title: Implementation of a Risk Stratification and Management Pathway for Acute Chest Pain in the Emergency Department.
abstract: Chest pain is a common complaint in the emergency department, and a small but important minority represents an acute coronary syndrome (ACS). Variation in diagnostic workup, risk stratification, and management may result in underuse, misuse, and/or overuse of resources.
  
  
  
  From July to October 2014, we conducted a prospective cohort study in an academic medical center by implementing a Standardized Clinical Assessment and Management Plan (SCAMP) for chest pain based on the HEART score. In addition to capturing adherence to the SCAMP algorithm and reasons for any deviations, we measured troponin sample timing; rates of stress test utilization; length of stay (LOS); and 30-day rates of revascularization, ACS, and death.
  
  
  
  We identified 239 patients during the enrollment period who were eligible to enter the SCAMP, of whom 97 patients were entered into the pathway. Patients were risk stratified into one of 3 risk tiers: high (n = 3), intermediate (n = 40), and low (n = 54). Among low-risk patients, recommendations for troponin testing were not followed in 56%, and 11% received stress tests contrary to the SCAMP recommendation. None of the low-risk patients had elevated troponin measurements, and none had an abnormal stress test. Mean LOS in low-risk patients managed with discordant plans was 22:26 h/min, compared with 9:13 h/min in concordant patients (P < 0.001). Mean LOS in intermediate-risk patients with stress testing was 25:53 h/min, compared with 7:55 h/min for those without (P < 0.001). At 30 days, 10% of intermediate-risk patients and 0% of low-risk patients experienced an ACS event (risk difference 10% [0.7%-19%]); none experienced revascularization or death. The most frequently cited reason for deviation from the SCAMP was lack of confidence in the tool.
  
  
  
  Compliance with SCAMP recommendations for low- and intermediate-risk patients was poor, largely due to lack of confidence in the tool. However, in our study population, outcomes suggest that deviation from the SCAMP yielded no additional clinical benefit while significantly prolonging emergency department LOS.
authors.affiliation: From the *Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; †Department of Medicine, Brigham and Women's Hospital, Boston, MA; ‡Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC; §Center for Healthcare Delivery Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and ¶Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA.
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Baugh
authors.forename: Jeffrey O
authors.initials: JO
authors.lastname: Greenberg
authors.forename: Simon A
authors.initials: SA
authors.lastname: Mahler
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Kosowsky
authors.forename: Jeremiah D
authors.initials: JD
authors.lastname: Schuur
authors.forename: Siddharth
authors.initials: S
authors.lastname: Parmar
authors.forename: George R
authors.initials: GR
authors.lastname: Ciociolo
authors.forename: Christina W
authors.initials: CW
authors.lastname: Carr
authors.forename: Roya
authors.initials: R
authors.lastname: Ghazinouri
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Scirica
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D000368:Aged; D000465:Algorithms; D002637:Chest Pain / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D019091:Critical Pathways / Q000592:standards*; D003657:Decision Making; D019468:Disease Management; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D058996:Quality Improvement; D018570:Risk Assessment; D012307:Risk Factors