From the 2019 HVPAA National Conference
Dr. Rebecca Vigen (University of Texas Southwestern), Dr. James de Lemos (UT Southwestern Medical Center), Dr. Deborah Diercks (UT Southwestern Medical Center), Dr. Ambarish Pandey (UT Southwestern Medical Center), Ms. Lin Zhong (UT Southwestern Medical Center), Ms. Patricia Kutscher (Parkland Health & Hospital System), Ms. Fernabelle Fernandez (Parkland Health & Hospital System), Ms. Amy Yu (Parkland Health & Hospital System), Mr. Bryan Bertulfo (Parkland Health & Hospital System), Prof. Imbrahim Hashim (UT Southwestern Medical Center), Dr. Kyle Molberg (UT Southwestern Medical Center), Dr. Jeffrey Metzger (UT Southwestern Medical Center), Dr. Jose Soto (UT Southwestern Medical Center), Dr. Dergham Alzubaidy (UT Southwestern Medical Center), Ms. Lorie Thibodeaux (Parkland Health & Hospital System), Dr. Jose Joglar (UT Southwestern Medical Center), Dr. Sandeep Das (University of Texas Southwestern)
Background
There is a need for streamlined protocols in the evaluation of chest pain in the emergency department (ED) to reduce unnecessary resource utilization and overcrowding. The incorporation of hs-cTnT assays which are more sensitive and precise that fourth generation troponin assays into chest pain rule out protocols may allow for more rapid triage of patients. Subsequent to the approval of the hs-cTnT assay in the United States, a multidisciplinary team at Parkland Health and Hospital System (PHHS) and the University of Texas Southwestern Medical Center developed a novel hs-cTnT Protocol and demonstrated it to be safe and effective in a small pilot study.
Objective
Determine whether the implementation of this novel hs-cTnT protocol was associated with improvements in resource utilization.
Methods
The hs-cTnT protocol was implemented in 12/2017. We identified patients from 1/1/2017 to 9/30/2018 who had both and ECG and cardiac biomarker testing ordered within 3 hours of arrival to PHHS. We evaluated trends in resource utilization from the electronic medical record including ED dwell time (the difference between ED arrival time and ED departure time), troponin to disposition decision time (the difference between the time the first troponin test was drawn and the time an order was placed for either inpatient admission, admission to observation, or discharge), and final patient disposition including discharge from ER, admit to observation or inpatient admission among all encounters and a subset with the chief complaint of chest pain. We merged these encounters with data from the Dallas Fort Worth Hospital Council to assess rates of admissions for myocardial infarction, death, or revascularization within 30 days of discharge from PHHS.
Results
We identified 31,543 unique ED encounters. The change in ED dwell time was downtrending in the pre-intervention period with a slope of -0.92. Post-intervention, this slope downtrended more sharply to -4.99. The troponin to disposition time was increasing in the pre-intervention period with a slope of 1.74. Post intervention, the slope downtrended to 0.38. In the subset of 11,149 encounters with a chief complaint of chest pain, the slope of ED dwell time was -1.35 pre-intervention and downtrended more significantly post-intervention to -9.34 and the slope of the troponin to disposition decision time was 1.89 pre-intervention and -1.59 post-intervention (Table). The proportion of patients discharged as compared to admitted to observation or inpatient admission increased throughout the study period (Figure). The rates of admissions for myocardial infarction, death, or revascularization within 30 days were low throughout the study period.
Conclusions
ED dwell time rates declined throughout the study period with a more significant decline after implementation of the hs-cTnT protocol. Troponin to disposition time rates increased throughout the study period with an attenuated increase after implementation of the new protocol. The proportion of patients discharged from the ED increased throughout the study period.
Clinical Implications
This or similar rapid rule out MI protocols have the potential to improve health care quality and reduce ED overcrowding by improving the efficiency of the triage of chest pain patients while maintaining safety.
Figures
