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Hill J, Yang EH, Lefebvre D, Doran S, Graham M, van Diepen S, Raizman JE, Tsui AK, Rowe BH. Effect of a High-Sensitivity Troponin I and Associated Diagnostic Protocol on Emergency Department Length of Stay: A Retrospective Cohort Study. CJC Open 2023; 5:925-933. [PMID: 38204856 PMCID: PMC10774082 DOI: 10.1016/j.cjco.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/11/2023] [Indexed: 01/12/2024] Open
Abstract
Background The objective of this study was to assess the introduction of a high-sensitivity troponin I (hs-TnI) assay and its associated accelerated protocol on emergency department (ED) length of stay (LOS) for patients presenting with chest pain, compared to an accelerated diagnostic protocol using conventional troponin (TnI) testing. Methods We conducted a retrospective cohort study of all adults with a primary presenting complaint of chest pain of cardiac origin and a Canadian Triage and Acuity Scale score of 2 or 3, between November 8, 2019 and November 9, 2021, to a tertiary-care urban Canadian ED. The primary outcome was ED LOS. Secondary outcomes included consultation proportions and major adverse cardiac events within 30 days of the index ED visit. Results A total of 2640 patients presenting with chest pain were included, with 1333 in the TnI group and 1307 in the hs-TnI group. Median ED LOS decreased significantly, from 392 minutes for the TnI group, and 371 minutes for the hs-TnI group (median difference = 21 minutes; 95% confidence interval: 5.3, 36.7). The numbers of consultations and admissions were not statistically different between study periods. The major adverse cardiac events outcomes did not change following the implementation of the hs-TnI test (13.6% vs 13.1%; P = 0.71). Conclusions The implementation of an accelerated chest pain protocol using an hs-TnI assay in a tertiary-care Canadian ED was associated with a modest reduction of LOS for all patients, and a substantial reduction of LOS for patients undergoing serial troponin testing. This strategy was safe, with no increase in adverse outcomes.
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Affiliation(s)
- Jesse Hill
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Esther H. Yang
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- The Alberta Strategy for Patient-Oriented Research Support Unit, Alberta Health Services (AHS), Edmonton, Alberta, Canada
| | - Dennis Lefebvre
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Shandra Doran
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle Graham
- Mazankowski Heart Institute, Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Sean van Diepen
- Mazankowski Heart Institute, Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Joshua E. Raizman
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- Alberta Precision Laboratories (APL), Alberta Health Services (AHS), Edmonton, Alberta, Canada
| | - Albert K.Y. Tsui
- Department of Laboratory Medicine and Pathology, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- Alberta Precision Laboratories (APL), Alberta Health Services (AHS), Edmonton, Alberta, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Heart Institute, Division of Cardiology, Department of Medicine, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
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2
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McDonald SA, Peterson ED. The HEART Pathway: Just a HEART score permutation or the future of clinical decision rules? Acad Emerg Med 2022; 29:1037-1039. [PMID: 35635767 DOI: 10.1111/acem.14542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Samuel A McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eric D Peterson
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Musey PI, Bellolio F, Upadhye S, Chang AM, Diercks DB, Gottlieb M, Hess EP, Kontos MC, Mumma BE, Probst MA, Stahl JH, Stopyra JP, Kline JA, Carpenter CR. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. Acad Emerg Med 2021; 28:718-744. [PMID: 34228849 DOI: 10.1111/acem.14296] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/21/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022]
Abstract
This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.
