title: Adherence to an Accelerated Diagnostic Protocol for Chest Pain: Secondary Analysis of the HEART Pathway Randomized Trial.
abstract: OBJECTIVE
  Accelerated diagnostic protocols (ADPs), such as the HEART Pathway, are gaining popularity in emergency departments (EDs) as tools used to risk stratify patients with acute chest pain. However, provider nonadherence may threaten the safety and effectiveness of ADPs. The objective of this study was to determine the frequency and impact of ADP nonadherence.
  
  
  METHODS
  A secondary analysis of participants enrolled in the HEART Pathway RCT was conducted. This trial enrolled 282 adult ED patients with symptoms concerning for acute coronary syndrome without ST-elevation on electrocardiogram. Patients randomized to the HEART Pathway (N = 141) were included in this analysis. Outcomes included index visit disposition, nonadherence, and major adverse cardiac events (MACEs) at 30 days. MACE was defined as death, myocardial infarction, or revascularization. Nonadherence was defined as: 1) undertesting-discharging a high-risk patient from the ED without objective testing (stress testing or coronary angiography) or 2) overtesting-admitting or obtaining objective testing on a low-risk patient.
  
  
  RESULTS
  Nonadherence to the HEART Pathway occurred in 28 of 141 patients (20%, 95% confidence interval [CI] = 14% to 27%). Overtesting occurred in 19 of 141 patients (13.5%, 95% CI = 8% to 19%) and undertesting in nine of 141 patients (6%, 95% CI = 3% to 12%). None of these 28 patients suffered MACE. The net effect of nonadherence was 10 additional admissions among patients identified as low-risk and appropriate for early discharge (absolute decrease in discharge rate of 7%, 95% CI = 3% to 13%).
  
  
  CONCLUSIONS
  Real-time use of the HEART Pathway resulted in a nonadherence rate of 20%, mostly due to overtesting. None of these patients had MACE within 30 days. Nonadherence decreased the discharge rate, attenuating the HEART Pathway's impact on health care use.
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Simon A
authors.initials: SA
authors.lastname: Mahler
authors.affiliation: Department of Internal Medicine Division of Cardiology, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Riley
authors.affiliation: Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Gregory B
authors.initials: GB
authors.lastname: Russell
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Hiestand
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: James W
authors.initials: JW
authors.lastname: Hoekstra
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Cedric W
authors.initials: CW
authors.lastname: Lefebvre
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Bret A
authors.initials: BA
authors.lastname: Nicks
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: David M
authors.initials: DM
authors.lastname: Cline
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Kim L
authors.initials: KL
authors.lastname: Askew
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: John
authors.initials: J
authors.lastname: Bringolf
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Stephanie B
authors.initials: SB
authors.lastname: Elliott
authors.affiliation: Department of Internal Medicine Division of Cardiology, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: David M
authors.initials: DM
authors.lastname: Herrington
authors.affiliation: Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Gregory L
authors.initials: GL
authors.lastname: Burke
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Chadwick D
authors.initials: CD
authors.lastname: Miller
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000628:therapy; D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000175:diagnosis* / Q000628:therapy; D002985:Clinical Protocols / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis; D010043:Outcome and Process Assessment, Health Care; D018570:Risk Assessment / Q000379:methods