Can a low-risk chest pain protocol reduce admission rates among patients presenting to the emergency department with chest pain? A quality project [abstract]
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Background: Chest pain is a common presenting complaint to the emergency department (ED) with high rates of hospital admission. The majority of patients presenting with chest pain have benign causes and admitting these patients represents a significant cost and resource burden. Objectives: In June 2011, we instituted a low-risk chest pain protocol aimed at reducing the rate of hospital admission of patients with chest pain of unclear etiology. The protocol included exercise stress testing the afternoon or morning after discharge from the ED with immediate interpretation by a cardiologist and appropriate follow-up assured. Patients were eligible for the protocol if they had a TIMI score of 0 or 1, had a normal or unchanged EKG, normal cardiac biomarkers and could walk on a treadmill. Methods: To evaluate the effectiveness of the protocol, the research team reviewed patient charts from all visits with chief complaint of chest pain from March 2011 to June 2011 (pre-implementation) and from March 2012 to June 2012 (post-implementation). Patients were included in analysis if they were evaluated by a physician who was working both before and after institution of the protocol and had seen at least 10 patients with chest pain. Results: There were 1,139 patient visits in the pre-intervention group and 1,113 in the post-intervention group. Thirty physicians were included during this period. The mean admission rate was significantly lower after the intervention, decreasing from 54% to 44% (odds ratio=1.50; 95% CI 1.26 - 1.77; p<0.001). During the same period, the incidence of acute coronary syndrome increased from 12% to 19%. In the patient group after the intervention, 118 patients were enrolled in the protocol. Twenty patients had TIMI scores greater than 1. Two stress tests showed evidence of ischemia leading to catheterization. One patient underwent PCI. No patient returned to the emergency department with acute coronary syndrome. Conclusion: After institution of a low-risk chest pain protocol, the admission rate decreased substantially despite an increase in the apparent acuity of patients. The protocol was utilized for a number of higher risk patients as well with no adverse events.