Improving patient flow in acute coronary syndromes in the face of hospital crowding.

BACKGROUND: The current paradigm for the evaluation of patients with suspected acute coronary syndromes (ACS) in the emergency department (ED) is focused on the identification of patients with active underlying coronary disease. The majority of patients evaluated in the ED setting do not have active underlying cardiac disease. OBJECTIVE: To measure the effect of bedside point-of-care (POC) cardiac biomarker testing on telemetry unit admissions from the ED. Furthermore, to evaluate the effect telemetry admissions have on ED length of stay (LOS) and overall hospital LOS. METHODS: Primary data were collected over two 6-month periods in an urban teaching hospital ED. This was an observational cohort study conducted pre- and post-availability of a POC testing platform for cardiac biomarkers. Major measures included number of overall telemetry admissions, ED LOS, hospital LOS, and disposition. Patients were followed at 30 days for significant cardiac events, repeat ED visit or admission, and death. RESULTS: In the post-implementation period there was a 30% (95% confidence interval [CI] 36-44%) reduction in admissions to telemetry with a 33% (95% CI 26-39%) reduction in ED LOS and a 20% (95% CI 7-34%) reduction in hospital LOS. There was a 62% reduction in overall mortality between the pre-implementation period and the post-implementation period (p=0.001). CONCLUSION: The focused use of a rapid cardiac disposition protocol can dramatically impact resource utilization, expedite patient flow, and improve short-term outcomes for patients with suspected ACS.

Comparing an Unstructured Risk Stratification to Published Guidelines in Acute Coronary Syndromes.

INTRODUCTION: Guidelines are designed to encompass the needs of the majority of patients with a particular condition. The American Heart Association (AHA) in conjunction with the American College of Cardiology (ACC) and the American College of Emergency Physicians (ACEP) developed risk stratification guidelines to aid physicians with accurate and efficient diagnosis and management of patients with acute coronary syndrome (ACS). While useful in a primary care setting, in the unique environment of an emergency department (ED), the feasibility of incorporating guidelines into clinical workflow remains in question. We aim to compare emergency physicians' (EP) clinical risk stratification ability to AHA/ACC/ACEP guidelines for ACS, and assessed each for accuracy in predicting ACS. METHODS: We conducted a prospective observational cohort study in an urban teaching hospital ED. All patients presenting to the ED with chest pain who were evaluated for ACS had two risk stratification scores assigned: one by the treating physician based on clinical evaluation and the other by the AHA/ACC/ACEP guideline aforementioned. The patient's ACS risk stratification classified by the EP was compared to AHA/ACC/ACEP guidelines. Patients were contacted at 30 days following the index ED visit to determine all cause mortality, unscheduled hospital/ED revisits, and objective cardiac testing performed. RESULTS: We enrolled 641 patients presenting for evaluation by 21 different EPs. There was a difference between the physician's clinical assessment used in the ED, and the AHA/ACC/ACEP task force guidelines. EPs were more likely to assess patients as low risk (40%), while AHA/ACC/ACEP guidelines were more likely to classify patients as intermediate (45%) or high (45%) risk. Of the 119 (19%) patients deemed high risk by EP evaluation, 38 (32%) were diagnosed with ACS. AHA/ACC/ACEP guidelines classified only 57 (9%) patients low risk with 56 (98%) of those patients diagnosed with no ACS. CONCLUSION: In the ED, physicians are more efficient at correctly placing patients with underlying ACS into a high-risk category. A small percentage of patients were considered low risk when applying AHA/ACC/ACEP guidelines, which demonstrates how clinical insight is often required to make an efficient assessment of cardiac risk and established criteria may be overly conservative when applied to an acute care population.