Improving Management of Chest Pain with a High Sensitivity Troponin-Based Protocol.

Abstract

Chest pain is one of the most common presenting complaints to emergency departments in the United States, and management centers on identifying myocardial infarction or other forms of rare but problematic cardiac diagnoses. The high-sensitivity troponin assay can detect abnormal troponin elevations at 10- to 100-fold lower levels compared with traditional troponin assays and thus can allow faster time to disposition and diagnosis, yet adoption has not been universal. Implementing a high-sensitivity troponin protocol with a risk prediction algorithm can decrease the numbers of patients admitted, reduce unnecessary testing, and shorten patient stays in the emergency department. This quality improvement project was undertaken in a community-academic health system lacking a system-wide protocol to workup patients presenting with chest pain to the emergency department. Key stakeholders evaluated multiple barriers and identified measures, planned implementation of the new assay and its associated algorithm, led postimplementation data monitoring and analysis, and delivered progress reports to organizational leaders. Chest pain admissions were managed by hospitalists in the absence of a cardiology inpatient service. The most important barriers were found to be individual provider strategy, electronic medical record design, and the lack of capacity for cardiology evaluations in both inpatient and outpatient settings. Stakeholder buy-in, monthly data reports, team meetings, and widespread education were used to support the changes in ordering patterns and evaluation. Postimplementation, 3293 patients were assessed over a 12-month period. Baseline mean length of stay for chest pain in the emergency department decreased from 297 minutes (SD, 53) to 274 minutes (SD, 33; P = 0.03). Hospital chest pain observation admissions decreased from 23% to 14% of patients presenting with chest pain (P <0.001). Stress tests ordered for observation patients decreased from 12 per month to 3 (P <0.001). Similarly, in observation patients, echocardiograms decreased from 61 to 46 per month (P <0.001), cardiology consultation decreased from 125 per month to 81 (P <0.001), and cardiac catheterization decreased from 41 per month to 32 following the intervention (P = 0.003). Developing a standardized management protocol and selecting physician leaders to maintain and revise protocols were high-impact, low to moderate-effort interventions resulting in significant changes in practice. This study demonstrated that a high-sensitivity troponin assay, combined with a chest pain clinical management protocol based on the Heart, EKG, Age, Risk factor, Troponin score, was able to achieve a reduction in emergency department length of stay, a decrease in hospital observation admissions, and reduced cardiac testing in this patient population.