Accelerated Diagnostic Protocol Research Articles

Effectiveness of accelerated diagnostic protocols for reducing emergency department length of stay in patients presenting with chest pain: A systematic review and meta-analysis.

In recent years, there has been an increase in the use of accelerated diagnostic protocols (ADPs) and high-sensitivity troponin assays (hsTn) for the assessment of chest pain in emergency departments (EDs). This study aimed to quantitatively summarize the operational and clinical outcomes of ADPs implemented for patients with suspected cardiac chest pain. To be considered eligible for inclusion, studies must have implemented some form of ADP within the ED for evaluating adult (age ≥18 years) patients presenting with chest pain using Tn assays. The primary outcome was ED length of stay (LOS). Secondary outcomes included the proportion of patients admitted and the proportion with 30-day major adverse cardiac events (MACE). Thirty-seven articles involving 404,566 patients met the inclusion criteria, including five randomized controlled trials (RCTs) and 32 observational studies. A significant reduction in total ED LOS was reported in 22 observational studies and four RCTs. Emergency departments with longer baseline ED LOS showed significantly larger reductions in LOS after ADP implementation. This observed association persisted after adjusting for both the change in serial Tn measurement interval and transition from conventional Tn assay to an hsTn assay (β = -0.26; 95% CI, -0.43 to -0.10). Three studies reported an increase in the proportion of patients admitted after introducing an ADP, one of which was significant while 15 studies reported a significant decrease in admission proportion. There was moderate heterogeneity among the 13 studies that reported MACE proportions, with a non-significant pooled risk ratio of 0.95 (95% CI, 0.86-1.04). Implementation of ADPs for chest pain presentations decreases ED LOS, most noticeably within sites with a high baseline LOS; this decreased LOS is seen even in the absence of any change in troponin assay type. The decrease in LOS occurred alongside reductions in hospital admissions, while not increasing MACE. The observed benefits translated across multiple countries and health regions.

Evaluation of the analytical and clinical performance of a high-sensitivity troponin I point-of-care assay in the Mersey Acute Coronary Syndrome Rule Out Study (MACROS-2).

The objective of this study is to evaluate the analytical and diagnostic performance of a high-sensitivity point-of-care (POC) cardiac troponin I assay, the Quidel TriageTrue™ (QuidelOrtho Inc, San Diego, USA), compared to central laboratory testing (CLT) in accelerated diagnostic protocols (ADP) in real time in a clinical environment. In a nested sub-study of a pragmatic randomised control trial, consecutive patients with suspected acute coronary syndrome (ACS) and chest pain <12 h duration were randomised to the ESC 0/1 and 0/3-h ADP. Subjects underwent sampling for Quidel TriageTrue POC hs-TnI whole blood and plasma, CLT hs-TnT Roche Elecsys and a validated, NICE approved CLT High sensitivity cardiac troponin I (hs-TnI) (Siemens Attellica) at each time point. Assay imprecision was assessed by repeat analysis of whole blood samples at three levels (low, near 10 % CV 5-10 ng/L, medium, approximating 99th percentile 15-25 ng/L and high, 3-5 times the 99th percentile, 60-100 ng/L). Final diagnosis was adjudicated at 6weeks by Roche hs-TnT using the 4th universal definition of myocardial infarction (MI). A total of 1,157 patients consented and had both investigational POC whole blood and plasma and central lab hs-cTn available. The median age was 59, 47.2 % were female and 15 % had suffered a previous MI. Assay imprecision of whole blood POC TriageTrue revealed 10 % CV at 8.6 ng/L (>50 % lower than 99th percentile [20.5 ng/L]) and a 20 % CV at 1.2 ng/L. Receiver operator characteristics (ROC) curves were computed for each assay against adjudicated index type 1 MI to study clinical performance. At all-time points there were excellent performance for whole blood POC TriageTrue: area under the curve (AUC) 0.97 [95 % CI 0.94-098], 0.98 [95 % CI 0.97-1.00] and 0.95 [95 % CI 0.92-0.98] at time 0, 1 and 3 h respectively. There was statistical equivalence for performance of whole blood and plasma POC TriageTrue hs-TnI and laboratory Siemens Atellica hs-TnI. The whole blood POC TriageTrue hs-TnI assay demonstrates imprecision levels consistent with high sensitivity characteristics and has a clinical performance equivalent to an established, validated and NICE approved laboratory Siemens Atellica hs-TnI.

