Emergency Department Implementation of a Multimodal Electronic Health Record-Integrated Clinical Intervention for...

In 2021, 7 professional organizations jointly released guidelines for chest pain evaluation advocating for use of high-sensitivity troponin (hs-cTnT) and structured clinical pathways.

We explored the impact of hs-cTnT recommendations on emergency department (ED) care quality, downstream testing, hospitalization, and standardization of physician practice after automated reflex testing alongside an accelerated diagnostic protocol.

A pre- and postobservational study in 9 EDs introduced hs-cTnT in February 2022. Adults with complaints suggestive of acute coronary syndrome were included. Primary outcomes were odds of troponin testing, ED discharge, and chest pain center observation; secondary outcomes included proportion of acute myocardial infarction diagnosis, odds of downstream testing, and changes in physician practice variation. Multivariable logistic regression was used adjusting for patient demographics and secular trends during the baseline period.

Of 68,301 visits in the 6-month preintervention period and 121,376 visits in the 12-month postintervention period, troponin was ordered 33,061 (48.4%) and 52,382 (43.2%), respectively. The intervention was associated with lower odds of troponin testing (odds ratio 0.79, 95% CI [0.76, 0.82]) and no difference in ED discharge (0.99 [0.95, 1.03]). There was increased odds of acute myocardial infarction diagnosis (1.17 [1.001, 1.36]), echocardiogram (1.08 [1.01, 1.15]), and cardiac catheterization (1.21 [1.07, 1.38]); decreased odds of cardiology consultation (0.88 [0.83, 0.93]); but no difference in stress testing (1.01 [0.87, 1.17]). Physicians with low preintervention discharge rates increased their discharge rates by 3.11% (2.9%, 3.3%) relative to peers.

hs-cTnT transition was associated with a decrease in troponin testing, varied effects on downstream cardiac testing, and a concurrent increase in diagnostic yield without appreciable impact upon ED disposition. Physicians with preintervention outlier practice moved toward department norms postintervention. Together, these findings suggest the intervention promoted diagnostic quality for ED patients with suspected acute coronary syndrome.