Feasibility of a rapid diagnostic protocol for an emergency department chest pain unit.
OBJECTIVE
To evaluate the applicability of a short-stay protocol for exclusion of acute ischemic heart disease without hospital admission and to analyze these results in the context of a conceptual model.


METHODS
An observational study of patients who presented with chest pain to the emergency department of an 886-bed inner-city municipal hospital and who needed hospital admission to rule out acute myocardial infarction (AMI). Patients were assessed by ED attending physicians to determine eligibility for an alternative, 12-hour protocol in an ED chest pain observation unit (CPOU) followed by immediate exercise testing. Outcome measures were proportion of patients eligible for the short-stay protocol, risk factor profile, and reasons for exclusion.


RESULTS
Of 500 patients screened, 446 had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% confidence interval [CI], 48.7% to 57.9%) were found to have low probability for AMI. After study exclusion criteria were applied to the patient cohort, 63 patients (14.1%; 95% CI, 10.9% to 17.3%) were eligible for the protocol. The most common reasons for exclusion were history of coronary artery disease (46%) and inability to perform an interpretable exercise tolerance test (42%).


CONCLUSIONS
Although most admitted patients with chest pain (53%) were at low probability for AMI, only a minority (14%) were eligible for a short-stay protocol that required patients to be free of known coronary artery disease and able to perform an exercise tolerance test. Factors affecting the operations and efficiency of a CPOU include clinical characteristics of the target patient population, protocol tests used, and hospital occupancy and reimbursement patterns.
Zalenski
R J
RJ
Department of Emergency Medicine, Cook County Hospital, Chicago, IL, USA. rzalensk@med.wayne.edu
Rydman
R J
RJ
McCarren
M
M
Roberts
R R
RR
Jovanovic
B
B
Das
K
K
Mensah
E K
EK
Kampe
L M
LM
D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D002637:Chest Pain / Q000191:economics / Q000209:etiology*; D002641:Chicago; D002985:Clinical Protocols; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital / Q000191:economics / Q000592:standards*; D005240:Feasibility Studies; D005260:Female; D006746:Hospital Bed Capacity, 500 and over; D006773:Hospitals, Municipal; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis* / Q000191:economics; D010043:Outcome and Process Assessment, Health Care; D018710:Pain Clinics / Q000191:economics / Q000592:standards*; D018579:Patient Selection; D012306:Risk; D012307:Risk Factors