Triage of patients with chest pain in the emergency department: a comparative study of physicians’ decisions

Reilly, Brendan M.; Evans, Arthur T.; Schaider, Jeffrey; Wang, Yue

doi:10.1016/s0002-9343(01)01054-3

Cited by 44 publications

(22 citation statements)

References 36 publications

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“…Previous studies have demonstrated variable results predicting physicians' use of health care resources, 10 including guidelines, decision rules and care plans; 11,12 and admitting practices 13,14 using a variety of predictor variables. The outcomes of our analysis are largely consistent with Reilly and coworkers' 15 finding that physicians vary widely in their clinical decisions about simulated cases, regardless of specialty, level of training or clinical experience.…”

Section: Discussionsupporting

confidence: 87%

Individual emergency physician admission rates: predictably unpredictable

Mutrie

Bailey

Malik

2009

CJEM

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Objective: We sought to determine the degree and possible causes of variability in admission practices among individual emergency physicians (EPs) at 1 emergency department (ED) using a Canadian Emergency Department Triage Acuity Scale (CTAS)-matched ED patient population. Methods: We distributed a survey measuring attitudes and demographics to all EPs (n = 30) at a large regional hospital. Hospital admissions data from 1 calendar year were matched to individual EP survey results. Emergency physicians were ranked as "lower," "average" or "higher" admitters and, using these categorical variables, the data set was analyzed for correlations and trends. Results: Overall, 97.0% of the EPs responded to the survey. Admissions by EPs ranged from 8.7% to 17.0%, (mean 12.52, standard deviation [SD] 2.21) of all patients seen. CTAS category-specific admission data demonstrated variability in the admission ranking of individual EPs. No EPs consistently performed at any 1 admission ranking across all CTAS categories. More years of emergency medicine experience was significantly correlated with higher admissions in the CTAS-2 ranking (r = 0.4, p < 0.05). Whether a physician worked full-time, part-time or as a locum was not associated with patterns of admission, nor was any particular postgraduate certification (e.g., CCFP, CCFP EM, FRCPC) or any of the surveyed attitudinal traits. Conclusion: Individual EPs' overall and CTAS-specific admissions varied substantially, and followed an approximately normal distribution curve. Emergency physicians with more years of experience had a statistically higher CTAS-2 admission rate; however, other variables, including postgraduate certification status, decision-related attitudes toward admission, and reported practices were not associated with admission proportions. Emergency physicians tend to have uniquely individual admission ranking profiles across all the CTAS categories.

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Section: Discussionsupporting

confidence: 87%

Individual emergency physician admission rates: predictably unpredictable

Mutrie

Bailey

Malik

2009

CJEM

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“…Using simulated cases, Reilly and colleagues compared physician predictions with the Goldman model, a widely known prediction rule. 26 In this study, they found triage decisions based on physician predictions to be both less sensitive and less specific than those based on the prediction rule. Mitchell and colleagues conducted a prospective multicentre study designed to measure the diagnostic accuracy of three methods of assessment of low-risk ED patients, one of which was the physician's written unstructured estimate.…”

Section: Ré Sumémentioning

confidence: 76%

“…11,38,39 Although some decision rules have been shown to predict ACS more accurately than physicians, none that have been validated have extremely high sensitivity and specificity. [24][25][26] ECGs at presentation have been used, but up to 18% of patients presenting to the ED with an AMI have normal or only nonspecific ECG changes. 40,41 Furthermore, EPs may not accurately interpret these ECGs.…”

Section: Discussionmentioning

confidence: 99%

Emergency physician estimates of the probability of acute coronary syndrome in a cohort of patients enrolled in a study of coronary computed tomographic angiography

