Background The HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early discharge. No randomized trials have compared the HEART Pathway with usual care. Methods and Results Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG (n=282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, emergency department providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for early discharge. Usual care was based on American College of Cardiology/American Heart Association guidelines. The primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay, early discharge, and major adverse cardiac events (death, myocardial infarction, or coronary revascularization), were assessed at 30 days by phone interview and record review. Participants had a mean age of 53 years, 16% had previous myocardial infarction, and 6% (95% confidence interval, 3.6%–9.5%) had major adverse cardiac events within 30 days of randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1% (68.8% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early discharges by 21.3% (39.7% versus 18.4%; P<0.001). No patients identified for early discharge had major adverse cardiac events within 30 days. Conclusions The HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases early discharges. These important efficiency gains occurred without any patients identified for early discharge suffering MACE at 30 days.

The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.

Objectives Accelerated diagnostic protocols (ADP), such as the HEART Pathway, are gaining popularity in emergency departments (EDs) as tools used to risk-stratify patients with acute chest pain. However, provider non-adherence may threaten the safety and effectiveness of ADPs. The objective of this study was to determine the frequency and impact of ADP non-adherence. Methods A secondary analysis of participants enrolled in the HEART Pathway RCT was conducted. This trial enrolled 282 adult ED patients with symptoms concerning for acute coronary syndrome without ST-elevation on electrocardiogram. Patients randomized to the HEART Pathway (N = 141) were included in this analysis. Outcomes included index visit disposition, non-adherence, and major adverse cardiac events (MACE) at 30 days. MACE was defined as death, myocardial infarction, or revascularization. Non-adherence was defined as: 1) under-testing: discharging a high-risk patient from the ED without objective testing (stress testing or coronary angiography); or 2) over-testing: admitting or obtaining objective testing on a low-risk patient. Results Non-adherence to the HEART Pathway occurred in 28 out of 141 patients (20%, 95% CI = 14% to 27%). Over-testing occurred in 19 of 141 patients (13.5%, 95% CI = 8% to 19%) and under-testing in 9 of 141 patients (6%, 95% CI = 3% to 12%). None of these 28 patients suffered MACE. The net effect of non-adherence was ten additional admissions among patients identified as low-risk and appropriate for early discharge (absolute decrease in discharge rate of 7%, 95% CI = 3% to 13%). Conclusions Real-time use of the HEART Pathway resulted in a non-adherence rate of 20%, mostly due to over-testing. None of these patients had MACE within 30 days. Non-adherence decreased the discharge rate, attenuating the HEART Pathway’s impact on health care use.

Background The Emergency Department Assessment of Chest pain Score – Accelerated Diagnostic Protocol (EDACS-ADP) is a decision aid designed to safely identify Emergency Department (ED) patients with chest pain for early discharge. Derivation and validation studies in Australasia have demonstrated high sensitivity (99-100%) for major adverse cardiac events (MACE). Objectives To validate the EDACS-ADP in a cohort of US ED patients with symptoms suspicious for acute coronary syndrome (ACS). Methods A secondary analysis of participants enrolled in the HEART Pathway Randomized Controlled Trial was conducted. This single-site trial enrolled 282 ED patients ≥ 21 years old with symptoms concerning for ACS, inclusive of all cardiac risk levels. Each patient was classified as low-risk or at-risk by the EDACS-ADP based on EDACS, ECG, and serial troponins. Potential early discharge rate and sensitivity for MACE at 30 days, defined as cardiac death, myocardial infarction (MI), or coronary revascularization were calculated. Results MACE occurred in 17/282 (6.0%) participants, including no deaths, 16/282 (5.6%) with MI, and 1/282 (0.4%) with coronary revascularization without MI. The EDACS-ADP identified 188/282 patients (66.7%, 95% CI 60.8-72.1%) as low-risk. Of these, 2/188 (1.1%, 95% CI 0.1-3.9%) had MACE at 30 days. EDACS-ADP was 88.2% (95% CI 63.6-98.5%) sensitive for MACE, identifying 15/17 patients. Of the 2 patients identified as low-risk with MACE, 1 had MI and 1 had coronary revascularization without MI. Conclusions Within a US cohort of ED patients with symptoms concerning for ACS, sensitivity for MACE was 88.2%. We are unable to validate the EDACS-ADP as sufficiently sensitive for clinical use.

Background:We have created and validated a checklist for performance of ultrasound guided internal jugular central venous catheter (US IJ CVC) placement using the modified Delphi method. We now seek to validate it for use in an educational environment in order to evaluate competency in procedure performance.Objectives: To evaluate a checklist tool for assessment of resident skill in US IJ CVC placement. We hypothesize that