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Affiliation(s)
- Paul I. Musey
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | | | - Suneel Upadhye
- Division of Emergency Medicine McMaster University Hamilton Canada
| | - Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA USA
| | - Deborah B. Diercks
- Department of Emergency Medicine UT Southwestern Medical Center Dallas TX USA
| | - Michael Gottlieb
- Department of Emergency Medicine Rush Medical Center Chicago IL USA
| | - Erik P. Hess
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Michael C. Kontos
- Department of Internal Medicine Virginia Commonwealth University Richmond VA USA
| | - Bryn E. Mumma
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA USA
| | - Marc A. Probst
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NY USA
| | | | - Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐SalemNC USA
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine and Emergency Care Research Core Washington University School of Medicine St. Louis MO USA
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4
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Ganguli I, Cui J, Thakore N, Orav EJ, Januzzi JL, Baugh CW, Sequist TD, Wasfy JH. Downstream Cascades of Care Following High-Sensitivity Troponin Test Implementation. J Am Coll Cardiol 2021; 77:3171-3179. [PMID: 34167642 DOI: 10.1016/j.jacc.2021.04.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with chest pain are often evaluated for acute myocardial infarction through troponin testing, which may prompt downstream services (cascades) of uncertain value. OBJECTIVES This study sought to determine the association of high-sensitivity cardiac troponin (hs-cTn) assay implementation with cascade events. METHODS Using electronic health record and billing data, this study examined patient-visits to 5 emergency departments from April 1, 2017, to April 1, 2019. Difference-in-differences analysis compared patient-visits for chest pain (n = 7,564) to patient-visits for other symptoms (n = 100,415) (irrespective of troponin testing) before and after hs-cTn assay implementation. Outcomes included presence of any cascade event potentially associated with an initial hs-cTn test (primary), individual cascade events, length of stay, and spending on cardiac services. RESULTS Following hs-cTn implementation, patients with chest pain had a 2.8% (95% confidence interval [CI]: 0.72% to 4.9%) net increase in experiencing any cascade event. They were more likely to have multiple troponin tests (10.5%; 95% CI: 9.0% to 12.0%) and electrocardiograms (7.1 per 100 patient-visits; 95% CI: 1.8 to 12.4). However, they received net fewer computed tomography scans (-1.5 per 100 patient-visits; 95% CI: -1.8 to -1.1), stress tests (-5.9 per 100 patient-visits; 95% CI: -6.5 to -5.3), and percutaneous coronary intervention (PCI) (-0.65 per 100 patient-visits; 95% CI: -1.01 to -0.30) and were less likely to receive cardiac medications, undergo cardiology evaluation (-3.5%; 95% CI: -4.5% to 2.6%), or be hospitalized (-5.8%; 95% CI: -7.7% to -3.8%). Patients with chest pain had lower net mean length of stay (-0.24 days; 95% CI: -0.32 to -0.16) but no net change in spending. CONCLUSIONS Hs-cTn assay implementation was associated with more net upfront tests yet fewer net stress tests, PCI, cardiology evaluations, and hospital admissions in patients with chest pain relative to patients with other symptoms.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Jinghan Cui
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nitya Thakore
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - James L Januzzi
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher W Baugh
- Harvard Medical School, Boston, Massachusetts, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. https://twitter.com/DrChrisBaugh
| | - Thomas D Sequist
- Harvard Medical School, Boston, Massachusetts, USA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Mass General Brigham, Boston, Massachusetts, USA. https://twitter.com/TomSequist
| | - Jason H Wasfy
- Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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5
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Ford JS, Chaco E, Tancredi DJ, Mumma BE. Impact of high-sensitivity cardiac troponin implementation on emergency department length of stay, testing, admissions, and diagnoses. Am J Emerg Med 2021; 45:54-60. [PMID: 33662739 DOI: 10.1016/j.ajem.2021.02.