title: Redesigning the diagnostic pathway for chest pain patients in emergency departments.
abstract: Patients presenting with chest pain at an emergency department in the United Kingdom receive troponin tests to assess the likelihood of an acute myocardial infarction (AMI). Until recently, serial testing with two blood samples separated by at least six hours was necessary in order to analyse the change in troponin levels over time. New high-sensitivity troponin tests, however, allow the inter-test time to be shortened from six to three hours. Recent evidence also suggests that the new generation of troponin tests can be used to rule out AMI on the basis of a single test if patients at low risk of AMI present with very low cardiac troponin levels more than three hours after onset of worst pain. This paper presents a discrete event simulation model to assess the likely impact on the number of hospital admissions if emergency departments adopt strategies for serial and single testing based on the use of high-sensitivity troponin. Data sets from acute trusts in the South West of England are used to quantify the resulting benefits.
authors.affiliation: University of Exeter, Medical School, St Luke's Campus, Exeter, EX1 2LU, UK. s.rachuba@exeter.ac.uk.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Rachuba
authors.affiliation: University of Exeter, Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Salmon
authors.affiliation: University of Exeter, Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
authors.forename: Zhivko
authors.initials: Z
authors.lastname: Zhelev
authors.affiliation: University of Exeter, Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Pitt
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000097:blood / Q000175:diagnosis*; D003198:Computer Simulation; D019091:Critical Pathways; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D004739:England; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis*; D019209:Troponin C / Q000097:blood*
chemical_list: D015415:Biomarkers; D019209:Troponin C
keywords: Avoidable admissions; Case study; Chest pain; Diagnostic pathways; Discrete event simulation; Emergency department