Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring

Syed, Shahbaz; Gatien, Mathieu; Perry, Jeffrey J.; Chaudry, Hina; Kim, Soo-Min; Kwong, Kenneth K.; Mukarram, Muhammad; Thiruganasambandamoorthy, Venkatesh

doi:10.1503/cmaj.160742

Cited by 4 publications

(8 citation statements)

References 22 publications

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“… 5 In addition, 40% of patients in our study occupied the limited number of telemetry beds, despite definitive evidence of the low utility of telemetry in low-risk patients in whom less than 1% develop arrhythmias. 20 – 24 …”

Section: Discussionmentioning

confidence: 99%

Received care compared to ADP-guided care of patients admitted to hospital with chest pain of possible cardiac origin

Perera¹,

Aggarwal²,

Scott³

et al. 2018

IJGM

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PurposeTo assess the extent to which accelerated diagnostic protocols (ADPs), compared to traditional care, identify patients presenting to emergency departments (EDs) with chest pain who are at low cardiac risk and eligible for early ED discharge.Patients and methodsRetrospective study of 290 patients admitted to hospital for further evaluation of chest pain following negative ED workup (no acute ischemic electrocardiogram [ECG] changes or elevation of initial serum troponin assay). Demographic data, serial ECG and troponin results, Thrombolysis in Myocardial Infarction (TIMI) score, cardiac investigations, and outcomes (confirmed acute coronary syndrome [ACS] at discharge and major adverse cardiac events [MACEs]) over 6 months of follow-up were analyzed. A validated ADP (ADAPT-ADP) was retrospectively applied to the cohort, and processes and outcomes of ADP-guided care were compared with those of care actually received.ResultsPatients had mean (±SD) TIMI score of 1.8 (±1.7); six (2.0%) patients were diagnosed with ACS at discharge. At 6 months, one patient (0.3%) re-presented with ACS and two (0.6%) died of non-coronary causes. The ADAPT-ADP defined 97 (33.4%) patients as being at low risk and eligible for early ED discharge, but who instead incurred mean hospital stay of 1.5 days, with 40.2% in telemetry beds, and 21.6% subject to non-invasive testing with only one positive result for coronary artery disease. None had a discharge diagnosis of ACS or developed MACE at 6 months.ConclusionCompared to traditional care, application of the ADAPT-ADP would have allowed one-third of chest pain patients with initially negative investigations in ED to have been safely discharged from ED.

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Section: Discussionmentioning

confidence: 99%

Received care compared to ADP-guided care of patients admitted to hospital with chest pain of possible cardiac origin

Perera¹,

Aggarwal²,

Scott³

et al. 2018

IJGM

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“…1 The rationale for this is a concern for arrhythmia, 2 although this recommendation is extrapolated from literature on inpatients with confirmed ACS or having an acute myocardial infarction, a group at high risk for life-threatening arrhythmia. 1,3 The ED population presenting with chest pain represent a very different risk category, as a diagnosis of ACS is only established in 12-15%, 4 and arrhythmias are rare, occurring in 0-2% of all patients evaluated for chest pain. [4][5][6][7] The incidence among patients without ECG evidence of acute ischaemia or infarction would be expected to be even lower.…”

Section: Introductionmentioning

confidence: 99%

“…1,3 The ED population presenting with chest pain represent a very different risk category, as a diagnosis of ACS is only established in 12-15%, 4 and arrhythmias are rare, occurring in 0-2% of all patients evaluated for chest pain. [4][5][6][7] The incidence among patients without ECG evidence of acute ischaemia or infarction would be expected to be even lower. A prospective observational study of ED chest pain patients with normal or non-specific ECGs who were placed on continuous monitoring demonstrated only 0.2% of monitor alarms were associated with an arrhythmia requiring intervention, representing one 4 The literature has shown that certain ED patients can be safely removed from continuous cardiac monitoring.…”

Section: Introductionmentioning

confidence: 99%

“…[4][5][6][7] The incidence among patients without ECG evidence of acute ischaemia or infarction would be expected to be even lower. A prospective observational study of ED chest pain patients with normal or non-specific ECGs who were placed on continuous monitoring demonstrated only 0.2% of monitor alarms were associated with an arrhythmia requiring intervention, representing one 4 The literature has shown that certain ED patients can be safely removed from continuous cardiac monitoring. A prospectively derived and validated clinical decision rule (the Ottawa Chest Pain Cardiac Monitoring Rule), where patients who were pain-free at initial assessment with a normal or non-specific ECG could be unmonitored, had 100% sensitivity for significant arrhythmia and allowed 36% of patients on continuous cardiac monitoring to be safely removed from monitoring.…”

Section: Introductionmentioning

confidence: 99%

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The HEART score to identify emergency department patients suspected of an acute coronary syndrome who can be removed from cardiac monitoring: A retrospective chart review

Asha

2021

Emerg Medicine Australasia

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Objective: Continuous cardiac monitoring has been recommended for ED patients being evaluated for possible acute coronary syndrome (ACS) due to concern for arrhythmia, although evidence suggests this risk is low. Indiscriminate use of monitored beds restricts access for other critically unwell patients and contributes to overcrowding. The objective of the present study was to determine if a low/intermediate-risk HEART score identified patients at very low risk for a clinically important arrhythmia who could be removed from cardiac monitoring. Methods: This was a single centre, retrospective, cohort study of consecutive ED patients in a tertiary referral hospital evaluated for possible ACS from July to August 2017. Patients with ST-elevation myocardial infarction or an arrhythmia at presentation which would mandate monitoring were excluded. Data was obtained by medical chart review. The primary outcome was the occurrence of an arrhythmia requiring treatment while in ED. Results: Inter-rater reliability for data extraction demonstrated very strong agreement (kappa 0.87, 95% confidence interval 0.83-0.91). There were 653 participants included with 83 (12.7%) having a final diagnosis of ACS. Three (0.5%) clinically important arrhythmias occurred. There were no cases of ventricular tachycardia, ventricular fibrillation or cardiac arrest. Five hundred and forty (82.7%) participants were low/intermediate-risk HEART score and one (0.2%) clinically important arrhythmia occurred (this was supraventricular tachycardia treated by a valsalva manoeuvre). Conclusion: Among ED patients presenting with a possible ACS, a low/intermediate-risk HEART score identified those at very low risk for having a clinically important arrhythmia while in ED.

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“…Real-time electronic clinical decision support applications are increasingly used to reduce providers' cognitive load, increase adherence to evidence-based care, and improve patient safety and outcomes for a variety of conditions. [17][18][19][20][21][22][23][24] Real-time clinical decision support for ED patients at risk of recurrent visits may similarly improve health outcomes. 25 To advance policy and practice, it is important to know the degree to which these automated alert systems may improve care and outcomes, and to identify which types of alerts (if any) are effective.…”

Section: Introductionmentioning

confidence: 99%

Real-Time Emergency Department Electronic Notifications Regarding High-Risk Patients: A Systematic Review

Kimmel

Brice

Trikalinos

et al. 2019

Telemedicine and e-Health

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Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring

Cited by 4 publications

References 22 publications

Received care compared to ADP-guided care of patients admitted to hospital with chest pain of possible cardiac origin

Received care compared to ADP-guided care of patients admitted to hospital with chest pain of possible cardiac origin

The HEART score to identify emergency department patients suspected of an acute coronary syndrome who can be removed from cardiac monitoring: A retrospective chart review

Real-Time Emergency Department Electronic Notifications Regarding High-Risk Patients: A Systematic Review

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