Improved Utilization of Serial Testing Without Increased Admissions after Implementation of High-Sensitivity Troponin
Laura Warren1, Brett G Fischer2, Amos Shemesh3
1Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA.
Insights
Transitioning to high-sensitivity cardiac troponin (hs-cTn) increased serial testing and emergency department length of stay, with no significant impact on hospital admissions or revisits. This study evaluated the clinical and operational effects of hs-cTn implementation.
Area of Science:
- Cardiology
- Clinical Chemistry
- Health Services Research
Background:
- Guidelines recommend high-sensitivity cardiac troponin (hs-cTn) for myocardial infarction diagnosis.
- hs-cTn use is increasing, but clinical and operational impacts require further study.
- Previous research on hs-cTn yielded conflicting results due to methodologic limitations.
Purpose of the Study:
- To evaluate the impact of transitioning from conventional cardiac troponin (cTn) to hs-cTn.
- Assessed changes in test utilization, resource use, operational efficiency, and patient safety.
- Examined effects on emergency department (ED) length of stay (LOS) and hospital admission rates.
Main Methods:
- Retrospective cohort study in two New York City hospitals comparing pre- and post-hs-cTn transition periods.
- Included consecutive emergency department (ED) patients with at least one cTn test.
- Utilized a multifaceted hs-cTn intervention bundle including diagnostic algorithms, education, and enhanced electronic medical record and nursing interventions.
Main Results:
- The hs-cTn intervention significantly increased serial cTn testing by 48 percentage points.
- Associated with a modest increase in ED LOS (50 minutes).
- No significant association found with hospital admission probability or 72-hour ED revisit resulting in admission.
Conclusions:
- Implementation of an hs-cTn intervention bundle improved serial cTn testing.
- Observed a neutral effect on hospital admission probability.
- Noted a modest increase in ED length of stay, suggesting a need for workflow optimization.
Background:
Guidelines recommend high-sensitivity cardiac troponin (hs-cTn) for diagnosis of myocardial infarction. Use of hs-cTn is increasing across the U.S., but questions remain regarding clinical and operational impact. Prior studies have had methodologic limitations and yielded conflicting results.
Objective:
To evaluate the impact of transitioning from conventional cardiac troponin (cTn) to hs-cTn on test and resource utilization, operational efficiency, and patient safety.
Design:
Retrospective cohort study in two New York City hospitals during the months before and after transition from conventional cTn to hs-cTn at Hospital 1. Hospital 2 served as a control.
Participants:
Consecutive emergency department (ED) patients with at least one cTn test resulted.
Intervention:
Multifaceted hs-cTn intervention bundle, including a 0/2-h diagnostic algorithm for non-ST-elevation myocardial infarction, an educational bundle, enhancements to the electronic medical record, and nursing interventions to facilitate timed sample collection.
Main Measures:
Primary outcomes included serial cTn test utilization, probability of hospital admission, ED length of stay (LOS), and among discharged patients, probability of ED revisit within 72 h resulting in hospital admission. Multivariable regression models adjusted for age, sex, temporal trends, and interhospital differences.
Key Results:
The intervention was associated with increased use of serial cTn testing (adjusted risk difference: 48 percentage points, 95% CI: 45-50, P < 0.001) and ED LOS (adjusted geometric mean difference: 50 min, 95% CI: 50-51, P < 0.001). There was no significant association between the intervention and probability of admission (adjusted relative risk [aRR]: 0.99, 95% CI: 0.89-1.1, P = 0.81) or probability of ED revisit within 72 h resulting in admission (aRR: 1.1, 95% CI: 0.44-2.9, P = 0.81).
Conclusions:
Implementation of a hs-cTn intervention bundle was associated with an improvement in serial cTn testing, a neutral effect on probability of hospital admission, and a modest increase in ED LOS.
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