title: Implementation of a Clinical Pathway for Chest Pain in a Pediatric Emergency Department.
abstract: OBJECTIVE
  To evaluate the impact of a pediatric emergency department (ED) chest pain clinical pathway on resource utilization.
  
  
  METHODS
  Motivated by perceived overuse of cardiology consultation for non-cardiac chest pain in the ED, clinicians from the Divisions of Cardiology and Emergency Medicine collaboratively developed a chest pain clinical pathway, educated staff, and implemented the pathway on March 1, 2014. We reviewed records of children aged 3 to 18 years without prior diagnoses of heart disease who presented to the ED with chest pain between March 1, 2013, and April 22, 2015. We compared diagnostic testing rates, ED length of stay, and cardiology consults before and after implementation of the pathway.
  
  
  RESULTS
  A total of 1687 patients were pathway eligible (675 patients preimplementation and 1012 postimplementation). Resource utilization was lower than expected before pathway implementation and remained low after implementation. There was a statistically significant reduction in rates of chest x-ray ordering after pathway implementation and ED length of stay but no change in other diagnostic testing or cardiology consultation. Follow-up in our health care system for pediatric chest pain increased from 15% to 29% with implementation, but none of these visits resulted in the diagnosis of a new cardiac condition. There were no instances identified where use of the pathway resulted in missed cardiac disease.
  
  
  CONCLUSIONS
  Implementation of a clinical pathway for pediatric chest pain did lead to a reduction in chest x-ray ordering in the ED and was associated with a higher rate of outpatient follow up for non-pathologic chest pain. Preimplementation utilization was lower than the prepathway perceptions of overuse suggested.
authors.forename: Shaun
authors.initials: S
authors.lastname: Mohan
authors.affiliation: Division of Cardiology.
authors.forename: Deipanjan
authors.initials: D
authors.lastname: Nandi
authors.affiliation: Division of Cardiology.
authors.forename: Paul
authors.initials: P
authors.lastname: Stephens
authors.affiliation: Division of Emergency Medicine, and.
authors.forename: Mirna
authors.initials: M
authors.lastname: MʼFarrej
authors.affiliation: Division of Cardiology.
authors.forename: R Lee
authors.initials: RL
authors.lastname: Vogel
authors.affiliation: Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Bonafide
mesh_terms: D000293:Adolescent; D002637:Chest Pain / Q000175:diagnosis*; D002648:Child; D002675:Child, Preschool; D019091:Critical Pathways / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D065228:Non-Randomized Controlled Trials as Topic; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data