Are we appropriately triaging patients with unstable angina?
BACKGROUND
It is uncertain how aggressively patients should be monitored and admitted to the hospital for chest pain syndromes and if the monitoring itself affects patient care, process, or outcomes. We assessed the appropriateness of care based on retrospective analysis of admission bed assignment (nonmonitored vs monitored) and Thrombolysis in Myocardial Infarction (TIMI) risk score in patients from the Global Unstable Angina Registry and Treatment Evaluation (GUARANTEE) Registry.


METHODS
Baseline characteristics, process of care, and outcomes were compared among 2939 patients admitted to 1 of 35 hospitals in the United States. Patients were stratified into low (0-2), intermediate (3 or 4), and high (5-7) risk based on TIMI risk score.


RESULTS
Among the patients, 92 (3%) were admitted to the cardiac care unit (CCU), 1602 (56%) were admitted to the telemetry unit, and 1163 (41%) were admitted to an unmonitored bed. Paradoxically, high-risk patients comprised only 1% of those in the CCU, 5% of those in telemetry, and 10% of those in nonmonitored units. Conversely, low-risk patients were 64% of those in the CCU, 53% of those in telemetry, and 42% of those in unmonitored beds. Procedures were done more often on patients admitted to nonmonitored units than those on telemetry or in the CCU irrespective of TIMI risk score.


CONCLUSIONS
This registry suggests that triage of patients does not routinely follow the risk-based approach suggested in the American College of Cardiology and American Heart Association guidelines and could therefore potentially lead to inefficiencies in care. Better implementation of risk stratification for acute coronary syndrome evaluation and management is necessary.
Gomberg-Maitland
Mardi
M
Advanced Heart Failure and Pulmonary Hypertension Program, University of Chicago Hospitals, Chicago, IL 60637, USA. mgomberg@medicine.bsd.uchicago.edu
Murphy
Sabina A
SA
Moliterno
David J
DJ
Cannon
Christopher P
CP
D000368:Aged; D000789:Angina, Unstable / Q000145:classification* / Q000175:diagnosis; D002637:Chest Pain / Q000175:diagnosis*; D003325:Coronary Care Units; D003937:Diagnosis, Differential; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods* / Q000706:statistics & numerical data; D009203:Myocardial Infarction / Q000175:diagnosis*; D010043:Outcome and Process Assessment, Health Care; D017410:Practice Guidelines as Topic; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013686:Telemetry; D014218:Triage