Potential impact of cardiology phone-consultation for patients risk-stratified by the HEART pathway

Objective Bedside consultation by cardiologists may facilitate safe discharge of selected patients from the emergency department (ED) even when admission is recommended by the History, Electrocardiogram, Age, Risk factors, Troponin (HEART) pathway. If bedside evaluation is unavailable, phone consultation between emergency physicians and cardiologists would be most impactful if the resultant disposition is discordant with the HEART pathway. We therefore evaluate discordance between actual disposition and that suggested by the HEART pathway in patients presenting to the ED with chest pain for whom cardiology consultation occurred exclusively by phone and to assess the impact of phone-consultation on disposition. Methods We performed a single-center, retrospective study of adults presenting to the ED with chest pain whose emergency physician had a phone consultation with a cardiologist. Actual disposition was abstracted from the medical record. HEART pathway category (low-risk, discharge; high-risk, admit) was derived from ED documentation. For discharged patients, major adverse cardiac events were assessed at 30 days by chart review and phone follow-up. Results For the 170 patients that had cardiologist phone consultation, discordance between actual disposition and the HEART pathway was 17%. The HEART pathway recommended admission for nearly 80% of discharged patients. Following cardiologist phone-consultation, 10% of high-risk patients were discharged, with the majority having undergone a functional study recommended by the cardiologist. At 30 days, discharged patients had experienced no episodes of major adverse cardiac events or rehospitalization for cardiac reasons. Conclusion For patients presenting to the ED with chest pain, cardiology phone-consultation has the potential to safely impact disposition, primarily by facilitating functional testing in high-risk individuals

Measuring outcome differences associated with STEMI screening and diagnostic performance: a multicentred retrospective cohort study protocol

Introduction: Advances in ST-segment elevation myocardial infarction (STEMI) management have involved improving the clinical processes connecting patients with timely emergency cardiovascular care. Screening upon emergency department (ED) arrival for an early ECG to diagnose STEMI, however, is not optimal for all patients. In addition, the degree to which timely screening and diagnosis are associated with improved time to intervention and postpercutaneous coronary intervention outcomes, under more contemporary practice conditions, is not known. Methods: We present the methods for a retrospective multicentre cohort study anticipated to include 1220 patients across seven EDs to (1) evaluate the relationship between timely screening and diagnosis with treatment and postintervention clinical outcomes; (2) introduce novel measures for cross-facility performance comparisons of screening and diagnostic care team performance including: door-to-screening, door-to-diagnosis and door-to-catheterisation laboratory arrival times and (3) describe the use of electronic health record data in tandem with an existing disease registry. Ethics and dissemination The completion of this study will provide critical feedback on the quality of screening and diagnostic performance within the contemporary STEMI care pathway that can be used to (1) improve emergency care delivery for patients with STEMI presenting to the ED, (2) present novel metrics for the comparison of screening and diagnostic care and (3) inform the development of screening and diagnostic support tools that could be translated to other care environments. We will disseminate our results via publication and quality performance data sharing with each site. Institutional ethics review approval was received prior to study initiation

Diagnostic Utility of Neuregulin for Acute Coronary Syndrome

The purpose of this study was to determine the diagnostic test characteristics of serum neuregulin-1β (NRG-1β) for the detection of acute coronary syndrome (ACS). We recruited emergency department patients presenting with signs and symptoms prompting an evaluation for ACS. Serum troponin and neuregulin-1β levels were compared between those who had a final discharge diagnosis of myocardial infarction (STEMI and NSTEMI) and those who did not, as well as those who more broadly had a final discharge diagnosis of ACS (STEMI, NSTEMI, and unstable angina). Of 319 study participants, 11% had evidence of myocardial infarction, and 19.7% had a final diagnosis of ACS. Patients with MI had median neuregulin levels of 0.16 ng/mL (IQR [0.16–24.54]). Compared to the median of those without MI, 1.46 ng/mL (IQR [0.16–15.02]), there was no significant difference in the distribution of results (P=0.63). Median neuregulin levels for patients with ACS were 0.65 ng/mL (IQR [0.16–24.54]). There was no statistical significance compared to those without ACS who had a median of 1.40 ng/mL (IQR [0.16–14.19]) (P=0.95). Neuregulin did not perform successfully as a biomarker for acute MI or ACS in the emergency department

Maximizing Equity in Acute Coronary Syndrome Screening across Sociodemographic Characteristics of Patients

