Do management algorithms improve chest pain triage?

Abstract

Objective To audit the use of management algorithms for chest pain in an emergency department. Design and setting Prospective study of all patients with chest pain presenting to the emergency department of an urban teaching hospital between 12 January and 4 May 1997. Staff were asked to complete a standardised admission form that incorporated the risk stratification algorithms for managing patients with suspected acute coronary syndrome. Main outcome measures Compliance with the use of management algorithms; concordance with a cardiologist's review of the triage grouping and admission/discharge decision; and major cardiovascular events over four months. Results Emergency department staff documented the triage group in 223 of 503 cases (45%). Concordance with the group assigned by a cardiologist was 70% (κ = 0.73; SEκ=0.04). When the management algorithm was applied correctly, 92% of triage decisions were correct (95% confidence interval [CI], 87%–96%). The triage decision was less often correct when risk stratification was not done (78% [73%–83%], P<0.001), overestimated (77% [66%–88%], P<0.01), or underestimated (50% [18%–82%], P<0.001). The proportion of patients free of major cardiovascular events at four‐month follow‐up was 50% for those with myocardial infarction with ST‐segment elevation, 47% for those with a high short‐term risk of an adverse cardiac event, 82% for those with intermediate risk, and 99% for those with a low risk or non‐coronary chest pain (P<0.001). Conclusions Use of management algorithms by emergency staff was poor. When used, triage decisions were more likely to be correct. Subsequent outcome confirms that the NHMRC risk stratification algorithms are useful for prognostic stratification of patients with suspected acute coronary syndrome.

In the public interest: autonomy and resistance to methods of standardising nurses’ advice and practices from a health call centre in Perth, Western Australia

“…The process has great significance at HealthDirect, as has its counterpart in hospital emergency departments. Fitzpatrick et al. (1999, 404) confirm that algorithms recommended by the National Health and Medical Research Council (NHMRC) guidelines can be ‘applied accurately by emergency medical staff and this improves triage and management decisions.’ If followed faithfully, nurses will activate the ‘right’ guideline.…”

Towards a Safer Culture: clinical pathways in acute coronary syndromes and stroke

“…The key tools used to implement TASC in participating hospitals are evidence‐based clinical pathways and a measurement system to promote improvement in clinical practice. Pathways for ACS management were initially developed at the Nepean Hospital for the triage of chest pain 7 . Pathways for stroke management, modelled on the ACS pathways, were then developed at John Hunter Hospital.…”

“…TASC pathway forms replace the handwritten medical record, improve documentation of clinical findings, and enable risk stratification to guide subsequent management, as described in an earlier article 7 . The forms are designed in a software program that enables data acquisition by scanning, optical character recognition and clinician verification (Box 2).…”

“…The key to establishing a system for triaging patients presenting with chest pain proved to be the adoption and application of risk‐stratification algorithms, 7 as recommended by the national guidelines 3 . This enabled establishment of four distinct pathways of care, for which key process and outcome indicators could be measured (see Box 3).…”

“…For high‐risk patients and those with ST elevation myocardial infarction (STEMI), clinical practice improvement focuses on appropriate therapy and rapid revascularisation to reduce late myocardial infarction and readmissions 7 …”