Cardiology consultation reduces provocative testing rates in an ED observation unit.
BACKGROUND
In evaluating patients with chest pain, emergency department observation units (EDOUs) may use a staffing model in which emergency physicians determine patient testing (EP model) or a model similar to a chest pain unit (CPU) in which cardiologists determine provocative testing (CPU model).


METHODS
We performed a prospective study with 30-day telephone follow-up for all chest pain patients placed in our EDOU. Halfway through the study period, our EDOU transitioned from an EP model to a CPU model. We compared provocative testing rates and outcomes between the 2 models.


RESULTS
Over the 34-month study period, our EDOU evaluated 1190 patients for chest pain. Patients placed in the EDOU during the 17-month CPU model were more likely to be moderate risk (Thrombolysis in Myocardial Infarction score 3-5) than those during the 17-month EP model: 24.9% vs 18.8%, P = .011. Despite this difference, rates of provocative testing (stress testing or coronary computed tomography) were lower during the CPU model: 47.1% vs 56.5%, P = .001. This reduction was particularly evident among low-risk patients (Thrombolysis in Myocardial Infarction score 0-2): 49.8% vs 58.1%, P = .011. Rates of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft were similar between the 2 groups (2.8% vs 3.2%, P = .140). We noted no significant events or missed diagnoses in either group during the 30-day follow-up.


CONCLUSIONS
An EDOU model that used mandatory cardiology consultation resulted in decreased provocative testing, particularly among low-risk chest pain patients. Future research should explore the cost-effectiveness of this model.
University of Utah School of Medicine, Salt Lake City, UT. Electronic address: troy.madsen@hsc.utah.edu.
Troy
T
Madsen
University of Utah School of Medicine, Salt Lake City, UT.
Cameron
C
Smyres
University of Utah School of Medicine, Salt Lake City, UT.
Talmage
T
Wood
University of Utah School of Medicine, Salt Lake City, UT.
Tamara
T
Moores
University of Utah School of Medicine, Salt Lake City, UT.
Matthew
M
Fuller
University of Utah School of Medicine, Salt Lake City, UT.
Virgil
V
Davis
University of Utah School of Medicine, Salt Lake City, UT.
Kurt
K
Bernhisel
D000328:Adult; D000368:Aged; D002309:Cardiology; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D000072226:Computed Tomography Angiography / Q000706:statistics & numerical data*; D017023:Coronary Angiography / Q000706:statistics & numerical data*; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D004635:Emergency Medicine; D004636:Emergency Service, Hospital; D005080:Exercise Test / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D019370:Observation; D062645:Percutaneous Coronary Intervention; D011446:Prospective Studies; D012017:Referral and Consultation; D018570:Risk Assessment