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE While high-sensitivity (hs) troponin (cTn) has been associated with shorter emergency department (ED) length of stay (LOS) and decreased hospital admissions outside the United States (US), concerns have been raised that it will have opposite effects in the US. In this study, we aimed to compare ED LOS, admissions, and acute coronary syndrome (ACS) diagnoses before and after the implementation of hs-cTn. METHODS We conducted a single-institution, retrospective study of two temporally matched six-month study periods before and after the implementation of hs-cTn. We included consecutive adults presenting with chest pain. The primary outcome was ED LOS, which was log transformed and analyzed using multiple linear regression. Binary secondary outcomes of admissions, cardiac testing, cardiology consultation, and ACS diagnoses were analyzed using multiple logistic regression. RESULTS We studied 1589 visits before and 1616 visits after implementation of hs-cTn. Median age and sex ratios were similar between study periods. Median ED LOS was longer in the post-implementation period [post: 384 (interquartile range, IQR 260-577) minutes; pre: 374 (IQR 250-564) minutes; adjusted geometric mean ratio 1.05; 95% confidence interval, CI 1.01-1.10)]. Admissions were lower in the post-implementation period [post: 24% (385/1616) vs. pre: 28% (447/1589); adjusted odds ratio, aOR 0.75 (95% CI 0.64-0.88)]. Cardiac risk stratification testing [pre: 9% (142/1589) vs post: 9% (144/1616); aOR 0.95 (95% CI 0.74-1.22)], cardiology consultation [pre: 13% (208/1589) vs post: 13% (207/1616); aOR 0.91 (95% CI 0.73-1.12)], and ACS diagnoses [pre: 7% (116/1589) vs post: 7% (120/1616); aOR 0.94 (95% CI 0.72-1.24)] were similar between the two study periods. CONCLUSION In this single-center study, transition to hs-cTn was associated with an increased ED LOS, decreased admissions, and no substantial change in cardiac risk stratification testing, cardiology consultation, or ACS diagnoses.
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Affiliation(s)
- James S Ford
- Department of Emergency Medicine, University of California, Davis, USA
| | - Ernestine Chaco
- Department of Emergency Medicine, University of California, Davis, USA
| | | | - Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis, USA.
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6
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Mumma BE, Casey SD, Dang RK, Polen MK, Kaur JC, Rodrigo J, Tancredi DJ, Narverud RA, Amsterdam EA, Tran N. Diagnostic Reclassification by a High-Sensitivity Cardiac Troponin Assay. Ann Emerg Med 2020; 76:566-579. [PMID: 32807538 PMCID: PMC7606506 DOI: 10.1016/j.annemergmed.2020.06.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/16/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Our objective is to describe the rates of diagnostic reclassification between conventional cardiac troponin I (cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) and between combined and sex-specific hs-cTnT thresholds in adult emergency department (ED) patients in the United States. METHODS We conducted a prospective, single-center, before-and-after, observational study of ED patients aged 18 years or older undergoing single or serial cardiac troponin testing in the ED for any reason before and after hs-cTnT implementation. Conventional cTnI and hs-cTnT results were obtained from a laboratory quality assurance database. Combined and sex-specific thresholds were the published 99th percentile upper reference limits for each assay. Cases underwent physician adjudication using the Fourth Universal Definition of Myocardial Infarction. Diagnostic reclassification occurred when a patient received a diagnosis of myocardial infarction or myocardial injury with one assay but not the other assay. Our primary outcome was diagnostic reclassification between the conventional cTnI and hs-cTnT assays. Diagnostic reclassification probabilities were assessed with sample proportions and 95% confidence intervals for binomial data. RESULTS We studied 1,016 patients (506 men [50%]; median age 60 years [25th, 75th percentiles 49, 71]). Between the conventional cTnI and hs-cTnT assays, 6 patients (0.6%; 95% confidence interval 0.2% to 1.3%) underwent diagnostic reclassification regarding myocardial infarction (5/6 reclassified as no myocardial infarction) and 166 patients (16%; 95% confidence interval 14% to 19%) underwent diagnostic reclassification regarding myocardial injury (154/166 reclassified as having myocardial injury) by hs-cTnT. CONCLUSION Compared with conventional cTnI, the hs-cTnT assay resulted in no clinically relevant change in myocardial infarction diagnoses but substantially more myocardial injury diagnoses.
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Affiliation(s)
- Bryn E Mumma
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA.
| | - Scott D Casey
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Robert K Dang
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Michelle K Polen
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Jasmanpreet C Kaur
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - John Rodrigo
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento CA
| | - Robert A Narverud
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Ezra A Amsterdam
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, Sacramento CA
| | - Nam Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, Sacramento, CA
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