Improving Management of Chest Pain with a High Sensitivity Troponin-Based Protocol

Area of Science:

• Emergency Medicine
• Cardiology
• Clinical Diagnostics

Background:

• Chest pain is a frequent emergency department (ED) complaint, necessitating accurate and efficient diagnosis of cardiac conditions like myocardial infarction.
• Traditional troponin assays have limitations in sensitivity and speed, impacting patient disposition and diagnostic timelines.
• High-sensitivity troponin (hs-cTn) assays offer improved detection at lower levels, potentially accelerating diagnosis and management.

Purpose of the Study:

• To implement and evaluate a quality improvement project for managing chest pain patients in an ED setting.
• To assess the impact of a high-sensitivity troponin assay combined with a risk prediction algorithm on patient care and resource utilization.
• To address barriers to adoption and optimize the workflow for chest pain evaluation.

Main Methods:

• A community-academic health system implemented a standardized protocol for chest pain workup utilizing a high-sensitivity troponin assay and a risk prediction algorithm (Heart, EKG, Age, Risk factor, Troponin score).
• Key stakeholders identified and addressed barriers including provider strategy, electronic medical record integration, and cardiology service capacity.
• Interventions included stakeholder buy-in, regular data reporting, team meetings, and comprehensive education to drive changes in practice.

Main Results:

• A 12-month post-implementation period involving 3293 patients showed a significant decrease in mean ED length of stay for chest pain from 297 to 274 minutes (P=0.03).
• Hospital observation admissions for chest pain decreased from 23% to 14% (P<0.001), alongside reductions in stress tests (12 to 3/month), echocardiograms (61 to 46/month), cardiology consultations (125 to 81/month), and cardiac catheterizations (41 to 32/month).
• Significant reductions in testing and admissions were observed across multiple cardiac diagnostic modalities (P<0.001 for most).

Conclusions:

• Implementing a standardized chest pain management protocol with a high-sensitivity troponin assay and risk score effectively reduced ED length of stay and hospital observation admissions.
• The protocol led to a significant decrease in unnecessary cardiac testing and consultations, optimizing resource allocation.
• Standardized protocols and physician leadership are high-impact interventions for improving chest pain management in the ED.