Standardizing Emergency Work-ups Around Risk Data

Study Overview
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Brief Summary
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Chest pain is the second leading reason for emergency department (ED) visits in the United States. Resource utilization for this ED subpopulation is particularly high, in part due to a dearth of accepted standardized clinical approaches and general overestimation of risk on the part of both providers and patients. This prospective observational cohort study seeks to address this issue by providing externally validated risk scores for major adverse cardiac events using a web-based clinical decision support platform (RISTRA) embedded within the electronic health record at 13 Kaiser Permanente Northern California (KPNC) EDs over a 12-month period. The decision support will provide risk estimates specific to the KPNC patient population. This studies hypothesis is that the provision of more accurate risk estimation for major adverse cardiac events will improve informed decision making by both providers and patients, resulting in less provocative testing and lower ED lengths of stay amongst low risk patients, as well as improving medical management among non-low risk patients and decreasing future rates of major adverse cardiac events.

Official Title
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Standardizing Emergency Work-ups Around Risk Data (STEWARD): The CREST Network Chest Pain Project

Conditions
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Acute Coronary Syndrome, Chest Pain, Risk Reduction

Intervention / Treatment
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* Other: modified HEART score and/or Emergency Department Assessment of Chest pain Risk Score (EDACS)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Emergency department chief complaint of chest pain or chest discomfort Clinical concern for possible cardiac ischemia

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Intervention/Treatment |
| --- |
|Other: modified HEART score and/or Emergency Department Assessment of Chest pain Risk Score (EDACS)|Provision of estimated risk for major cardiac events at 60 days based on the modified HEART and/or EDACS, using KPNC specific estimates derived from an internal validation study|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Major adverse cardiac event (MACE) | A composite outcome of either acute myocardial infarction, cardiac arrest, malignant arrhythmia, cardiac-related mortality | 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Provocative and anatomic cardiac testing rates | Treadmill stress test, myocardial perfusion imaging, stress echocardiography, CT coronary angiography, catheter-based coronary angiography | 12 months | 
| Emergency department length of stay | Total hours spent in the emergency department among study eligible patients | 12 months | 
| Hospital admission rate | Percentage of hospital admissions among study eligible patients | 12 months |