Lee

Hoffmann²,

Bamberg³

et al. 2012

CJEM

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Introduction: Little information exists regarding how accurately emergency physicians (EPs) predict the probability of acute coronary syndrome (ACS). Our objective was to determine if EPs can accurately predict ACS in a prospectively identified cohort of emergency department (ED) patients who met enrolment criteria for a study of coronary computed tomographic angiography (CCTA) and were admitted for a ''rule out ACS'' protocol. Methods: A prospective observational pilot study in an academic medical centre was carried out. EPs caring for patients with chest pain provided whole-number estimates of the probability of ACS after clinical review. This substudy was part of the now published Rule Out Myocardial Infarction/ Ischemia Using Computer Assisted Tomography (ROMICAT) study, a study of CCTA and admission of patients for a rule out ACS protocol after a nondiagnostic evaluation. Predictions were grouped into probability groups based on the validated Goldman criteria. ACS was determined by an adjudication committee using American Heart Association/American College of Cardiology/European Society of Cardiology guidelines. Results: A total of 334 predictions were obtained for a study population with a mean age of 54 (SD 12) years, 63% of whom were male. There were 35 ACS events. EPs predicted ACS better than by chance, and increasingly higher estimates were associated with a higher incidence of ACS (p 5 0.0004). The percentage of patients with ACS was 0%, 6%, 7%, and 17%, respectively, for very low, low, intermediate, and high probability groups. EPs' estimates had a sensitivity of 63% using a . 20% probability of ACS to define a positive test. Lowering this threshold to . 7% to define a test as positive increased the sensitivity of physician estimates to 89% but lowered specificity from 65% to 24%.

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“…For patients in whom ACS is a concern, disposition decisions are complex and multifactorial and have traditionally been a source of considerable variation. 1,2 An important factor in disposition decisions for these patients may be physician-perceived medicolegal risk and related professional concerns. [3][4][5] Previous work has been done examining the concept of a test threshold, or "acceptable miss rate," for ACS.…”

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confidence: 99%

The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates

et al. 2015

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Objectives: For patients in whom acute coronary syndrome (ACS) is a concern, disposition decisions are complex and multifactorial and have traditionally been a source of considerable variation. An important factor in disposition decisions for these patients may be physician-perceived medicolegal risk and related professional concerns. The study aim was to determine, at the point of care, how much less frequently physicians report that they would admit possible ACS patients if there was either zero or a defined medicolegal risk.Methods: This was a point-of-care emergency physician survey. Research assistants approached physicians at or immediately following the moment of disposition decisions for patients who were being admitted for ACS. The primary outcome measures were the proportion of physicians reporting that patients would not have been admitted if medicolegal issues were of no concern and the proportion of physicians reporting that patients would not have been admitted if there was an "acceptable miss rate" of 1% to 2% for ACS patients.Results: During the 3-month study period, 576 patients were admitted to an inpatient unit or to the ED observation protocol. Physicians were approached in 271 cases, and 259 surveys were completed. When presented with hypothetical zero medicolegal risk, physicians answered that they would not have admitted the patients in 30% of cases. With a hypothetical 1% to 2% acceptable miss rate, physicians indicated that they would not have admitted the patients in 29% of the cases.Conclusions: ED medicolegal and professional concerns may substantially increase admissions for possible ACS. An acceptable miss rate or a zero medicolegal risk environment could potentially lead to a major reduction in admissions that physicians feel to be clinically unnecessary.ACADEMIC EMERGENCY MEDICINE 2015;22:883-886 © 2015 by the Society for Academic Emergency Medicine A cute coronary syndrome (ACS) is a common concern in emergency department (ED) settings and a common reason for extended evaluation using accelerated diagnostic protocols in observation units or inpatient hospital settings. For patients in whom ACS is a concern, disposition decisions are complex and multifactorial and have traditionally been a source of considerable variation.1,2 An important factor in disposition decisions for these patients may be physician-perceived medicolegal risk and related professional concerns. [3][4][5] Previous work has been done examining the concept of a test threshold, or "acceptable miss rate," for ACS. [6][7][8] However, such thresholds have not been routinely integrated into disposition decision-making and their possible effect on physician decision-making has, to our knowledge, not been previously reported.We aimed to determine, at the point of care, how often perceived medicolegal concerns affect physician

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Triage of patients with chest pain in the emergency department: a comparative study of physicians’ decisions

Cited by 44 publications

References 36 publications

Individual emergency physician admission rates: predictably unpredictable

Individual emergency physician admission rates: predictably unpredictable

Emergency physician estimates of the probability of acute coronary syndrome in a cohort of patients enrolled in a study of coronary computed tomographic angiography

The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates

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