The Impact of an Accelerated Diagnostic Protocol Using Conventional Troponin I for Patients With Cardiac Chest Pain in the Emergency Department

BackgroundThis study strove to assess the impact of the implementation of an accelerated diagnostic protocol (ADP), using shortened serial-testing intervals and a conventional troponin I (c-TnI) test, on emergency department (ED) length of stay (LOS). MethodsThis retrospective cohort study included adults (aged ≥ 18 years) presenting to a Canadian ED with a primary complaint of cardiac chest pain between January 14, 2017 and January 15, 2019. For non-high-risk patients, the troponin delta timing decreased from 6 hours to 3 hours, and a different conventional troponin I level cut-point was implemented on January 15, 2018. The primary outcome was ED LOS. Secondary outcomes included disposition status, consultation proportions, and major adverse cardiac events within 30 days. ResultsA total of 3133 patient interactions were included. Although the overall decrease in median ED LOS was not significant (P = 0.074), a significant reduction occurred in ED LOS (-33 minutes; 95% confidence interval: -53.6 to -12.4 minutes) among patients who were discharged in the post-ADP group. Consultations were unchanged between groups (36.1% before vs 33.8% after; P = 0.17). The major adverse cardiac events outcomes were unchanged across cohorts (15.9% vs 15.3%; P = 0.62). ConclusionsThe implementation of an ADP, with a conventional troponin I test, for cardiac chest pain in a Canadian ED was not associated with a significant reduction of LOS for all patients; however, a significant reduction occurred for patients who were discharged, and the strategy appears safe.

Implementation of the European Society of Cardiology 0/3-hour accelerated diagnostic protocol, using high sensitive troponin T: a clinical practice evaluation of safety and effectiveness involving 3003 patients with suspected acute coronary syndrome

BackgroundThere have been relatively few studies detailing the real-world effectiveness and safety of accelerated diagnostic protocols (ADP), using high sensitivity cardiac troponin (hs-cTn).ObjectiveTo analyse the safety and effectiveness of early...

Imprecision and clinical performance of a whole blood high sensitivity point of care troponin I: the first prospective real-time study in suspected acute coronary syndrome

Abstract Introduction Implementation of accelerated diagnostic protocols (ADP) for suspected ACS, with resultant improvement in patient flow, will be facilitated by the use of point of care (POC) testing. To date there has been no published data on the use of a whole blood POC high sensitive troponin (hstn) in real time in a clinical environment. Methods In a nested sub-study of a pragmatic randomised controlled trial consecutive patients with suspected ACS and CP&amp;lt;12 hours duration, underwent sampling for quidell triage true POC hstn I whole blood and plasma (as well as a central laboratory hstn I [Siemens Attellica]. Subjects were randomised to ESC 0/1 and 0/3 hour ADP and had repeat whole blood and plasma POC tn I and laboratory hstn I at these time points. (ClinicalTrials.gov Identifier: NCT05322395). Assay imprecision was assessed by duplicate analysis of whole blood samples at seven levels. Final diagnosis was adjudicated based on all relevant clinical and imaging data together with hstn T as the diagnostic biomarker in clinical use. (Roche diagnostics, 10% coefficient of variation (CV) 3-5 ng/L, 99th percentile 14 ng/L) using the 4th universal definition of myocardial infarction (MI) Results 1157 patients consented and had both investigational POC whole blood and plasma (taken and analysed in real time) and central lab hstn I available. The mean age was 58, 48% were female and 15.4% patients had suffered a previous MI. Assay imprecision of whole blood POC quidel triage true revealed 10% CV at 8.6 ng/L, (&amp;gt;50% lower level than 99th percentile [20.4ng/l]) and a 20% CV at 1.2 ng/l). There was excellent overall agreement between laboratory hsTnI method and whole blood poc cTnI [Quidell triage true = 1.28cTnI Attelica +1.3]. ROC (receiver operator characteristics) curves were computed for each assay against adjudicated index MI to study clinical performance. At all time points there were excellent performance for whole blood POC: AUC 0.97 [95% CI 0.94-098]), 0.98 [95% CI 0.97-1.00] and 0.95 [95% CI0.92-0.98] at time 0 (presentation, figure), 1 and 3 hours respectively. There was statistical equivalence for performance of whole blood POC and plasma POC hstn I and laboratory hstn I Conclusion The POC whole blood quidell triage true demonstrates imprecision levels consistent with high sensitivity characteristics and has a clinical performance equivalent to an established and well validated laboratory hstn I. This is the first clinical validation of Whole blood POC hstn assay studied real-time in a clinical environment.

