Evaluation of chest pain in the ED: factors affecting triage decisions

The emergency physician's (EP) fast and correct diagnosis of patients with chest pain is crucial for preventing inappropriate discharge and dire consequences. To determine which factors affect admission decisions in the ED, we studied epidemiologic characteristics of both discharged and admitted patients, and the percentage of discharged patients who returned to the ED with acute myocardial infarction. The study included 185 patients seen in the ED because of chest pain between July 1 and 31, 1997 (every third day not included). Ninety patients were admitted: 36.7% were admitted for "observation of chest pain" and 63.3% met the criteria for active coronary heart disease. A form was used to collect personal data, medical history, risk factors, clinical examination, electrocardiogram interpretation, laboratory data, and admittance decision. EPs' diagnosis of cardiac chest pain demonstrated a sensitivity of 93.4%, a specificity of 73.4%, and a positive predictive value of 63.3%. Sensitivity for diagnosing acute myocardial infarct was 100%, with no erroneous discharges. The EP's ability to integrate the medical history information, including risk factors and pain characteristics, had a marked influence on the admittance decision. Efforts to reduce missed diagnoses are warranted.