Association of a Novel Protocol for Rapid Exclusion of Myocardial Infarction With Resource Use in a US Safety Net
Rebecca Vigen1, Deborah B Diercks2, Ibrahim A Hashim3
1Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas.
Insights
A new high-sensitivity cardiac troponin T (hs-cTnT) protocol reduced emergency department (ED) dwell times and improved patient throughput. This approach enhances healthcare quality and safety for chest pain evaluations.
Area of Science:
- Emergency Medicine
- Cardiology
- Health Services Research
Background:
- High-sensitivity cardiac troponin T (hs-cTnT) assays are crucial for evaluating chest pain in the emergency department (ED).
- Optimizing ED protocols can mitigate overcrowding and improve resource utilization.
Purpose of the Study:
- To assess the impact of a novel hs-cTnT protocol on ED resource use and patient safety.
- The protocol integrated serial troponin measurements (0, 1, and 3 hours) with the modified HEART score.
Main Methods:
- Retrospective cohort study of 31,543 ED encounters at a large safety net hospital.
- Compared pre- and post-implementation periods of the hs-cTnT protocol (implemented December 2017).
- Analyzed ED dwell time, troponin-to-disposition time, patient disposition, and 30-day major adverse cardiac events.
Main Results:
- ED dwell time decreased significantly post-intervention (-4.69 min/month vs. -1.09 min/month pre-intervention).
- The rate of increase in troponin-to-disposition time slowed post-intervention.
- The proportion of patients discharged from the ED increased (48% to 54%).
- No significant difference in 30-day major adverse cardiac events was observed.
Conclusions:
- Implementation of a serial hs-cTnT protocol combined with the Modified HEART score effectively reduced ED dwell times.
- This protocol shows potential for improving ED efficiency and healthcare quality in chest pain management while maintaining safety.
- The findings support the adoption of similar protocols to address ED overcrowding.
Importance:
High-sensitivity cardiac troponin T (hs-cTnT) protocols for the evaluation of chest pain in the emergency department (ED) may reduce unnecessary resource use and overcrowding.
Objective:
To determine whether the implementation of a novel hs-cTnT protocol, which incorporated troponin values drawn at 0, 1, and 3 hours after ED presentation and the modified HEART score (history, electrocardiogram, age, risk factors), was associated with improvements in resource use while maintaining safety.
Design, Setting, And Participants:
This retrospective cohort study from Parkland Health and Hospital System, a large safety net hospital in Dallas, Texas, included data on 31 543 unique ED encounters in which patients underwent electrocardiographic and troponin testing from January 1, 2017, to October 16, 2018. The hs-cTnT protocol was implemented in December 2017.
Main Outcomes And Measures:
Resource use outcomes included trends in ED dwell time, troponin to disposition decision time (the difference between the first troponin draw time and the time an order was placed for inpatient admission, admission to observation, or discharge), and final patient disposition. Safety outcomes included readmission for myocardial infarction and death.
Results:
In 31 543 encounters, mean (SD) patient age was 54 (14.4) years and 14 675 patients (48%) were female. Department dwell time decreased by a mean of -1.09 (95% CI, -2.81 to 0.64) minutes per month in the preintervention period. The decline was steeper after the intervention (-4.69 [95% CI, -9.05 to -0.33] minutes per month) (P for interaction = .007). The troponin to disposition time was increasing in the preintervention period by 1.72 (95% CI, 1.08 to 2.36) minutes per month; postintervention, the mean difference increased more slowly (0.37 [95% CI, -1.25 to 1.99 minutes per month; P value for interaction = .007]). The proportion of patients discharged from the ED increased after the intervention (48% vs 54%, P < .001). Thirty-day major adverse cardiac event rates were low and did not differ before and after the intervention.
Conclusions And Relevance:
Implementation of a novel protocol incorporating serial hs-cTnT measurements over 3 hours with the Modified HEART Score was associated with reduction in ED dwell times and attenuation of temporal increases in time from troponin measurement to disposition. This or similar protocols to rule out myocardial infarction have the potential to reduce ED overcrowding and improve health care quality while maintaining safety.
More Related Videos
18:11A Research Method For Detecting Transient Myocardial Ischemia In Patients With Suspected Acute Coronary Syndrome Using Continuous ST-segment Analysis
Published on: December 28, 2012
09:21Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Related Concept Videos
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:30Acute Coronary Syndrome I: Introduction