Abstract 13433: Outcomes of Chest Pain Discharge Decisions Following Launch of a Heart Score Clinical Decision Support Alert

Background: The use of a bioclinical risk score such as the HEART score is recommended for the evaluation of pts presenting to the ED with chest pain (CP). Prior studies have demonstrated that CP pts with HEART score &lt; 3 and “ruled out” with cardiac troponin series are low risk for 30d death/MI (MACE). There is limited data regarding whether the addition of the HEART score to a validated high sensitivity troponin accelerated diagnostic protocol (ADP) has beneficial effects on CP patient discharge decisions in the ED. Research Question: Did the addition of an EHR-embedded automated HEART score clinical decision support alert (CDSA) have a beneficial effect on discharge decision making of ED CP pts in Geisinger Health System? Methods: Retrospective analysis of 30day MACE following ED visit for CP for the 6mo period prior to and 10mo following the launch of a HEART score CDSA (11/2021-3/2023). Discharges were stratified using a previously validated accelerated hsTnT ADP into those that ruled in (ADP+) or ruled out (ADP-). Comparison of MACE in pre- vs. post-CDSA periods was performed using chi square analysis. Results: MACE stratified by study period and ADP results are summarized in the Table. There were no significant differences in 30-day MACE pre- vs. post-CDSA, both overall and in ADP+ and ADP- subgroups. In contrast, the presence or absence of a high risk (&gt;3) HEART score in isolation did significantly predict the risk of MACE [11/2360 (0.47%) for HEART score &lt; 3 vs 36/966 (4.04%) for HEART score &gt;3, p&lt;0.001]. Conclusions: Addition of an EHR-embedded HEART Score CDSA did not have a significant effect on 30d outcomes following ED provider discharge decisions. While the HEART score by itself did stratify risk of 30d MACE, our study suggests the additive benefit of the HS CDSA to clinical decision making based on an established hsTnT ADP unclear.

Abstract 13592: Addition of the Heart Score to a hsTnT Accelerated Diagnostic Protocol: Effect on Negative Predictive Value at Different hsTnT Thresholds

Background: The majority of pts with CP and low to modest elevations of high sensitivity troponin (hsTn) are safe for discharge from the ED; thus improvement of the negative predictive value (NPV) of the CP accelerated diagnostic protocol (ADP) can have significant impact on ED throughput. Prior studies have examined the role of adding bioclinical risk scores such as the HEART score (HS) to a hsTn ADP. In general these studies suggest the HS does not add to prediction of 30d MACE for pts with low peak troponin levels, i.e. less that the 99 th percentile. Little is known about the effect of the HS on hsTn ADP for higher values of troponin. Research question: How would the addition of the HS affect the NPV of a hsTnT ADP across a range of modest hsTnT elevations? Methods: Retrospective analysis of pts presenting with CP and assessed with a validated hsTnT ADP as well as an EHR-embedded HS decision tool from 5/2022-3/2023. The hsTnT ADP was derived from the ESC guidelines and pts were excluded if peak hsTnT was &gt; 52ng/l (the cutoff for “rule-in”). For calculation of NPV for MACE at 30 days post-discharge pts were grouped by peak hsTnT as &lt;6ng/l, &lt;12ng/l, and &lt;52ng/l. HS was grouped as &lt; 3 (low risk) or &gt;3 (intermediate-high risk). Comparison of NPV results was performed using chi square analysis. Results: Summarized in the Table. The addition of the HS did not significantly change the NPV for 30d MACE for CP pts with peak hsTnT &lt;6ng/l or &lt;12ng/l. In contrast, NPV in pts with peak hsTnT &lt;52ng/l was improved significantly by addition of the HS. Conclusion: The additive value of the HS to a hsTnT ADP for identifying pts safe for ED discharge depends on the range of troponin measurement- HS did not change NPV at very low levels (ie from &lt; limit of quantitation – approx. 99 th percentile) but did improve the NPV at modest elevations between the 99 th percentile and the cutoff for “rule-in” by our ADP. This findings should be considered when designing hsTn CP evaluation protocols that incorporate HS into the algorithm.