We compared four methods to screen emergency department (ED) patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI) in a 5-year retrospective cohort through observed practice, objective application of screening protocol criteria, a predictive model, and a model augmenting human practice. We measured screening performance by sensitivity, missed acute coronary syndrome (ACS) and STEMI, and the number of ECGs required. Our cohort of 279,132 ED visits included 1397 patients who had a diagnosis of ACS. We found that screening by observed practice augmented with the model delivered the highest sensitivity for detecting ACS (92.9%, 95%CI: 91.4–94.2%) and showed little variation across sex, race, ethnicity, language, and age, demonstrating equity. Although it missed a few cases of ACS (7.6%) and STEMI (4.4%), it did require ECGs on an additional 11.1% of patients compared to current practice. Screening by protocol performed the worst, underdiagnosing young, Black, Native American, Alaskan or Hawaiian/Pacific Islander, and Hispanic patients. Thus, adding a predictive model to augment human practice improved the detection of ACS and STEMI and did so most equitably across the groups. Hence, combining human and model screening––rather than relying on either alone––may maximize ACS screening performance and equity

Effectiveness, safety, and efficiency of a drive‐through care model as a response to the COVID‐19 testing demand in the United States

Abstract Objectives Here we report the clinical performance of COVID‐19 curbside screening with triage to a drive‐through care pathway versus main emergency department (ED) care for ambulatory COVID‐19 testing during a pandemic. Patients were evaluated from cars to prevent the demand for testing from spreading COVID‐19 within the hospital. Methods We examined the effectiveness of curbside screening to identify patients who would be tested during evaluation, patient flow from screening to care team evaluation and testing, and safety of drive‐through care as 7‐day ED revisits and 14‐day hospital admissions. We also compared main ED efficiency versus drive‐through care using ED length of stay (EDLOS). Standardized mean differences (SMD) >0.20 identify statistical significance. Results Of 5931 ED patients seen, 2788 (47.0%) were walk‐in patients. Of these patients, 1111 (39.8%) screened positive for potential COVID symptoms, of whom 708 (63.7%) were triaged to drive‐through care (with 96.3% tested), and 403 (36.3%) triaged to the main ED (with 90.5% tested). The 1677 (60.2%) patients who screened negative were seen in the main ED, with 440 (26.2%) tested. Curbside screening sensitivity and specificity for predicting who ultimately received testing were 70.3% and 94.5%. Compared to the main ED, drive‐through patients had fewer 7‐day ED revisits (3.8% vs 12.5%, SMD = 0.321), fewer 14‐day hospital readmissions (4.5% vs 15.6%, SMD = 0.37), and shorter EDLOS (0.56 vs 5.12 hours, SMD = 1.48). Conclusion Curbside screening had high sensitivity, permitting early respiratory isolation precautions for most patients tested. Low ED revisit, hospital readmissions, and EDLOS suggest drive‐through care, with appropriate screening, is safe and efficient for future respiratory illness pandemics

Changes in low‐acuity patient volume in an emergency department after launching a walk‐in clinic

Abstract Objective Unscheduled low‐acuity care options are on the rise and are often expected to reduce emergency department (ED) visits. We opened an ED‐staffed walk‐in clinic (WIC) as an alternative care location for low‐acuity patients at a time when ED visits exceeded facility capacity and the impending flu season was anticipated to increase visits further, and we assessed whether low‐acuity ED patient visits decreased after opening the WIC. Methods In this retrospective cohort study, we compared patient and clinical visit characteristics of the ED and WIC patients and conducted interrupted time‐series analyses to quantify the impact of the WIC on low‐acuity ED patient visit volume and the trend. Results There were 27,211 low‐acuity ED visits (22.7% of total ED visits), and 7,058 patients seen in the WIC from February 26, 2018, to November 17, 2019. Low‐acuity patient visits in the ED reduced significantly immediately after the WIC opened (P = 0.01). In the subsequent months, however, patient volume trended back to pre‐WIC volumes such that there was no significant impact at 6, 9, or 12 months (P = 0.07). Had WIC patients been seen in the main ED, low‐acuity volume would have been 27% of the total volume rather than the 22.7% that was observed. Conclusion The WIC did not result in a sustained reduction in low‐acuity patients in the main ED. However, it enabled emergency staff to see low‐acuity patients in a lower resource setting during times when ED capacity was limited