Emergency physicians’ attitudes toward a clinical prediction rule for the identification and early discharge of low risk patients with chest discomfort

MacGougan, Cameron K.; Christenson, James M.; Innes, Grant; Raboud, Janet

doi:10.1017/s1481803500005303

Cited by 21 publications

(23 citation statements)

References 21 publications

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“…This "miss rate" is more than twice that reported by Pope and colleagues 8 from a large US study (2.1%). In a previous survey of Canadian emergency physicians, 18 only 5% reported using a systematic follow-up process to identify missed cases, but half estimated that their miss rate for AMI was greater than 2%. Most (94%) indicated that an earlydischarge prediction tool would be helpful as long as it did not increase the rate of missed AMI above 2%.…”

Section: Discussionmentioning

confidence: 99%

Safety and efficiency of emergency department assessment of chest discomfort

Christenson¹

2004

Canadian Medical Association Journal

126

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Background: Most Canadian emergency departments use an unstructured, individualized approach to patients with chest pain, without data to support the safety and efficiency of this practice. We sought to determine the proportions of patients with chest discomfort in emergency departments who either had acute coronary syndrome (ACS) and were inappropriately discharged from the emergency department or did not have ACS and were held for investigation. Methods: Consecutive consenting patients aged 25 years or older presenting with chest discomfort to 2 urban tertiary care emergency departments between June 2000 and April 2001 were prospectively enrolled unless they had a terminal illness, an obvious traumatic cause, a radiographically identifiable cause, severe communication problems or no fixed address in British Columbia or they would not be available for follow-up by telephone. At 30 days we assigned predefined explicit outcome diagnoses: definite ACS (acute myocardial infarction [AMI] or definite unstable angina) or no ACS. Results: Of 1819 patients, 241 (13.2%) were assigned a 30-day diagnosis of AMI and 157 (8.6%), definite unstable angina. Of these 398 patients, 21 (5.3%) were discharged from the emergency department without a diagnosis of ACS and without plans for further investigation. The clinical sensitivity for detecting ACS was 94.7% (95% confidence interval [CI] 92.5%-96.9%) and the specificity 73.8% (95% CI 71.5%-76.0%). Of the patients without ACS or an adverse event, 71.1% were admitted to hospital or held in the emergency department for more than 3 hours. Interpretation: The current individualized approach to evaluation and disposition of patients with chest discomfort in 2 Canadian tertiary care emergency departments misses 5.3% of cases of ACS while consuming considerable health care resources for patients without coronary disease. Opportunities exist to improve both safety and efficiency.

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Section: Discussionmentioning

confidence: 99%

Safety and efficiency of emergency department assessment of chest discomfort

Christenson¹

2004

Canadian Medical Association Journal

126

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“…A survey of Canadian emergency physicians indicated that most (94%) would use a clinical prediction rule for ACS, provided that it did not increase the miss rate above 2%. 42 In the United States, however, physicians' triage decisions may be influenced more by perceived medical and legal risk, and it is not known what miss rate would be acceptable to most US physicians.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: a systematic review

Hess

Thiruganasambandamoorthy

Wells

et al. 2008

CJEM

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Objective: We sought to determine the diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome (ACS) in the emergency department (ED) setting. Methods: We searched MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. We contacted content experts to identify additional articles for review. Reference lists of included studies were hand searched. We selected articles for review based on the following criteria: 1) enrolled consecutive ED patients; 2) incorporated variables from the history or physical examination, electrocardiogram and cardiac biomarkers; 3) did not incorporate cardiac stress testing or coronary angiography into prediction rule; 4) based on original research; 5) prospectively derived or validated; 6) did not require use of a computer; and 7) reported sufficient data to construct a 2 ∞ 2 contingency table. We assessed study quality and extracted data independently and in duplicate using a standardized data extraction form. Results: Eight studies met inclusion criteria, encompassing 7937 patients. None of the studies verified the prediction rule with a reference standard on all or a random sample of patients. Six studies did not report blinding prediction rule assessors to reference standard results, and vice versa. Three prediction rules were prospectively validated. Sensitivities and specificities ranged from 94% to 100% and 13% to 57%, and positive and negative likelihood ratios from 1.1 to 2.2 and 0.01 to 0.17, respectively. Conclusion: Current prediction rules for ACS have substantial methodological limitations and have not been successfully implemented in the clinical setting. Future methodologically sound studies are needed to guide clinical practice. RÉSUMÉObjectif : Nous avons cherché à déterminer l'exactitude diagnostique des règles de prévision clinique visant à exclure le syndrome coronarien aigu (SCA) dans les salles d'urgence.