Frequency, compliance, and yield of cardiac testing after high-sensitivity troponin accelerated diagnostic protocol implementation

BackgroundAmong persons presenting to the emergency department with suspected acute myocardial infarction (MI), cardiac troponin (cTn) testing is commonly used to detect acute myocardial injury. Accelerated diagnostic protocols (ADPs) guide clinicians to integrate cTn results with other clinical information to decide whether to order further diagnostic testing. ObjectiveTo determine the change in the rate and yield of stress test or coronary CT angiogram following cTn measurement in patients with chest pain presenting to the emergency department pre- and post-transition to a high-sensitivity (hs-cTn) assay in an updated ADP. MethodsUsing electronic health records, we examined visits for chest pain at five emergency departments affiliated with an integrated academic health system 1-year pre- and post-hs-cTn assay transition. Outcomes included stress test or coronary imaging frequency, ADP compliance among those with additional testing, and diagnostic yield (ratio of positive tests to total tests). ResultsThere were 7564 patient-visits for chest pain, including 3665 in the pre- and 3899 in the post-period. Following the updated ADP using hs-cTn, 862 (23.5 per 100 patient visits) visits led to subsequent testing versus 1085 (27.8 per 100 patient visits) in the pre-hs-cTn period, (P < 0.001). Among those who were tested, the protocol-compliant rate fell from 80.9% to 46.5% (P < 0.001), but the yield of those tests rose from 24.5% to 29.2% (P = 0.07). Among tests that were noncompliant with ADP guidance, yield was similar pre- and post-updated hs-cTn ADP implementation (pre 13.0%, post 15.4% (P = 0.43). ConclusionImplementation of hs-cTn supported by an updated ADP was associated with a lower rate of stress testing and coronary CT angiogram.

Rural and socioeconomic differences in the effectiveness of the HEART Pathway accelerated diagnostic protocol.

The HEART Pathway is a validated accelerated diagnostic protocol (ADP) for patients with possible acute coronary syndrome (ACS). This study aimed to compare the safety and effectiveness of the HEART Pathway based on patient rurality (rural vs. urban) or socioeconomic status (SES). We performed a preplanned subgroup analysis of the HEART Pathway Implementation Study. The primary outcomes were death or myocardial infarction (MI) and hospitalization at 30 days. Proportions were compared by SES and rurality with Fisher's exact tests. Logistic regression evaluated for interactions of ADP implementation with SES or rurality and changes in outcomes within subgroups. Among 7245 patients with rurality and SES data, 39.9% (2887/7245) were rural and 22.2% were low SES (1607/7245). The HEART Pathway identified patients as low risk in 32.2% (818/2540) of urban versus 28.1% (425/1512) of rural patients (p= 0.007) and 34.0% (311/915) of low SES versus 29.7% (932/3137) high SES patients (p= 0.02). Among low-risk patients, 30-day death or MI occurred in 0.6% (5/818) of urban versus 0.2% (1/425) rural (p= 0.67) and 0.6% (2/311) with low SES versus 0.4% (4/932) high SES (p= 0.64). Following implementation, 30-day hospitalization was reduced by 7.7% in urban patients (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.66-0.87), 10.6% in low SES patients (aOR 0.68, 95% CI 0.54-0.86), and 4.5% in high SES patients (aOR 0.83, 95% CI 0.73-0.94). However, rural patients had a nonsignificant 3.3% reduction in hospitalizations. HEART Pathway implementation decreased 30-day hospitalizations regardless of SES and for urban patients but not rural patients. The 30-day death or MI rate was similar among low-risk patients.

