Introducing a chest pain pathway in the emergency department to improve quality of care for patients with possible cardiac chest pain.
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ABSTRACT:
SUBMITTER: Byrne J
PROVIDER: S-EPMC4645935 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ObjectiveTo evaluate the impact of a pediatric emergency department (ED) chest pain clinical pathway on resource utilization.MethodsMotivated 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.ResultsA 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.ConclusionsImplementation 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.
| S-EPMC5359077 | biostudies-literature
Project description:Many patients who attend an emergency department (ED) with chest pain receive a diagnosis of non-cardiac chest pain (NCCP), and often suffer poor psychological outcomes and continued pain. This study assessed the role of illness representations in explaining psychological distress and continued chest pain in patients attending an ED.ED NCCP patients (N = 138) completed measures assessing illness representations, anxiety, depression and quality of life (QoL) at baseline, and chest pain at one month.Illness representations explained significant amounts of the variance in anxiety (Adj. R² = .38), depression (Adj. R² = .18) and mental QoL (Adj. R² = .36). A belief in psychological causes had the strongest associations with outcomes. At one month, 28.7% of participants reported experiencing frequent pain, 13.2% infrequent pain and 58.1% no pain. Anxiety, depression and poor QoL, but not illness representations, were associated with continued chest pain.The findings suggest that (i) continued chest pain is related to psychological distress and poor QoL, (ii) interventions should be aimed at reducing psychological distress and improving QoL and (iii) given the associations between perceived psychological causes and psychological distress/QoL, NCCP patients in the ED might benefit from psychological therapies to manage their chest pain.
| S-EPMC4192860 | biostudies-other
Project description:It is important that patients with symptoms of acute coronary syndrome receive appropriate medical care as soon as possible. Little is known about the preadmission actions that patients with chest pain take before arrival at the Emergency Department (ED).This study aimed to describe the actions of patients with chest pain or pressure after onset of symptoms. What is the first action following onset of symptoms? Who is the first lay or professional person to be contacted? Which steps are taken first? How is the patient transported to the hospital?Consecutive patients, arriving at the ED of two large hospitals in Belgium, were asked additional questions during the initial assessment.Overall, 35% of 412 consecutive patients with chest pain admitted to the ED were diagnosed with acute coronary syndrome. A total of 57% contacted a GP between symptom onset and arrival at the ED. Only 32% of the patients were transported to the ED by ambulance, 16% drove themselves and 52% arrived by other means of transport (by family, neighbour, GP, public transport).In Belgium, the GP is still the first professional to be contacted for most patients. Other patients initially rely on their partner, family or friends when symptoms emerge. Too often, patients with chest pain rely on other transport to get to the ED instead of calling the Emergency Medical Services. This study included only patients who ultimately attended the ED.
| S-EPMC5671801 | biostudies-other
Project description:BackgroundA big-data-driven and artificial intelligence (AI) with machine learning (ML) approach has never been integrated with the hospital information system (HIS) for predicting major adverse cardiac events (MACE) in patients with chest pain in the emergency department (ED). Therefore, we conducted the present study to clarify it.MethodsIn total, 85,254 ED patients with chest pain in three hospitals between 2009 and 2018 were identified. We randomized the patients into a 70%/30% split for ML model training and testing. We used 14 clinical variables from their electronic health records to construct a random forest model with the synthetic minority oversampling technique preprocessing algorithm to predict acute myocardial infarction (AMI) < 1 month and all-cause mortality < 1 month. Comparisons of the predictive accuracies among random forest, logistic regression, support-vector clustering (SVC), and K-nearest neighbor (KNN) models were also performed.ResultsPredicting MACE using the random forest model produced areas under the curves (AUC) of 0.915 for AMI < 1 month and 0.999 for all-cause mortality < 1 month. The random forest model had better predictive accuracy than logistic regression, SVC, and KNN. We further integrated the AI prediction model with the HIS to assist physicians with decision-making in real time. Validation of the AI prediction model by new patients showed AUCs of 0.907 for AMI < 1 month and 0.888 for all-cause mortality < 1 month.ConclusionsAn AI real-time prediction model is a promising method for assisting physicians in predicting MACE in ED patients with chest pain. Further studies to evaluate the impact on clinical practice are warranted.
| S-EPMC7488862 | biostudies-literature
Project description:BackgroundThe HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early discharge. No randomized trials have compared the HEART Pathway with usual care.Methods and resultsAdult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG (n=282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, emergency department providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for early discharge. Usual care was based on American College of Cardiology/American Heart Association guidelines. The primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay, early discharge, and major adverse cardiac events (death, myocardial infarction, or coronary revascularization), were assessed at 30 days by phone interview and record review. Participants had a mean age of 53 years, 16% had previous myocardial infarction, and 6% (95% confidence interval, 3.6%-9.5%) had major adverse cardiac events within 30 days of randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1% (68.8% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early discharges by 21.3% (39.7% versus 18.4%; P<0.001). No patients identified for early discharge had major adverse cardiac events within 30 days.ConclusionsThe HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases early discharges. These important efficiency gains occurred without any patients identified for early discharge suffering MACE at 30 days.Clinical trial registrationURL: http://www.clinicaltrials.gov. Unique Identifier: NCT01665521.
