Abstract
Study objectiveHigh-sensitivity cardiac troponin assays enable myocardial infarction to be excluded in the emergency department (ED). As part of a prospective clinical trial, we explore how introducing an early rule-out pathway may affect patient experience of chest pain.MethodsIn a qualitative study, participants presenting to the ED with suspected acute coronary syndrome, and for whom the diagnosis of myocardial infarction was excluded, were interviewed before (n=23) or after (n=26) implementation of an early rule-out pathway. Preimplementation, diagnosis of myocardial infarction was excluded on serial troponin testing requiring admission to the hospital. Postimplementation, diagnosis could be excluded in the ED, enabling direct patient discharge. Semistructured interviews exploring the patients’ illness experience were conducted approximately 1 week postdischarge, transcribed verbatim, and analyzed thematically. Themes emerging pre- and postimplementation are described.ResultsCommon themes emerged across both pathways: participants commonly sought health care advice before presenting to the ED; a discordance may exist between the objective interpretation of troponin results by clinicians and the patients’ experience of illness; and pretest information, trust in the clinician, and active listening may enhance reassurance gained from negative test results. Other themes related to the care pathway were that routine care procedures appeared to be a source of frustration for participants requiring hospital admission, and patients assessed with the early rule-out pathway appeared less likely to appraise their future health status.ConclusionThe early rule-out of myocardial infarction may be enhanced by recognition of patient out-of-hospital experience and improved communication surrounding reassurance and future cardiovascular health goals.
Highlights
BackgroundPatients with suspected acute coronary syndrome are responsible for 6% of emergency department (ED) presentations.[1]
Previous research into the experience of patients with acute chest pain who present to the ED has shown that they may be discharged with unanswered questions,[15] feelings of uncertainty,[16] and the need to feel more supported after discharge.[17]. Goals of This Investigation In this qualitative study embedded into a prospective clinical trial,[18] we aimed to explore the experience of 2 groups of patients undergoing assessment for suspected acute coronary syndrome before and after implementation of an early rule-out pathway for myocardial infarction to identify how the assessment pathway affects the patients’ experience
Patients older than 18 years, for whom the attending clinician requested cardiac troponin-level testing for suspected acute coronary syndrome, and who were discharged on the basis of a negative evaluation result for myocardial infarction were eligible for inclusion
Summary
Patients with suspected acute coronary syndrome are responsible for 6% of emergency department (ED) presentations.[1] The majority of these patients will not receive a diagnosis of myocardial infarction,[2] but clinical guidelines have recommended serial cardiac troponinlevel testing to safely rule out the diagnosis, which often requires admission to the hospital.[3,4] Because EDs are under increasing pressure to reduce the number of patients admitted to the hospital,[5] the use of highsensitivity troponin assays to exclude myocardial infarction earlier or at presentation may increase efficiency in the ED setting. Importance The European Society of Cardiology and the National Institute for Health and Care Excellence have endorsed early rule-out pathways based on highsensitivity cardiac troponin assays.[6,7] The Food and Drug Administration has approved highsensitivity cardiac troponin assays for clinical use. A number of strategies have been proposed to identify patients at presentation or 1 to 2 hours after
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