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Redesigning the diagnostic pathway for chest pain patients in emergency departments
Sebastian Rachuba1, Andrew Salmon2, Zhivko Zhelev2
1University of Exeter, Medical School, St Luke's Campus, Exeter, EX1 2LU, UK. s.rachuba@exeter.ac.uk.
Insights
New high-sensitivity troponin tests can shorten testing times for acute myocardial infarction (AMI). This may reduce hospital admissions by enabling faster rule-outs with single or serial testing strategies.
Area of Science:
- Cardiology
- Medical Diagnostics
- Health Services Research
Background:
- Chest pain evaluation in UK emergency departments relies on troponin testing to rule out acute myocardial infarction (AMI).
- Traditional serial troponin testing required a minimum six-hour interval between blood samples.
- Advancements in high-sensitivity troponin assays have emerged.
Purpose of the Study:
- To evaluate the impact of high-sensitivity troponin testing strategies on hospital admission rates.
- To compare the efficiency of shortened serial testing (3 hours) versus single-test strategies.
- To model the potential benefits of new troponin testing protocols in emergency care.
Main Methods:
- Development of a discrete event simulation model.
- Utilisation of data from acute trusts in the South West of England.
- Assessment of strategies employing serial and single high-sensitivity troponin testing.
Main Results:
- High-sensitivity troponin tests allow for a reduced six-hour to three-hour interval for serial testing.
- Single-test strategies may rule out AMI in low-risk patients with very low troponin levels.
- Simulation models the potential reduction in hospital admissions based on these new strategies.
Conclusions:
- Implementing high-sensitivity troponin testing strategies can optimize emergency department workflows.
- Faster diagnostic capabilities may lead to decreased unnecessary hospital admissions for chest pain.
- Further research can refine these models for broader clinical application.
Abstract:
Patients presenting with chest pain at an emergency department in the United Kingdom receive troponin tests to assess the likelihood of an acute myocardial infarction (AMI). Until recently, serial testing with two blood samples separated by at least six hours was necessary in order to analyse the change in troponin levels over time. New high-sensitivity troponin tests, however, allow the inter-test time to be shortened from six to three hours. Recent evidence also suggests that the new generation of troponin tests can be used to rule out AMI on the basis of a single test if patients at low risk of AMI present with very low cardiac troponin levels more than three hours after onset of worst pain. This paper presents a discrete event simulation model to assess the likely impact on the number of hospital admissions if emergency departments adopt strategies for serial and single testing based on the use of high-sensitivity troponin. Data sets from acute trusts in the South West of England are used to quantify the resulting benefits.