Performance analysis considering endpoints for three accelerated diagnostic protocols for chest pain

IntroductionThe modified accelerated diagnostic protocol (ADP) to assess patients with chest pain symptoms using troponin as the only biomarker (mADAPT), the History, ECG, Age, Risk factors, and Troponin (HEART) pathway, and the Emergency Department Assessment of Chest Pain Rule (EDACS)-ADP, are the three most well-known ADPs for patients with chest pain. These ADPs define major adverse cardiac event (MACE) as components of acute myocardial infarction, revascularization, and death; unstable angina is not included as an endpoint. MethodsWe performed a single-center prospective observational study comparing the performance of these 3 ADPs for patients with 30-day MACE with and without unstable angina. We hypothesized that these ADPs will have high sensitivities for MACE without unstable angina, a definition used for score derivation studies. However, when unstable angina is included in the MACE, their performances would be lower than the acceptable rate of >99% sensitivity. ResultsA total of 1,214 patients were included in the analysis. When unstable angina was not included in the endpoint, sensitivities for MACE were 99.1% (95% confidence interval [CI]: 96.7–99.9%), 99.5% (95% CI: 97.4–100%), and 100% (95% CI: 98.3–100%) for mADAPT, EDACS-ADP, and HEART pathway, respectively. The HEART pathway had the highest proportion of patients classified as low risk (39.2%, 95% CI: 35.8–42.9%), followed by EDACS-ADP (31.3%, 95% CI: 28.2–34.6%) and mADAPT (29.3%, 95% CI: 26.4–32.5%). However, when unstable angina was included in the MACE, sensitivities were 96.6% (95% CI: 94.4–98.1%) for mADAPT, 97.3% (95% CI: 95.3–98.6%) for EDACS-ADP, and 97.3% (95% CI: 95.3–98.6%) for the HEART pathway, respectively. There were 15 false-negative cases with mADAPT, and 12 false-negative cases each for EDACS-ADP and HEART pathway. ConclusionAll three ADPs—mADAPT, EDACS-ADP, and HEART pathway—were similarly accurate in their discriminatory performance for the risk stratification of ED patients presenting with possible ACS when unstable angina was not included in the endpoint. The HEART pathway showed the best combination of sensitivity and proportion of patients that can be classified as safe for early discharge. However, when unstable angina was added to the endpoint, all three ADPs did not show appropriate safety levels and their performances were lower than the acceptable risk of MACE.

Implementation of the ESC 0/3hour accelerated diagnostic protocol,utilising high sensitive troponin T, for suspected acute coronary syndrome:a study on clinical effectiveness involving 3016 patients

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Liverpool University Hospitals NHS Foundation Trust Background There have been relatively few studies detailing the real-world effectiveness and safety of accelerated diagnostic protocols (ADP), using high sensitivity troponins (HSTN). Purpose To analyse the safety and effectiveness of early emergency room (ER) discharge following implementation of the ESC 0/3-hour ADP for suspected acute coronary syndromes (ACS) Method We prospectively studied 2 cohorts of consecutive suspected acute coronary syndromes (ACS) presentations to ER before (n = 1642) and after (n = 1376, 2 centres) implementation of the ESC 0/3-hour ADP incorporating limit of detection rule out. All index presentations with HSTNT (high sensitive troponin T) &amp;gt;99th percentile underwent independent two physician adjudication for MI (myocardial infarction) using all available data to six weeks. Safety was defined by both NPV (negative predictive value) and sensitivity for type 1 or type 2 MI for those with ER discharge and clinical effectiveness by percentage ER discharge. Results In the pre-implementation period there was a higher prevalence of MI. Discharge from ER increased by &amp;gt;100% to 56% of the cohort, when the ADP was implemented. This correlated with a marked reduction in length of stay overall and a more modest reduction for those discharged from ER (table) The greatly increased ER discharge was safe with no signal for hazard. Analysis of HSTNT values and ECGS revealed a maximum ER discharge rate of 69%, by applying the 0/3-hour protocol, implying potential for further increasing safe ER discharge. Conclusions Implementation of an ADP with HSTNs is safe and effective for early rule-out and discharge of suspected ACS. Further research into the shortfall between theoretical and actual early ER discharge achieved is warranted. DischargePre-implementation0/3hour ADP implementationP valuen16421376% male52.352.1nsAge (median)5855&amp;lt;0.001Index Type 1 or 2 MI prevalence (%)11.96&amp;lt;0.001% discharged from ER2756&amp;lt;0.001Median total length of stay (hours) {global population}16.37.1&amp;lt;0.001Median length of stay (hours)- discharged from ER6.25.4&amp;lt;0.001NPV for index type 1 or 2 MI (discharged from ER)99.399.7nsSensitivity index type 1 or 2 MI (discharged from ER)98.597.6ns

Comparison of two diagnostic protocols in the management of possible cardiac chest pain: One follow-up study in Iran.

