Clinician Perception of Risk As a Barrier to Implementation of a High-sensitivity Troponin Accelerated Diagnostic Protocol

Abstract

Background: To assess emergency department (ED) clinician perception of patient risk, we measured willingness to discharge patients categorized as increased risk by traditional risk stratification modalities for acute coronary syndrome but low risk by a validated high-sensitivity troponin accelerated diagnostic protocol (HST-ADP). Methods: This was a cross-sectional descriptive survey study distributed to ED clinicians at an urban academic medical center. Four clinical vignettes classified hypothetical patients as low risk for 30-day acute coronary syndrome according to the 0-/1-hour HST-ADP. Vignettes additionally identified patients with History, Electrocardiogram, Age, Risk factors, and initial Troponin (HEART) scores of 4 or 6 (2 cases each). One patient in each subset had preexisting coronary artery disease (CAD). ED clinicians selfreported willingness to discharge patients from the ED on a 10-point Likert scale. Results: Among 66 eligible participants, 36 (55%) participated in the survey. ED clinicians reported a mean willingness to discharge patients of 6.07 (95% confidence interval, 5.34-6.80). They reported higher mean willingness to discharge patients with HEART scores of 4 compared with those with HEART scores of 6 (mean difference, 3.61; 95% confidence interval, 2.19-5.03). There were no differences in willingness to discharge regarding presence or absence of CAD or between clinician types (attending, resident, advanced practice provider). Conclusions: ED clinicians accustomed to the HEART Pathway demonstrated limited willingness to discharge patients from the ED categorized as moderate risk by the HEART score despite simultaneous classification as low risk by the 0-/1-hour HST-ADP. Willingness to discharge was higher with lower HEART scores but not affected by the presence of CAD and did not vary between clinician types.

Cardiac Biomarkers in 2022 – a Vital Tool for Emergency Care

“…75 Interestingly, physicians used to the HEART score demonstrated limited willingness to discharge early from the ED patients classified as having low risk by the ESC algorithm but moderate risk by the HEART score. 76 A modified HEART score, integrating capillary cTn determined using a new point-of-care test, was able to rule out ACS in patients presenting to the ED for chest pain, with a sensitivity of 97.0% and specificity of 97.6%, opening the route for point-of-care devices for Tn measurement. 77 However, several scores excluding cTn have been also proposed to establish the safety of early discharge in patients presenting to the ED for chest pain, in an attempt…”