Maryland's first inpatient chest pain short stay unit as an alternative to emergency room-based observation unit

Approximately 8 million people in the United States visit emergency rooms (ERs) annually for chest pain but only about 1.2 million were ultimately diagnosed with acute myocardial infarction. Of concern, up to 4% to 5% of patients with acute myocardial infarction are those inappropriately discharged from the ER. ER-based observation units (EROU) were developed to enable safe, expedited, and effective management of these patients with negative initial workup. In the state of Maryland, the unique reimbursement system serves as a disincentive to operate EROU. The inpatient chest pain short stay unit (CPSSU) at St. Agnes hospital is the first in Maryland dedicated to evaluating patients with chest pain. We study the performance of CPSSU as compared with that of EROU.

The project is a prospective observational study that involved consecutive patients presenting to St. Agnes ER with the primary complaint of chest pain between June 1, 2005 and November 30, 2005. After negative initial electrocardiograms and cardiac enzymes, the patients were further evaluated using a standard CPSSU protocol in ER or CPSSU. Primary outcome variables were myocardial infarction or death.

A total of 332 patients were enrolled among which 202 were worked up in ER and 130 in CPSSU. There were no deaths and only 1 patient with significant coronary artery disease, representing 0.3% of study population was missed. Thirteen patients (3.9%) were detected with significant coronary artery disease. Severe 3 vessel disease was found in 4 (1.2%) patients. Median cost (and revenue) of evaluation in ER and CPSSU was $978.323 ($1203.533) and $1543.287 ($2947.85), respectively.

Inpatient CPSSU initiative is an effective alternative to EROU for evaluating chest pain patients with negative initial workup. Furthermore, this is achieved with net profit gain of $1744.37 over that of EROU evaluation.