Impact of a chest-pain guideline on clinical decision-making.
OBJECTIVE
To evaluate the impact of a chest-pain guideline on clinical decision-making and medium-term outcomes of patients presenting to a hospital emergency department (ED) with non-traumatic chest pain.


METHODS
Before-and-after guideline implementation study.


METHODS
Bankstown-Lidcombe Hospital, Sydney, NSW (454-bed metropolitan teaching hospital), in the six-month periods before and after guideline implementation in February 2001.


METHODS
Patients presenting to the ED with non-traumatic chest pain who had chest-pain assessment forms completed by ED doctors, comprising 422/768 (54.9%) of those presenting before and 461/691 (66.7%) after guideline implementation.


METHODS
Appropriateness of admission/discharge decisions compared with decision of senior cardiologist based on guideline; death, recurrent chest pain, ED re-presentation and hospital readmission in the ensuing three months.


RESULTS
After guideline implementation, appropriate admission/discharge decisions increased significantly from 180/265 (68%) to 261/324 (81%) (difference, 13%; 95% CI, 6%-20%). The largest increase was for patients at moderate risk of death or acute myocardial infarction within six months, from 39/96 (38%) to 57/103 (55%) (difference, 18%; 95% CI, 4%-31%). Increases were seen for both junior doctors (interns and resident medical officers) (18%; 95% CI, 7%-30%) and senior doctors (11%; 95% CI, 2%-19%). Logistic regression showed that implementation of the guideline, seniority of assessing doctor and patient history of coronary disease were independent predictors of appropriate decisions. There was a significant decline in re-presentations to ED with recurrent chest pain in patients previously presenting with cardiac or possibly cardiac pain, from 46/201 (23%) before implementation to 32/247 (13%) after (difference, 210%; 95% CI, 217% to 23%).


CONCLUSIONS
The chest-pain guideline resulted in a significant improvement in clinical decision-making in the ED and reduced re-presentations with cardiac/possibly cardiac chest pain.
Boufous
Soufiane
S
South Western Sydney Area Health Service, Sydney, NSW, Australia.
Kelleher
Peter W
PW
Pain
Charles H
CH
Dann
Linda M
LM
Ieraci
Susan
S
Jalaludin
Bin B
BB
Gray
Anne-Louise
AL
Harris
Susan E
SE
Juergens
Craig P
CP
D000787:Angina Pectoris / Q000097:blood / Q000175:diagnosis* / Q000628:therapy; D002637:Chest Pain / Q000097:blood / Q000175:diagnosis* / Q000209:etiology; D003402:Creatine Kinase / Q000097:blood; D052279:Creatine Kinase, MB Form; D019091:Critical Pathways; D003657:Decision Making; D003937:Diagnosis, Differential; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007527:Isoenzymes / Q000097:blood; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000175:diagnosis* / Q000628:therapy; D010343:Patient Admission / Q000592:standards; D017410:Practice Guidelines as Topic / Q000592:standards*; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D016896:Treatment Outcome; D014218:Triage / Q000379:methods*; D019210:Troponin I / Q000097:blood
D007527:Isoenzymes; D019210:Troponin I; D003402:Creatine Kinase; D052279:Creatine Kinase, MB Form