Comparing the Safety and Efficacy of a Rapid High-Sensitivity Cardiac Troponin I Protocol Between Hospital-Based and Free-Standing Emergency Departments

Study Objectives: Current high sensitivity cardiac troponin I (hs-cTnI) research has been conducted almost exclusively in hospital-based emergency department (HBED) settings and the translation of these protocols into free-standing emergency departments (FSED) has yet to be explored. This study compared the safety and efficacy of applying a rapid-rule out protocol using hs-cTnI for exclusion of acute myocardial infarction (AMI) in HBEDs and FSEDs. Methods: This was a secondary analysis of a randomized trial of patients evaluated for possible AMI in 9 emergency departments (ED) from July 2020 through March 2021. The trial arms included a new 0/1-hour rapid protocol using hs-cTnI versus standard care, which used a 0/3-hour protocol without reporting hs-cTnI values below the 99th percentile. The primary outcome was safe ED discharge, defined as discharge with no death or AMI within 30-days. Analysis included a mixed-effect model adjusting for demographic variables. Results: There was a statistically significant difference in safe discharges from FSEDs when comparing the standard care arm (86.2%) to the rapid rule-out protocol (95.1%). There was a statistically significant reduction in FSED length of stay with application of a rapid rule-out protocol at 3.43 hours vs. 3.97 hours using standard care. The percentage of patients who ruled-out with their initial hs-cTnI (\u3c4 ng/L) at FSEDs (74%) was also significantly larger when compared to HBEDs (54%). Conclusion: Implementation of a hs-cTnI rapid 0/1-hour protocol to evaluate for AMI in FSEDs is feasible and had greater impact on safe ED discharge and length of stay compared to HBEDs

Project #65: Reducing Door to Balloon Time in STEMI: Celebrating the EMS, ED and Cardiology QI Collaboration

Project Aim: To employ a multidisciplinary approach, engaging local emergency medical services (EMS), emergency department (ED), and cardiology teams to assure that STEMI patients in our community receive prompt, equitable, consistent, safe, and high-quality revascularization of their coronary arteries; and to deploy a variety of educational, operational and feedback tools to initiatve early prehospital EKG transmission and Cath lab activation for patients in our community suffering from ST segment elevated myocardial infarction (STEMI).https://scholarlycommons.henryford.com/qualityexpo2023/1002/thumbnail.jp

Project #82: HFWH Vertical Treatment Zone

Problem Statement: Limited Emergency Department bed capacity and increased acuity resulted in increased left without completing service (LWCS) resulting in increased patient safety risk. Goal: Design a new patient throughput workflow to provide safe, timely and quality patient-centered care resulting in decreased LWSC, decreased arrival to provider times, decreased LOS of the discharged patient, and increased patient satisfaction.https://scholarlycommons.henryford.com/qualityexpo2023/1007/thumbnail.jp

49 Comparing the Safety and Efficacy of a Rapid High-Sensitivity Cardiac Troponin I Protocol Between Hospital-Based and Free-Standing Emergency Department

Study Objectives: Significant variability exists in patient population and diagnostic capabilities of large academic tertiary, community-based hospital, and free-standing emergency departments (ED). Current high sensitivity cardiac troponin I (hs-cTnI) research has been conducted almost exclusively in hospital-based ED (HBED) settings and the translation of these protocols into the free-standing EDs (FSED) has yet to be explored. This study compared the safety, efficacy, and ED throughput of applying a 0/1-hour, rapid-rule out protocol using hs-cTnI for exclusion of acute myocardial infarction (AMI) in HBEDs and FSEDs. Methods: This was a pre-planned, secondary analysis of a stepped wedge cluster randomized trial of patients evaluated for possible AMI in 9 EDs in an integrated health system from July 2020 through March of 2021. Five of the EDs were HBEDs and four were FSEDs. The trial arms included a new 0/1-hour rapid protocol using hs-cTnI versus standard care, which used a 0/3-hour protocol without reporting hs-cTnI values below the 99th percentile. All adult ED patients were eligible if the treating clinician ordered an ECG and cardiac troponin. We excluded patients with STEMI, a hs-cTnI \u3e18 ng/L in the ED, or a traumatic cause of symptoms. The primary outcome was safe ED discharge, defined as discharge with no death or AMI within 30-days. Analysis included a mixed effect model adjusting for ED site, time, sex, age, and race. We report adjusted odds ratios (aOR). Results: The trial included 32,609 patients, of whom 26,957 were seen in HBEDs and 5,652 were seen in FSEDs. Safe discharge from HBED occurred 53% (5947/11,062) of the time in the standard care arm and 50.4% (8,005/15894) under the rapid rule-out protocol (aOR 1.04, 95% CI 0.94 – 1.15, p = 0.5). Safe discharge from a FSED occurred 86.2% (2106/2443) of the time in the standard care arm and increased to 95.1% (3052/3209) under the rapid protocol (aOr 1.48, 95% CI 1.03 – 2.13, p=.033). Initiation of a rapid rule-out protocol had no significant impact on overall ED length of stay (aOR 1.00, 95% CI 0.98-1.03, p = 0.8). There was a statistically significant reduction in FSED length of stay with application of a rapid rule-out protocol (3.43 hours (2.55, 4.58) vs. 3.97 hours (2.88, 4.77) using standard care, aOR 0.91, 95% CI 0.87- 0.95, p \u3c0.001). The percentage of patients who rule-out with their initial hs-cTnI (\u3c4 ng/L) at FSEDs (74%) was significantly larger when compared to hospital based EDs (54%), p\u3c.001. Safe discharge data for all 9 ED sites is detailed in table 1. Conclusion: Implementation of a hs-cTnI rapid 0/1-hour protocol to evaluate for AMI in FSEDs is feasible and had greater impact on safe ED discharge and length of stay compared to HBEDs