Background:Chest pain indicating acute coronary syndrome (ACS) accounts for approximately 5-10% of presents in the emergency departments (EDs). Rapid decision making is very important because longer hospital stay is associated with higher financial burden. The aim of this study was to compare current practice with a 2-hour accelerated diagnostic protocol (ADP) to manage chest pain in patients suspected to have ACS.Methods:This is a longitudinal follow-up study on 900 patients with negative troponin measured on entrance to the ED and initially low-risk for myocardial infarction according to the emergency department of chest pain assessment score (EDACS) at the Loghman Hakim Hospital, Tehran, Iran in 2018. Patients were divided in two groups (based on odd or even days at admission time) at a ratio of 2:1 (i) current protocol with a second troponin measuring after 6 hours and (ii) ADP with a second troponin measured after 2 hours. Major adverse cardiac events (MACE) associated factors assessed in two groups over 30-days.Results:Totally, the rate of return to EDs with the major adverse cardiac events was 4% (n=24) in the current protocol group and 1% (n=1) in the ADP group within 30 days. The odds ratio for MACE in 30 days in the current protocol was 4.3 times more than ADP group (95% CI: 1.28-14.56, OR: 4.33, p:0.02). In multivariable logistic regression analysis, this estimation for the current protocol was 4.10 times more than comparison group (95% CI: 1.23-13.81, OR: 4.10, p:0.01).Conclusion:A 2-hour ADP in patients at low-risk for myocardial infarction by EDACS had fewer adverse follow-up events than the current protocol.

Optimal Detection of Acute Myocardial Injury and Infarction with Cardiac Troponin: Beyond the 99th Percentile, into the High-Sensitivity Era.

Cardiac troponin (cTn) is the biomarker of choice for the diagnosis of acute myocardial infarction (MI); use of this biomarker has centered around the 99th percentile upper reference limit (URL) for healthy populations. Recent development and regulatory approval of high-sensitivity cardiac troponin (hs-cTn) assays have required a fresh look at utilization of the 99th percentile URL. This review covers issues regarding the 99th percentile URL and approaches for use of cTn as biomarker for detecting cardiac injury and diagnosis of acute myocardial infarction. Development of hs-cTn assays has allowed determination and use of sex-specific 99th percentile URLs for assessing cardiac injury and increased the utility of cTn values below the 99th percentile URL. This improved analytical performance for hs-cTn assays has allowed for development of accelerated diagnostic protocols (ADPs) for rapid assessment and disposition of patients based on serial sampling of cTn for use in acute MI diagnosis as soon as 0-1h after clinical presentation. The 99th percentile URLs of cTn is essential for detecting cardiac injury; however, use of the 99th percentile URLs in the era of hs-cTn results may be modified. ADPs have the potential to substantially decrease the time many patients spend under evaluation for acute MI, thereby potentiating improvement in patient satisfaction, decreased healthcare costs, and reducing the burden on emergency departments.

High-Sensitivity Cardiac Troponin-Based Strategies for the Assessment of Chest Pain Patients-A Review of Validation and Clinical Implementation Studies.

The introduction of high-sensitivity cardiac troponin (hs-cTn) assays has improved the early assessment of chest pain patients. A number of hs-cTn-based algorithms and accelerated diagnostic protocols (ADPs) have been developed and tested subsequently. In this review, we summarize the data on the performance and clinical utility of these strategies. We reviewed studies investigating the diagnostic and prognostic performance of hs-cTn algorithms [level of detection (LoD) strategy, 0/1-h, 0/2-h, and 0/3-h algorithms) and of hs-cTn-based ADPs, together with the implications of these strategies when implemented as clinical routine. The LoD strategy, when combined with a nonischemic electrocardiogram, is best suited for safe rule-out of myocardial infarction and the identification of patients eligible for early discharge from the emergency department. The 0/1-h algorithms appear to identify most patients as being eligible for rule-out. The hs-cTn-based ADPs mainly focus on prognostic assessment, which is in contrast with the hs-cTn algorithms. They identify smaller proportions of rule-out patients, but there is increasing evidence from prospective studies on their successful clinical implementation. Such information is currently lacking for hs-cTn algorithms. There is a trade-off between safety and efficacy for different hs-cTn-based strategies. This trade-off should be considered for the intended strategy, along with its user-friendliness and evidence from clinical implementation studies. However, several gaps in knowledge remain. At present, we suggest the use of an ADP in conjunction with serial hs-cTn results to optimize the early assessment of chest pain patients.

