Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge : HEART Pathway Accelerated Diagnostic Protocol

Abstract

<div class="section"> <a class="named-anchor" id="S1"> <!-- named anchor --> </a> <h5 class="section-title" id="d599239e242">Background:</h5> <p id="P1">The HEART Pathway is an accelerated diagnostic protocol (ADP) designed to identify low-risk Emergency Department (ED) patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30 day death and myocardial infarction rate &lt;1% in low-risk patients) and effective (reduces 30 day hospitalizations) in ED patients with possible acute coronary syndrome (ACS). </p> </div><div class="section"> <a class="named-anchor" id="S2"> <!-- named anchor --> </a> <h5 class="section-title" id="d599239e247">Methods:</h5> <p id="P2">A prospective pre/post study was conducted at three US sites among 8,474 adult ED patients with possible ACS. Patients included were ≥21 years old, investigated for possible ACS, and had no evidence of ST-segment elevation myocardial infarction on electrocardiography. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013- January 2016. The HEART Pathway ADP was integrated into each site’s electronic health record as an interactive clinical decision support tool. Following ADP integration, ED providers prospectively utilized the HEART Pathway to identify patients with possible ACS as low-risk (appropriate for early discharge without stress testing or angiography) or non-low-risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death and myocardial infarction (MI) and hospitalization rates at 30 days, were determined from health records, insurance claims, and death index data. </p> </div><div class="section"> <a class="named-anchor" id="S3"> <!-- named anchor --> </a> <h5 class="section-title" id="d599239e252">Results:</h5> <p id="P3">Pre- and post-implementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low-risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the post- vs pre-implementation cohort (55.6% vs 61.6%; aOR: 0.79, 95%CI: 0.71–0.87). During the index visit more MIs were detected in the post-implementation cohort (6.6% vs 5.7%; aOR: 1.36, 95%CI: 1.12–1.65). Rates of death or MI during follow-up were similar (1.1% vs 1.3%; aOR: 0.88, 95% CI: 0.58–1.33). </p> </div><div class="section"> <a class="named-anchor" id="S4"> <!-- named anchor --> </a> <h5 class="section-title" id="d599239e257">Conclusions:</h5> <p id="P4">HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients that can be safely discharged without stress testing or angiography. </p> </div><div class="section"> <a class="named-anchor" id="S5"> <!-- named anchor --> </a> <h5 class="section-title" id="d599239e262">Clinical Trial Registration:</h5> <p id="P5"> <a data-untrusted="" href="http://clinicaltrials.gov" id="d599239e266" target="xrefwindow">clinicaltrials.gov</a> Identifier: NCT02056964 </p> </div>