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“…Several studies have attempted to use Global Registry of Acute Coronary Events (GRACE) or TIMI scores to predict ACS, but 3 to 4% of the low-risk patients had a 30-day ACS outcome, 15,16 a risk that may be unacceptable to clinicians. 21 Many rules are hampered by selection bias, a suboptimal methodological design, or low sensitivity. 28,29 There has been no widely used clinical prediction rule for safe early discharge of such patients, and the few rules that have been validated permit risk stratification of selected patients but do not allow for minimal investigations or early discharge.…”

Section: Comparison With Other Studiesmentioning

confidence: 99%

“…Based on a previous Canadian survey of emergency physicians, 21 the goal was for ACS sensitivity to exceed 98% while identifying the maximum number of low-risk patients who did not require hospitalization or prolonged testing.…”

Section: Introductionmentioning

confidence: 99%

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Scheuermeyer

Wong

et al. 2014

CJEM

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Objectives: Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing. Methods: This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000-2003 (development cohort) and 2006 (validation cohort). The primary outcome was 30-day ACS diagnosis. A recursive partitioning model incorporated reliable and predictive cardiac risk factors, pain characteristics, electrocardiographic findings, and cardiac biomarker results. Results: In the derivation cohort, 165 of 763 patients (21.6%) had a 30-day ACS diagnosis. The derived prediction rule was 100.0% sensitive and 18.6% specific. In the validation cohort, 119 of 906 patients (13.1%) had ACS, and the prediction rule was 99.2% sensitive (95% CI 95.4-100.0) and 23.4% specific (95% CI 20.6-26.5). Patients have a very low ACS risk if arrival and 2-hour troponin levels are normal, the initial electrocardiogram is nonischemic, there is no history of ACS or nitrate use, age is , 50 years, and defined pain characteristics are met. The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule. Conclusion: The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to adoption and implementation. RÉ SUMÉObjectif: D'aprè s les lignes directrices actuelles, on ne peut renvoyer du service des urgences (SU) les patients qui souffrent de douleurs thoraciques de nature probablement isché mique mais qui connaissent un faible risque de maladie cardiaque sans d'abord leur faire subir une exploration approfondie ou sans les hospitaliser afin de ré duire le plus possible le risque de syndrome coronarien aigu (SCA) passé inaperç u. Aussi avons-nous tenté d'é laborer et de valider une rè gle pré visionnelle qui permettrait de renvoyer en toute sé curité de 20 à 30% des patients ne souffrant pas d'un SCA au cours des 2 heures suivant leur arrivé e au SU, et ce, sans leur faire subir d'autres é preuves d'exploration cardiaque. August 20, 2012) suggest over 600,000 annual ED visits. Between 2 and 5% of patients with acute coronary syndrome (ACS) may be discharged with an incorrect non-ACS diagnosis and no further follow-up, 3,4 leading to adverse patient ...

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Emergency physicians’ attitudes toward a clinical prediction rule for the identification and early discharge of low risk patients with chest discomfort

Cited by 21 publications

References 21 publications

Safety and efficiency of emergency department assessment of chest discomfort

Safety and efficiency of emergency department assessment of chest discomfort

Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: a systematic review

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

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