Received care compared to ADP-guided care of patients admitted to hospital with chest pain of possible cardiac origin.

PurposeTo assess the extent to which accelerated diagnostic protocols (ADPs), compared to traditional care, identify patients presenting to emergency departments (EDs) with chest pain who are at low cardiac risk and eligible for early ED discharge.Patients and methodsRetrospective study of 290 patients admitted to hospital for further evaluation of chest pain following negative ED workup (no acute ischemic electrocardiogram [ECG] changes or elevation of initial serum troponin assay). Demographic data, serial ECG and troponin results, Thrombolysis in Myocardial Infarction (TIMI) score, cardiac investigations, and outcomes (confirmed acute coronary syndrome [ACS] at discharge and major adverse cardiac events [MACEs]) over 6 months of follow-up were analyzed. A validated ADP (ADAPT-ADP) was retrospectively applied to the cohort, and processes and outcomes of ADP-guided care were compared with those of care actually received.ResultsPatients had mean (±SD) TIMI score of 1.8 (±1.7); six (2.0%) patients were diagnosed with ACS at discharge. At 6 months, one patient (0.3%) re-presented with ACS and two (0.6%) died of non-coronary causes. The ADAPT-ADP defined 97 (33.4%) patients as being at low risk and eligible for early ED discharge, but who instead incurred mean hospital stay of 1.5 days, with 40.2% in telemetry beds, and 21.6% subject to non-invasive testing with only one positive result for coronary artery disease. None had a discharge diagnosis of ACS or developed MACE at 6 months.ConclusionCompared to traditional care, application of the ADAPT-ADP would have allowed one-third of chest pain patients with initially negative investigations in ED to have been safely discharged from ED.

The HAS-Choice study: Utilizing the HEART score, an ADP, and shared decision-making to decrease admissions in chest pain patients

ObjectiveThe HAS-Choice pathway utilizes the HEART Score, an accelerated diagnostic protocol (ADP), and shared decision-making using a visual aid in the evaluation of chest pain patients. We seek to determine if our intervention can improve resource utilization in a community emergency department (ED) setting while maintaining safe patient care. MethodsThis was a single-center prospective cohort study with historical that included ED patients ≥21years old presenting with a primary complaint of chest pain in two time periods. The primary outcome was patient disposition. Secondary outcomes focused on 30-day ED bounce back and major adverse cardiac events (MACE). We used multivariate logistic regression to estimate the odds ratio (OR) and its 95% confidence interval (CI). ResultsIn the pre-implementation period, the unadjusted disposition to inpatient, observation and discharge was 6.5%, 49.1% and 44.4%, respectively, whereas in the post period, the disposition was 4.8%, 41.5% and 53.7%, respectively (chi-square p<0.001). The adjusted odds of a patient being discharged was 40% higher (OR=1.40; 95% CI, 1.30, 1.51; p<0.001) in the post-implementation period. The adjusted odds of patient admission was 30% lower (OR=0.70; 95% CI, 0.60, 0.82; p<0.001) in the post-implementation period. The odds of 30-day ED bounce back did not statistically differ between the two periods. MACE rates were <1% in both periods, with a significant decrease in mortality in the post-implementation period. ConclusionOur study suggests that implementation of a shared decision-making tool that integrates an ADP and the HEART score can safely decrease hospital admissions without an increase in MACE.

Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project.

To evaluate hospital length of stay (LOS) and admission rates before and after implementation of an evidence-based, accelerated diagnostic protocol (ADP) for patients presenting to emergency departments (EDs) with chest pain. Quasi-experimental design, with interrupted time series analysis for the period October 2013 - November 2015. Setting, participants: Adults presenting with chest pain to EDs of 16 public hospitals in Queensland. Implementation of the ADP by structured clinical re-design. Primary outcome: hospital LOS. ED LOS, hospital admission rate, proportion of patients identified as being at low risk of an acute coronary syndrome (ACS). Outcomes were recorded for 30 769 patients presenting before and 23 699 presenting after implementation of the ADP. Following implementation, 21.3% of patients were identified by the ADP as being at low risk for an ACS. Following implementation of the ADP, mean hospital LOS fell from 57.7 to 47.3 hours (rate ratio [RR], 0.82; 95% CI, 0.74-0.91) and mean ED LOS for all patients presenting with chest pain fell from 292 to 256 minutes (RR, 0.80; 95% CI, 0.72-0.89). The hospital admission rate fell from 68.3% (95% CI, 59.3-78.5%) to 54.9% (95% CI, 44.7-67.6%; P < 0.01). The estimated release in financial capacity amounted to $2.3 million as the result of reduced ED LOS and $11.2 million through fewer hospital admissions. Implementing an evidence-based ADP for assessing patients with chest pain was feasible across a range of hospital types, and achieved a substantial release of health service capacity through reductions in hospital admissions and ED LOS.

