Incorporation of the HEART Score Into a Low-risk Chest Pain Pathway to Safely Decrease Admissions.

Chest pain can be a challenging complaint to manage in the emergency department. A missed diagnosis can result in significant morbidity or mortality, whereas avoidable testing and hospitalizations can lead to increased health care costs, contribute to hospital crowding, and increase risks to patients. The HEART score is a validated decision aid to identify patients at low risk for acute coronary syndrome who can be safely discharged without admission or objective cardiac testing. In the largest and one of the longest studies to date (N = 31,060; 30 months), we included the HEART score into a larger, newly developed low-risk chest pain decision pathway, using a retrospective observational pre/post study design with the objective of safely lowering admissions. The modified HEART score calculation tool was incorporated in our electronic medical record. A significant increase in discharges of low-risk chest pain patients (relative increase of 21%; p < 0.0001) in the postimplementation period was observed with no significant difference in the rates of major adverse cardiac events between the pre and post periods. There was a decrease in the amount of return admissions for 30 days (4.65% fewer; p = 0.009) and 60 days (3.78% fewer; p = 0.020). No significant difference in length of stay was observed for patients who were ultimately discharged. A 64% decrease in monthly coronary computed tomography angiograms was observed in the post period (p < 0.0001). These findings support the growing consensus in the literature that the adoption of the HEART pathway or similar protocols in emergency departments, including at large and high-volume medical institutions, can substantially benefit patient care and reduce associated health care costs.

Comparison of 3 Symptom Classification Methods to Standardize the History Component of the HEART Score.

OBJECTIVES: The History, Electrocardiography, Age, Risk factors, Troponin (HEART) score enables rapid risk stratification of emergency department patients presenting with chest pain. However, the subjectivity in scoring introduced by the history component has been criticized by some clinicians. We examined the association of 3 objective scoring models with the results of noninvasive cardiac testing. METHODS: Medical records for all patients evaluated in the chest pain center of an academic medical center during a 1-year period were reviewed retrospectively. Each patient's history component score was calculated using 3 models developed by the authors. Differences in the distribution of HEART scores for each model, as well as their degree of agreement with one another, as well as the results of cardiac testing were analyzed. RESULTS: Seven hundred forty nine patients were studied, 58 of which had an abnormal stress test or computed tomography coronary angiography. The mean HEART scores for models 1, 2, and 3 were 2.97 (SD 1.17), 2.57 (SD 1.25), and 3.30 (SD 1.35), respectively, and were significantly different (P < 0.001). However, for each model, the likelihood of an abnormal cardiovascular test did not correlate with higher scores on the symptom component of the HEART score (P = 0.09, 0.41, and 0.86, respectively). CONCLUSIONS: While the objective scoring models produced different distributions of HEART scores, no model performed well with regards to identifying patients with abnormal advanced cardiac studies in this relatively low-risk cohort. Further studies in a broader cohort of patients, as well as comparison with the performance of subjective history scoring, is warranted before adoption of any of these objective models.

Structured inspection of medications carried and stored by emergency medical services agencies identifies practices that may lead to medication errors.

BACKGROUND: Medications are essential to emergency medical services (EMS) agencies when providing lifesaving care, but the EMS environment has challenges related to safe medication storage when compared with a hospital setting. We developed a structured process, based on common pharmacy practices, to review medications carried by EMS agencies to identify situations that may lead to medication error and to determine some best practices that may reduce potential errors and the risk of patient harm. OBJECTIVE: To provide a descriptive account of EMS practices related to carrying and storing medications that have the potential for causing a medication administration error or patient harm. METHODS: Using a structured process for inspection, an emergency medicine pharmacist and emergency physician(s) reviewed the medication carrying and storage practices of all nine advanced life support ambulance agencies within a five-county EMS region. Each medication carried and stored by the EMS agency was inspected for predetermined and spontaneously observed issues that could lead to medication error. These issues were documented and photographed. Two EMS medical directors reviewed each potential error for the risk of producing patient harm and assigned each to a category of high, moderate, or low risk. Because issues of temperature on EMS medications have been addressed elsewhere, this study concentrated on potential for EMS medication administration errors exclusive of storage temperatures. RESULTS: When reviewing medications carried by the nine EMS agencies, 38 medication safety issues were identified (range 1 to 8 per EMS agency). Of these, 16 were considered to be high risk, 14 moderate risk, and eight low risk for patient harm. Examples of potential issues included carrying expired medications, container-labeling issues, different medications stored in look-alike vials or prefilled syringes in the same compartment, and carrying crystalloid solutions next to solutions premixed with a medication. When reviewing medications stored at the EMS agency stations, eight safety issues were identified (range from 0 to 4 per station), including five moderate-risk and three low-risk issues. No agency had any high-risk medication issues related to storage of medication stock in the station. CONCLUSION: We observed potential medication safety issues related to how medications are carried and stored at all nine EMS agencies in a five-county region. Understanding these issues may assist EMS agencies in reducing the potential for a medication error and risk of patient harm. More research is needed to determine whether following these suggested best practices for carrying medications on EMS vehicles actually reduces errors in medication administration by EMS providers or decreases patient harm.

Traumatic dissection of the internal carotid artery.

We present the case of an 11-year-old male who had a dissection of his left internal carotid artery following a rather innocuous mechanism of injury. Although this phenomenon is documented in the medical literature, it remains a relatively rare event following blunt injury to the head and neck (0.3% occurrence rate in 1 study spanning 7 years). (Despite its rarity, it remains an important cause of cerebrovascular accidents in children. 2) Children presenting with gross neurologic abnormalities following blunt trauma to the head or neck should be considered to have sustained injury to the carotid arteries until proven otherwise.