Troponin Testing in the Emergency Setting: How Good are we?

Abstract

Objectives: The purpose of this audit was to ascertain whether troponin tests are requested appropriately for acute admissions via A&E and EAU at the John Radcliffe Hospital, Oxford. Troponin tests are not 100% specific, and commencing the ACS protocol is not without risks. Inappropriate tests could result in minimally positive levels, and starting antiplatelets in these situations could lead to unnecessary complications.Methods: Data was collected on two 24-hour periods for all admissions to A&E and EAU (Emergency Assessment Unit). Admissions were monitored on the electronic whiteboard and follow-up was through a combination of reading notes and using 'Case Notes'. The primary outcome was whether troponin tests were requested appropriately. Criteria for appropriateness of requests were decided after meeting with cardiologists. The secondary outcome was whether the troponin tests were requested within an appropriate time frame, i.e. at admission and at 12 hours.Results: A total of 55 patients had troponin tests. Mean age was 72.3 years. Nine requests came via EAU and the majority through A&E. Of these 55 patients, 40% had a troponin requested inappropriately, the majority of which were requested by the nursing staff. Mean time for the first troponin test was 63.5 minutes. Repeat troponins were requested at a range (5 hours to 13 hours). Three patients were actually started on ACS protocol inappropriately. The cost of inappropriate tests totaled £320. Conclusion:Although there were no adverse events in the patients that were sampled during this audit, the ACS protocol was started inappropriately in three patients. Cutting down inappropriate troponin tests in the acute setting could, by extrapolation, amount to savings of £58,400 per annum. We presented this audit at several local and regional meetings, and came up with recommendations to put in place within our hospital. Our intervention in the form of checklists, posters and widespread teaching, improved results considerably, with only 5% inappropriate tests requested in the second audit cycle.

Appropriateness of troponin testing in emergency department at a tertiary care hospital in Saudi Arabia

“…4 A study from a large teaching hospital in Oxford where 40% of the troponin tests were ordered inappropriately showed that in addition to patient harm and over utilization of hospital resources, the cost of inappropriate tests amounted to 320£ over a period of just 48 hours. 12 In our study, single troponin orders were used more extensively and inappropriately compared to serial orders. This is similar to what has been observed by Davey's 14 audit in 3 Australian hospitals where it was shown that majority of the single troponin orders were used more than the serial orders.…”

“…The serial troponin orders were further categorized as shown in troponin testing that revealed 23-46% of requested troponin tests to be inappropriate. 3,4,[12][13][14] In one such study, Abusalma et al 3 found that 41.8% of the Tn I tests were requested inappropriately. The study was followed up after some educational intervention which resulted in the reduction of inappropriate testing of troponin almost by half compared to earlier numbers.…”

“…As the hospital does not have its own guideline for troponin ordering, we consulted the guidelines for pathology testing in ED provided by the Australasian College for Emergency Medicine along with other similar studies. 4,[10][11][12][13] Troponin testing was advised in patients presenting with cardiorespiratory symptoms, radiating pain and central nervous system symptoms. The clinical reasons for ordering troponin pathology test are mentioned in Table 1.…”