Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice

Than, Martin; Pickering, John W.; Aldous, Sally; Cullen, Louise; Frampton, Christopher; Peacock, W. Frank; Jaffe, Allan S.; Goodacre, Steve; Richards, A. Mark; Ardagh, Michael; Deely, John; Florkowski, Chris; George, Peter M.; Hamilton, Greg; Jardine, David L.; Troughton, Richard W.; Wyk, Pieter van; Young, Joanna M.; Bannister, Laura; Lord, Sarah J.

doi:10.1016/j.annemergmed.2016.01.001

Cited by 115 publications

(123 citation statements)

References 19 publications

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“…75 A subsequent validation of the EDACS-ADP using a Canadian cohort of patients classified a similar proportion of patients as low risk with optimal sensitivity and NPV. 76 The EDACS-ADP has been validated in an RCT 77 and is now being used in multiple hospitals in New Zealand and Australia.…”

Section: State Of the Artmentioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

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ABSTRACT:It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.A bout 20 million patients present with symptoms possibly suggestive of acute coronary syndrome (ACS) to emergency departments (ED) in North America and Europe each year.1-3 Patients with ACS and acute myocardial infarction (AMI) present with a wide variety of symptoms such as chest pain, shortness of breath, weakness, nausea, vomiting, and even fatigue, making the diagnosis difficult. Demographics, cardiac risk factors, chest pain characteristics, and physical examination can assist disposition decisions but are insufficient to identify who does and does not have an ACS.4-7 Some patients may have objective evidence of a clearcut diagnosis, but the majority do not. 8 The majority ultimately will be found not to have ACS, but symptoms caused by noncardiac and often benign disorders such as musculoskeletal pain, pleuritis, or gastroesophageal reflux make the rapid rule-out of ACS more difficult and result in huge medical expenses. Safe and early rule-out of ACS contributes to more efficient and high-value healthcare delivery. History And PHysicAl ExAminAtionClinical features, alone or in combination with an ECG, are poorly predictive for AMI (Table 1). 9,10 In addition, they have variable reliability. Features classically associated with a lower probability of AMI such as pleuritic, positional, and sharp chest pain have poor to fair interphysician reliability (κ=0.27-0.44), 11 whereas high-risk features (radiation to left arm, substernal location, and history of AMI) are more reliable (κ=0.74-0.89). 11Traditional cardiac risk factors, derived from population-based longitudinal cohort studies of asymptomatic patients, are poor predictors of risk for AMI or ACS in symptomatic patients in the ED. 6,7 Similarly, the physical examination seldom is useful for distinguishing patients with ACS from patients with noncardiac chest pain.Trials of medications, onc...

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Section: State Of the Artmentioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

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“…ADPs required troponin measurement on arrival and then at 1, 2, or 3 hours to determine eligibility for early discharge. ADPs that were considered were the 2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) 10,14 ; Emergency Department Assessment of Chest Pain Score (EDACS) 15,17,18 ; History, ECG, Age, Risk Factors, and Troponin (HEART) 11,19 ; the High Sensitivity Cardiac Troponin T Assay for Rapid Rule-Out of AMI (TRAPID-AMI) 20,21 ; and the new Vancouver Chest Pain Rule. 13 Before implementation, there were meetings involving the first author and representatives from each stakeholder group (including but not limited to the ED, cardiology, general medicine physicians and nurses, hospital management, diagnostic laboratory directors, cardiac technicians, and hospital data analysts).…”

Section: Intervention Phasementioning

confidence: 99%

“…8,[10][11][12][13] Randomized implementation trials of clinical pathways incorporating ADPs at Christchurch Hospital (Christchurch, NZ) demonstrated that early safe discharge rates could be improved (from 11.0% to 32.3%). 14,15 Immediate and successful implementation of clinical pathways incorporating an ADP at Christchurch Hospital prompted the New Zealand Ministry of Health to mandate that all hospitals implement similar clinical pathways for possible ACS.…”

mentioning

confidence: 99%

ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome)

Than¹,

Pickering

Dryden³

et al. 2018

Circulation

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Background: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. Methods: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation Results: There were 11 529 participants in the preimplementation phase (range, 284–3465) and 19 803 in the postimplementation phase (range, 395–5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%–37.7%) to 18.4% (6.8%–43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3–2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4–3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P =0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. Conclusions: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. Clinical Trial Registration: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.

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“…Newer bespoke tools have been developed for assessing risk in ED populations such as the Manchester Acute Coronary Syndromes rule,30 the Christchurch Emergency Department Acute Coronary Syndrome ADP31 and the Triage rule-out using hs-cTnI ADP,32 and future prospective comparison of these scores with HEART will prove important.…”

Section: Discussionmentioning

confidence: 99%

Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events

et al. 2018

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Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice

Cited by 115 publications

References 19 publications

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome)

Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events

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