| S-EPMC4413911 | biostudies-literature
Project description:Background More than 4 million cardiac noninvasive diagnostic tests are performed annually in the United States. However, questions remain regarding their effectiveness in improving clinical outcomes. We sought to evaluate whether noninvasive diagnostic tests were associated with lower rates of myocardial infarction or cardiovascular death when compared with no testing. Methods and Results We performed a retrospective, population-based cohort study of adults evaluated for chest pain and discharged home from an emergency department in Ontario, Canada. Propensity score matching was employed to reduce confounding between the testing and nontesting groups. There were 370 863 patients evaluated in our cohort. Rates of the composite outcome were low for both groups after propensity-score matching (0.29% and 0.78% for the nontesting group at 90 days and 1 year, respectively, and 0.34% and 0.68% for the noninvasive diagnostic test group at 90 days and 1 year respectively). Over 1 year, patients undergoing noninvasive diagnostic testing had a small but statistically significant lower hazard of developing the composite outcome of myocardial infarction or cardiovascular mortality (hazard ratio, 0.87; 95% CI, 0.78-0.96 [P<0.01]), which appears to be driven by the high-risk subgroup (hazard ratio, 0.75; 95% CI, 0.61-0.92 [P<0.01]). Conclusions We report a lower observed rate of the composite outcome of cardiovascular death or myocardial infarction associated with noninvasive diagnostic testing following evaluation for chest pain in the emergency department. This lower rate was driven by the high-risk subgroup. These results suggest that risk-based testing should be considered for patients discharged from the emergency department for chest pain.
| S-EPMC6898808 | biostudies-literature
Project description:The aim of this study was to assess the frequency of chest pain presentations and the subsequent non-cardiac chest pain diagnoses in an emergency department (ED) over a 3 year period.Administrative data on ED attendances to an urban general hospital in Northern Ireland between March 2013 and March 2016 were used. Data were coded and analysed to estimate frequencies of 'chest pain' presentation and the subsequent diagnoses for each year.Both chest pain presentations and chest pain presentations with a subsequent diagnosis of unknown cause increased each year. In total, 58.7% of all chest presentations across 3 years resulted in a non-cardiac diagnosis of either 'anxiety', 'panic' or 'chest pain of unknown cause'.There is a significant amount of patients in the ED leaving with a non-cardiac diagnosis, following an initial presentation with chest pain.Given the link between non-cardiac chest pain and frequent use of services, the degree of repeat attendance should be investigated.
| S-EPMC5550987 | biostudies-other
Project description:ObjectivesA decrease in Emergency Department (ED) visits for cardiac conditions has recently been reported from the US and Western Europe due to the COVID-19 pandemic. The data are still scant, and the correlation between cardiac symptoms and confirmed diagnoses are not available. There are no reports on changes in ED volumes at a national level, or from countries in the Asia-Middle Eastern region. We report data from national referral centers for tertiary care and cardiac care centers in Qatar, which see > 80% of cardiac emergencies in the country.ResultsWe analyzed 102,033 ED visits in the COVID-19-era (March-April 2020 and 2019) and determined the proportion presenting for cardiac symptoms and their confirmed diagnoses. We observed a 16-37% decline in ED volumes overall, with a 25-50% decline in patients presenting with cardiac symptoms in March and April 2020 compared with March and April 2019. Among those presenting with cardiac symptoms, we observed a 24-43% decline in cardiac diagnoses in March and April 2020 compared with March and April 2019.
| S-EPMC7672168 | biostudies-literature
Project description:The management of patients with chest pain is a common and challenging clinical problem. Although most of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent management of a serious problem such as acute coronary syndrome (ACS) and those with more benign entities who do not require admission. Although clinical judgment continues to be paramount in meeting this challenge, new diagnostic modalities have been developed to assist in risk stratification. These include markers of cardiac injury, risk scores, early stress testing, and noninvasive imaging of the heart. The basic clinical tools of history, physical examination, and electrocardiography are currently widely acknowledged to allow early identification of low-risk patients who have less than 5% probability of ACS. These patients are usually initially managed in the emergency department and transitioned to further outpatient evaluation or chest pain units. Multiple imaging strategies have been investigated to accelerate diagnosis and to provide further risk stratification of patients with no initial evidence of ACS. These include rest myocardial perfusion imaging, rest echocardiography, computed tomographic coronary angiography, and cardiac magnetic resonance imaging. All have very high negative predictive values for excluding ACS and have been successful in reducing unnecessary admissions for patients at low to intermediate risk of ACS. As patients with acute chest pain transition from the evaluation in the emergency department to other outpatient settings, it is important that all clinicians involved in the care of these patients understand the tools used for assessment and risk stratification.
| S-EPMC2843115 | biostudies-literature
Project description:Despite good physical prognosis, patients who receive a diagnosis of non-cardiac chest pain (NCCP) may experience persistent pain and distress. While cognitive-behavioural interventions have been found to be effective for this group, they are difficult to deliver in busy emergency department (ED) settings. Addressing the acceptability and relevance of self-help interventions is an important initial step in addressing this need. This study sought to examine the acceptability and relevance of an evidence-based self-help intervention for ED patients with persistent NCCP and anxiety. Patient (interviews: N = 11) and specialist chest pain nurse (focus group: N = 4) views on acceptability and feasibility were examined. Data were analysed using thematic analysis. Patients and nurses reported that there was a need for the intervention, as stress and anxiety are common among patients with NCCP, and provision of psychosocial support is currently lacking. Both patients and nurses reported that the intervention was relevant, acceptable, and potentially useful. Some changes to the intervention were suggested. Nurses reported that the intervention could be used within the existing staff resources available in an ED setting. This study represents an important first step towards developing a brief self-help intervention for ED patients with NCCP and anxiety. Further research should seek to determine the efficacy of the intervention in a pilot trial.
| S-EPMC5105082 | biostudies-literature