Reducing unnecessary coronary care unit admissions: a comparison of three decision aids

To determine whether published decision rules for ischemic heart disease have practical value in reducing unnecessary admissions to coronary care units.

Prospective cohort study.

A community hospital emergency room.

235 consecutive patients presenting to an emergency room with a chief complaint of chest pain.

Clinical information, including observations needed to use previously published decision aids, was collected on special forms at the time of the emergency room visit. Follow-up information was obtained from the medical records of patients who were admitted and by telephone interviews with patients who were discharged. The authors compared the residents' actual decisions with the predictions of the decision aids regarding their ability to predict complications (that is, to identify patients who needed admission or intensive care).

None of the decision aids could reduce unnecessary admissions without seriously increasing the rate of inappropriate discharges. However, within the clinically relevant subgroup of patients for whom the decision to admit or discharge was not obvious on clinical grounds (those without complications on presentation whom the residents chose not to discharge), the decision aids examined, used in combination to verify the need for admission, might have safely averted some unnecessary admissions.