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[Suspected acute coronary events in emergency room patients]
Insights
Accurate diagnosis of acute coronary events in emergency rooms is challenging. Implementing a triage algorithm can improve accuracy, reduce unnecessary hospital admissions for chest pain, and conserve resources.
Area of Science:
- Emergency Medicine
- Cardiology
- Diagnostic Accuracy
Background:
- Chest pain is a common emergency room complaint, making accurate diagnosis of acute coronary events critical.
- Current diagnostic practices lead to a high rate of unnecessary admissions for observation or to rule out myocardial infarction (MI).
- Unnecessary hospitalizations result in significant medical, psychological, and economic burdens.
Purpose of the Study:
- To evaluate the diagnostic accuracy of chest pain assessment in the emergency room.
- To determine the rate of unnecessary hospital admissions and unjustified discharges.
- To highlight the potential benefits of a triage algorithm in improving diagnostic accuracy and resource allocation.
Main Methods:
- A prospective study of 2280 patients presenting to the ER with chest pain.
- Follow-up of patients for 2 weeks to ascertain diagnoses and admission appropriateness.
- Analysis of admission rates to CCU and medical wards, and diagnostic outcomes.
Main Results:
- Of 2280 patients, 1362 were discharged, while 16.1% were admitted to CCU and 83.9% to medical wards.
- Acute myocardial infarction (AMI) was diagnosed in 64.6% of CCU admissions and 12.7% of medical ward admissions.
- Unnecessary hospitalizations were 10.2% in CCU and 29.8% in medical wards; unjustified ER discharges were 4.3%.
Conclusions:
- Current emergency room practices for chest pain evaluation result in substantial unnecessary hospitalizations.
- A validated triage algorithm could significantly improve the accuracy of differentiating coronary heart disease from other causes of chest pain.
- Improved diagnostic accuracy will lead to more efficient use of healthcare resources.
Abstract:
Identification of patients in whom chest pain is due to an acute coronary event is among the most challenging problems in emergency medicine. Because of the dangers of missing the diagnosis in patients with a possibly fatal condition, emergency room (ER) physicians often admit patients for 'observation' or 'to rule out MI.' As a result of such a policy, only 30-50% of such patients admitted to the CCU may finally be diagnosed as having an acute myocardial infarction (AMI), resulting in deleterious medical, psychological and economic consequences for the others. A series of 2280 patients who were referred to the ER was followed for 2 weeks. 1362 (59.7%) of those admitted were discharged; 16.1% were hospitalized in the CCU and 83.9% in medical wards. 95 (64.6%) of those hospitalized in the CCU and 97 (12.7%) of those admitted to medical wards had an AMI. The proportion of cases in which hospitalization was unnecessary was 10.2% in the CCU and 29.8% in the medical wards. Unjustified discharges from the ER were 4.3% of referrals. These data are similar to those reported from the USA and from our first study in 1969. It is hoped that by using a triage algorithm in the ER, differentiation between chest pain due to coronary heart disease and that due to other causes will be more accurate and therefore the demand on scarce resources due to unnecessary admissions will be substantially reduced.