title: REACTED - Reducing Acute Chest pain Time in the ED: A prospective pre-/post-interventional cohort study, stratifying risk using early cardiac multi-markers, probably increases discharges safely.
abstract: OBJECTIVE
  ED chest pain assessments can be challenging, lengthy and contribute to overcrowding. Rapid accurate risk stratification strategies should improve ED length of stay (EDLOS). Emergency, Biochemistry and Cardiology implemented new guidelines using paired (<3 h) multiple cardiac markers to stratify patients. The intervention would reduce chest pain EDLOS. We observed for safety and disposition effects.
  
  
  METHODS
  This is a single-site, prospective observational, before and after intervention study. In December 2009, paired multiple cardiac markers, the second at least 4 h from pain, replaced late troponins. The 4 h rule (ED flow improvement) started in April 2009 (unplanned confounder). Demographics, clinical features, risk assessment and disposition; preferably prospective. Administrative datasets provided disposition outcomes, 4 months pre-/post-intervention. Follow up with partially blinded adjudications assessed for 45 day major adverse cardiac events (MACE). Before intervention, consecutive patients were enrolled with mixed prospective/retrospective data. After, sampling occurred whenever prospective data were collected.
  
  
  RESULTS
  Adjudicated patients were n = 1029 (14.2% MI, 14.9% MACE), 426 before, 603 after. EDLOS reduced 87 min (416-329; P < 0.001), similar to triage 2 patients without chest pain. Possibly, avoidable MACE occurred in five of 598 discharges (0.8%, CI 0.3-1.8%) with non-significant decreases (0.5%, CI 0.1-1.8%) post-intervention. Disposition changes included greater observation ward use (3.8-12.3%; P < 0.001), more discharges (47.4-52.9%, P = 0.002), less transfers (9.3-6.9%, P = 0.014) and less late inpatient discharge decisions (15.2-8.7%, P = 0.001).
  
  
  CONCLUSIONS
  Paired cardiac markers performed adequately for avoidable MACE, and disposition improved significantly. A confounding system change meant the reduced EDLOS (primary outcome) was unable to be associated with the intervention.
authors.affiliation: School of Primary, Aboriginal and Rural Health Care (Emergency), University of Western Australia, Perth, Western Australia, Australia.|Department of Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Mountain
authors.affiliation: School of Primary, Aboriginal and Rural Health Care (Emergency), University of Western Australia, Perth, Western Australia, Australia.|Department of Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
authors.forename: Tor
authors.initials: T
authors.lastname: Ercleve
authors.affiliation: School of Primary, Aboriginal and Rural Health Care (Emergency), University of Western Australia, Perth, Western Australia, Australia.|Department of Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Allely
authors.affiliation: School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.|Department of Cardiovascular Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
authors.forename: Brendan
authors.initials: B
authors.lastname: McQuillan
authors.affiliation: Department of Cardiovascular Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
authors.forename: Eric
authors.initials: E
authors.lastname: Yamen
authors.affiliation: School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia.|Department of Biochemistry, Pathwest, Perth, Western Australia, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Beilby
authors.affiliation: School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia.|Department of Biochemistry, Pathwest, Perth, Western Australia, Australia.
authors.forename: Ee-Mun
authors.initials: EM
authors.lastname: Lim
authors.affiliation: Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Western Australia, Australia.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Rogers
authors.affiliation: School of Population Health, University of Western Australia, Perth, Western Australia, Australia.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Geelhoed
mesh_terms: D000208:Acute Disease; D000368:Aged; D015415:Biomarkers / Q000097:blood*; D002637:Chest Pain / Q000175:diagnosis* / Q000628:therapy*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data*; D061214:Patient Safety; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012189:Retrospective Studies; D018570:Risk Assessment; D014336:Troponin / Q000097:blood*; D014904:Western Australia
chemical_list: D015415:Biomarkers; D014336:Troponin
keywords: chest pain; emergency service; hospital; patient discharge; risk assessment; troponin