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Coagulation Studies are Frequently Ordered in Emergency Department Chest Pain Patients and do not Change Emergency
Jarryd Rivera1, Samidha Dutta1, Karly Castellaw2
1Southern Ohio Medical Center, Department of Internal Medicine, Portsmouth, OH.
Insights
Routine coagulation panels are frequently ordered for emergency department chest pain evaluations, despite evidence showing they are often unnecessary and do not alter patient management. This study found most ordered tests were not indicated and abnormal results rarely changed care.
Area of Science:
- Emergency Medicine
- Clinical Practice Guidelines
- Diagnostic Testing
Background:
- Coagulation panels are commonly ordered in emergency departments (EDs) for chest pain evaluations.
- Existing research indicates these tests are often unnecessary and do not impact patient management.
- There is a gap in understanding the current clinical practice regarding these orders.
Purpose of the Study:
- To determine the frequency of coagulation studies (prothrombin time [PT]/international normalized ratio [INR]) in ED chest pain patients.
- To assess if ordered coagulation tests are clinically indicated based on patient conditions or medications.
- To evaluate if abnormal coagulation results lead to changes in ED management.
Main Methods:
- Retrospective chart review of 830 chest pain patients across three rural EDs.
- Data abstraction by blinded medical students to assess test indication (preexisting conditions, warfarin use).
- Evaluation of whether abnormal results prompted therapeutic interventions or management changes.
Main Results:
- Coagulation panels were performed in 53.0% of analyzed chest pain patients.
- Only 12.5% of ordered coagulation tests were clinically indicated.
- Among patients without indications, 1.8% had elevated INR, and none experienced a change in ED management.
Conclusions:
- Over half of ED chest pain patients undergo coagulation testing, with most lacking clear indications.
- Abnormal coagulation results in non-indicated cases do not typically alter emergency department management.
- This highlights a persistent deviation from evidence-based practice in ED chest pain protocols.
Background:
Despite research findings, implementation into clinical practice is often delayed. Coagulation panels are still ordered as part of an emergency department (ED) chest pain evaluation, despite multiple studies showing that it is unnecessary and does not change management.
Objective:
Our primary outcome is to determine if the practice of ordering coagulation studies (prothrombin time [PT]/international normalized ratio [INR]) is still occurring in ED chest pain patients. Our secondary outcome is to determine if abnormal results change management.
Methods:
We performed an institutional review board (IRB) approved retrospective chart review of patients with chest pain presenting to three rural-community EDs over 49 months. Medical students, blinded to the study intent, performed data abstraction using the approach of Gilbert and Lowenstein to determine if coagulation testing (PT/INR) was "indicated" based on a preexisting condition (i.e., liver disease) or medication use (warfarin). Next, the data abstractors determined if the abnormal coagulation results prompted a therapeutic intervention or change in the management in the ED.
Results:
We randomly identified 1,200 patients with chest pain before covid-19 and, after exclusions, analyzed 830 patient charts. 440 patients (53.0%) had coagulation panels completed, but they were only indicated in 55 of the 440 patients (12.5%). Of the 385 patients without indications, 378 (98.2%) had an INR level in the normal range and 7 patients (1.8%) had an elevated INR. None of these 7 patients had a change in ED management.
Conclusions:
In this multicenter study, 53% of ED patients with chest pain had coagulation studies ordered. Only 12.5% were indicated. None of the abnormal results in patients without indications resulted in a change in ED management.
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