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An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense:
M A Gomez1, J L Anderson, L A Karagounis
1LDS Hospital, Salt Lake City, Utah 84143, USA.
Insights
A rapid emergency department protocol for ruling out myocardial ischemia significantly reduced hospital time and costs for low-risk chest pain patients. This approach maintained diagnostic accuracy, ensuring no myocardial infarction or unstable angina diagnoses were missed.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Services Research
Background:
- Missed diagnosis of myocardial infarction leads to high mortality.
- Routine hospital care for low-risk patients may be inefficient.
- Need for effective and cost-efficient diagnostic protocols in emergency settings.
Purpose of the Study:
- To evaluate an emergency department-based protocol for rapid rule-out of myocardial ischemia.
- To determine if the protocol reduces hospital time and expense while maintaining diagnostic accuracy.
- To compare the protocol's efficacy against routine hospital care and historical controls.
Main Methods:
- One hundred low-risk patients randomized to a rapid rule-out protocol (n=50) or routine care (n=50).
- Rapid protocol included serial enzyme testing, ECGs with ST monitoring, and predischarge exercise testing.
- Comparison with 160 historical control subjects.
Main Results:
- No myocardial infarction or unstable angina diagnoses were missed in either group.
- The rapid protocol significantly reduced hospital stay duration and charges compared to routine care.
- Patients in the rapid protocol group experienced shorter hospital stays and lower initial and 30-day charges.
Conclusions:
- The emergency department-based rapid protocol effectively rules out myocardial infarction and unstable angina.
- This protocol is more time- and cost-effective than routine hospital care for low-risk chest pain patients.
- The findings support the implementation of rapid diagnostic protocols in emergency departments.
Objectives:
We tested the hypothesis that an emergency department-based protocol for rapidly ruling out myocardial ischemia would reduce hospital time and expense but maintain diagnostic accuracy.
Background:
Patients with a missed diagnosis of myocardial infarction have a high mortality rate; however, providing routine hospital care to low risk patients may not be time- or cost-effective.
Methods:
One hundred low risk patients were entered into the study and randomized either to an emergency department-based rapid rule-out protocol (n = 50) or to routine hospital care (n = 50). Patients receiving routine care were managed by their attending physicians. The rapid protocol included serum enzyme testing at 0, 3, 6 and 9h, serial electrocardiograms with continuous ST segment monitoring and, if results were negative, a predischarge graded exercise test. Study patients were also compared with 160 historical control subjects.
Results:
Myocardial infarction or unstable angina occurred in 6% of patients within 30 days; no diagnoses were missed. By intention to treat analysis (n = 50 in each group), the hospital stay was shorter and charges were lower with the rapid protocol than with routine care (p = 0.001). Among patients in whom ischemia was ruled out, those assigned to the rapid protocol had a shorter hospital stay (median 11.9 vs. 22.8 h, p = 0.0001) and lower initial ($893 vs $1,349, p = 0.0001) and 30-day ($898 vs. $1,522, p = 0.0001) hospital charges than did patients given routine care. In historical control subjects, the hospital stay was longer (median 34.5 h, p = 0.001 vs. either group) and charges greater (median $2,063, p = 0.001, vs rapid protocol, p = 0.02, vs. routine care group).
Conclusions:
In low risk patients who present to the emergency department with chest pain, the rapid protocol ruled out myocardial infarction and unstable angina more quickly and cost-effectively than did routine hospital care.