Why Won't Emergency Physicians Discharge Patients With a Low HEART Score From an Observation Unit Without Further Evaluation?

Abstract

The History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score is a prospectively validated risk stratification tool for patients presenting to the emergency department (ED) with chest pain. Data demonstrate that patients with low HEART scores (0-3) can be safely discharged from the ED. ED physicians, however, may be reluctant to discharge patients based on the score. To identify specific factors why ED physicians are reluctant to discharge patients with low-risk HEART scores from an ED observation unit (EDOU) without further evaluation. This was a single-center prospective, cross-sectional analysis of ED patients from an urban ED placed in an EDOU for evaluation of chest pain, from July 1, 2016, to August 31, 2016. ED physicians completed a questionnaire that included documentation of patient HEART score and if the patient would or would not be a good candidate for outpatient stress testing or follow-up within 72 hours without further EDOU testing or consultant evaluation. Providers selected reasons why patients were not a good candidate for outpatient stress testing/follow-up. There were 279 patient questionnaires completed, 42% (117/279) had a HEART score of 0-3. Within this group, 54.7% (64/117) of the patients were identified as not being good candidates for outpatient stress testing/follow-up within 72 hours because of concerns for poor follow-up (n = 14), concerning risk factors (n = 14), concerning symptoms (n = 11), and other (n = 7). ED physicians in this urban ED felt that over half of patients with a low-risk HEART score were not good candidates for discharge from the EDOU without further evaluation due to poor follow-up, concerning risk factors or symptoms, or coexisting conditions.