P124: The Ottawa Chest Pain Rule would increase stretcher capacity if implemented for cardiac chest pain patients

Introduction: Reducing the number of patients requiring cardiac monitoring would increase system capacity and improve emergency department (ED) patient flow. The Ottawa Chest Pain Rule helps physicians identify chest pain patients who do not require cardiac monitoring and is based on a ‘normal or non-specific’ ECG and being pain-free on initial physician assessment. Our objective was to measure the impact that the implementation of this decision rule would have on cardiac monitoring bed utilization in adult EDs in Calgary. Methods: A convenience sample of patients was prospectively obtained at each of the four Calgary adult emergency sites. All patients presenting with the Canadian Triage Acuity Scale chief complaint of “cardiac pain”, or “chest pain with cardiac features” were captured for inclusion in the study. Real time interviews and survey assessments were conducted with the primary nurse and physician involved in each patient’s care. Results: A total of 61 patients were captured by the study. Physicians identified cardiac as the primary rule-out pathology in 51% of these patients. The average Heart Score of all study patients was 4.2, and 30% of patients were ultimately admitted. Physicians believed that 39% of the 61 patients needed cardiac monitoring, while primary nurses believed that 59% needed monitoring. Of the 61 patients, 59% were triaged to areas providing cardiac monitoring. The application of the Ottawa Rule would have allowed 47% of patients triaged to cardiac monitoring to be taken off cardiac monitoring. This would translate to a total of greater than 74 hours saved or a reduction of 30% of the total cardiac monitored patient time. Conclusion: The Ottawa rule appears to be a low-risk emergency department flow intervention that has the potential to help reduce resource utilization in emergency departments. This change may result in increased emergency department capacity and improved overall patient flow. This simple rule based only on ECG findings and absence of chest pain can easily be applied and implemented without increasing physician workload or increasing risk to patients.

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Nurse-led chest pain hot clinics: improving patient flow in the emergency department

British Journal of Cardiac Nursing ◽

10.12968/bjca.2019.0122 ◽

2020 ◽

Vol 15 (5) ◽

pp. 1-11

Author(s):

Jon Taylor ◽

Agnieszka Kopanska ◽

Tessa Cobb

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Length Of Stay ◽

Troponin I ◽

Patient Flow ◽

Low Risk ◽

Heart Score ◽

Ensure Patient Safety ◽

Number Of Patients ◽

Risk Patients

This article describes the authors' experiences of a specialist pathway for low-risk patients with chest pain admitted to the emergency department. This pathway uses a modified HEART score and highly sensitive troponin I testing to categorise patients. This was introduced to facilitate safe and speedy discharge of these patients within the 4-hour target. The aim was to demonstrate a reduction in length of stay and a reduction in overcrowding in the emergency department. This also included the introduction of a new nurse-led chest pain hot clinic to provide a specialist cardiology review within 72 hours of discharge. This clinic enabled more appropriate targeted investigation and treatment for patients. As a new initiative, it was important to ensure patient safety with a <1% incidence of major adverse cardiac event at 30 days, which was achieved. The modified HEART score also enabled more low-risk patients to be rapidly discharged from the emergency department. The chest pain hot clinics ensure patients are appropriately assessed and investigated for coronary artery disease reducing the number of unnecessary investigations. It also demonstrated a reduction in the number of computerised tomography coronary angiogram requests enabling more appropriate and timely investigations. In addition, there was a reduction in medical admissions and emergency department overcrowding. These initiatives also reduced the overall length of stay and increased the number of patients discharged within the 4-hour target from the emergency department.

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Is cardiac monitoring during transport of low-risk chest pain patients from the emergency department necessary?

Emergency Medicine Australasia ◽

10.1111/j.1742-6723.2007.00966.x ◽

2007 ◽

Vol 19 (3) ◽

pp. 229-233 ◽

Cited By ~ 2

Author(s):

Andrew Lin ◽

Debra Kerr ◽

Anne-Maree Kelly

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Low Risk ◽

Cardiac Monitoring ◽

Pain Patients

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A prospective validation of the HEART score for chest pain patients at the emergency department

International Journal of Cardiology ◽

10.1016/j.ijcard.2013.01.255 ◽

2013 ◽

Vol 168 (3) ◽

pp. 2153-2158 ◽

Cited By ~ 218

Author(s):

B.E. Backus ◽

A.J. Six ◽

J.C. Kelder ◽

M.A.R. Bosschaert ◽

E.G. Mast ◽

...

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Heart Score ◽

Pain Patients

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LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay

CJEM ◽

10.1017/cem.2017.159 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S61-S62 ◽

Cited By ~ 1

Author(s):

J. Andruchow ◽

A. McRae ◽

T. Abedin ◽

D. Wang ◽

G. Innes ◽

...

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Troponin T ◽

High Sensitivity ◽

Low Risk ◽

Moderate Risk ◽

Heart Score ◽

High Sensitivity Troponin ◽

High Sensitivity Troponin T ◽

Pain Patients

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

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