presenting to the ED in the US, accounting for more than 7 million visits annually.[4] In patients with suspected acute coronary syndrome (ACS), US guidelines recommend observation and serial troponin testing over 3 to 6 hours.[5] the prevalence of ACS among patients with chest pain is low and decreasing over time.[6] Prolonged observation of patients with chest pain at low risk for ACS exacerbates the problem of ED overcrowding. Streamlined protocols for the evaluation of chest pain in the ED offer the potential to improve efficiency and reduce resource use. Considering the large number of patients with chest pain evaluated annually, even small reductions in ED length of stay may have a meaningful impact on overcrowding
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