Accelerated Diagnostic Protocols for Evaluating Patients with Chest Pain to Improve Emergency Department Efficiency
Creators: Hill, Jesse Lee
Publisher: name: University of Alberta Library
Year: 2023

<p>Most emergency departments (ED) within North America report issues with overcrowding. Overcrowding is defined as an inability to provide quality care in an appropriate time course to ED patients. Delays to see a care provider produce poor patient outcomes; recent research demonstrates corresponding increased time to antibiotics for infection, treatment for asthma and COPD, and increased overall mortality. Interventions to mitigate ED crowding appear justified, when supported by research.<br>
Chest pain is the second most common ED presenting complaint in Canada. The approach to chest pain is an ideal condition to address when considering potential ways to mitigate overcrowding. Cardiac biomarkers, accelerated diagnostic protocols (ADP), and scoring systems have gained attention as strategies to reliably exclude acute coronary syndrome. Plasma cardiac troponins require time to accumulate to a detectable level after cardiac muscle necrosis. Development of higher sensitivity troponin assays lead to improved sensitivity for measurement of lower troponin concentrations. We conducted a systematic review to quantitatively summarize the operational and clinical outcomes of ADPs implemented for patients with suspected cardiac chest pain. The primary outcome was ED length of stay (ED LOS). Twenty-one articles involving 248,721 patients met the inclusion criteria, including three RCTs and 18 observational studies. A significant reduction in the total ED LOS was reported in 12 (67%) observational studies and two (67%) RCTs. Overall, ADP implementation helps decrease ED LOS and should be considered by hospitals or health care entities searching for strategies to improve operational efficiency; this decreased LOS is seen even in the absence of any change in troponin assay type. The decrease in LOS did not come at the cost of increased hospital admissions or more patients experiencing subsequent adverse events (e.g., major adverse cardiovascular events [MACE], heart failure, strokes, etc.). The observed benefits translated across multiple health regions.<br>
We conducted two retrospective cohort studies of all adults (≥ 18 yr) presenting to a tertiary-care, urban, Canadian ED who were triaged with a primary presenting complaint of chest pain of cardiac origin over several distinct periods of time. Firstly, we evaluated the impact of introducing an ADP and associated decrease in serial conventional troponin measurement intervals (6- to 3-hours). Compared to the identical time period in the pre-ADP period, the median ED LOS decreased by 30 minutes (95% CI: 11.2, 48.8) in the post-ADP period. Among patients who were discharged, there was a decrease in LOS by 33 minutes (95% CI: 5.3, 36.7) in the post-ADP group. Subsequently, we evaluated the impact of introducing a high-sensitivity troponin and its associated evaluation pathway at the same hospital. Compared to the identical pre-period, the median ED LOS decreased by 20 minutes (95% CI: 5.3, 36.7).) in the post-ADP period. Among patients who were discharged, there was a significant decrease in LOS by 34 minutes (95% CI: 18.1, 49.9) following the implementation of the high-sensitivity assay. Across both comparisons, the proportions of consultations, admissions, and patients experiencing major adverse cardiac events were unchanged. <br>
Emergency department overcrowding (EDOC) will continue to feature prominently amongst the most important issues facing our healthcare system here in Canada and in many developed countries. Presentations to the ED for chest pain are, and will continue to be, a major component of ED volume. Any efforts to minimize patients’ length of stay within the ED are worth evaluating as one prong of a system-wide approach to reduce EDOC.</p>