A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients.

Guidelines recommend a 0-hour/1-hour high-sensitivity cardiac troponin T (hs-cTnT) diagnostic strategy in acute chest pain patients. There are, however, little data on the performance of this strategy when combined with clinical risk stratification. We aimed to evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP) using the 0-hour/1-hour hs-cTnT strategy together with an adapted Thrombolysis In Myocardial Infarction (TIMI) score and electrocardiogram (ECG) for ruling out major adverse cardiac events (MACE) within 30 days. This prospective observational study enrolled consecutive emergency department (ED) chest pain patients. TIMI score variables, ED physicians' assessments of the ECG, and 0- and 1-hour hs-cTnT were collected. Thirty-day MACE was defined as acute myocardial infarction (AMI), unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause. A total of 1,020 patients were included in the final analysis. The combination of an adapted TIMI score ≤1, a nonischemic ECG, and either a 0-hour hs-cTnT<5 ng/L or a 0-hour hs-cTnT<12 ng/L combined with a 1-hour increase<3 ng/L identified 432 (42.4%) patients as very low risk with a negative predictive value of 99.5% (95% confidence interval [CI]= 98.3%-99.9%) and a negative likelihood ratio of 0.04 (95% CI= 0.01-0.14) for 30-day MACE. The ADP missed only two patients with UA and no patients with AMI or other forms of MACE. An ADP using the guideline recommended 0-hour/1-hour hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients.

Identifying Low-risk Patients for Early Discharge From Emergency Department Without Using Subjective Descriptions of Chest Pain: Insights From Providing Rapid Out of Hospital Acute Cardiovascular Treatment (PROACT) 3 and 4 Trials.

Several accelerated diagnostic protocols (ADPs) have been developed to allow emergency department (ED) physicians to identify appropriate patients for safe early discharge after presentation with symptom of chest pain. Most ADPs require chest pain to be described and modify the algorithm based on the subjective chest pain characteristics. We investigated the performance of three established major ADPs simplified by eliminating the need for chest pain as a descriptor. We pooled patients from PROACT-3 and -4 trials, in which patients presenting to emergency medical services with chest pain or dyspnea were enrolled. The simplified Vancouver Chest Pain Rule (sVCPR), the simplified Emergency Department Assessment of Chest Pain Score (sEDACS) ADP and the Accelerated Diagnostic protocol to Assess Patients with chest pain using contemporary troponins as the only biomarker (ADAPT-ADP) were compared using the sensitivity, specificity, and positive and negative predictive values (NPV). The primary outcome of interest was 30-day major adverse cardiac events (MACE); the diagnosis of acute coronary syndrome (ACS) occurring within 30 days after ED presentation was also explored. A total of 1,081 patients were included (median age= 67 years, 53% male, median GRACE score= 113) of which 222 ACS diagnoses and 150 cardiac events occurred within 30 days after index ED presentation. The sVCPR, sEDACS≥3, and ADAPT-ADP, respectively, identified 9.7, 13.3, and 4.1% of patients as low risk with a sensitivity and NPV of 100% for the primary outcome of 30-day MACE. The sEDACS-ADP identified 24.2% of patients as low risk with a cut-point score of 4 (sensitivity of 98.0% and NPV of 98.8%). The sVCPR, sEDACS≥3, and ADAPT-ADP, respectively, had NPVs of 98.1, 95.8, and 93.3% in identifying patients at higher risk of ACS diagnosis within 30 days after index ED visit. The diagnostic protocols performed well without their chest pain characteristics component. Further studies are suggested to explore the performance of ADPs when these simplified ADPs are combined with high-sensitive troponin assays.

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