Some chest pain patients may be discharged early
Some chest pain patients may be discharged early
Study’s findings still are preliminary
A team of Canadian researchers has developed the "Vancouver Chest Pain Rule," that they say may be used to identify and safely discharge emergency patients with chest pain from the emergency department, following evaluation.
In a study published on-line by the Annals of Emergency Medicine1, the team reported that the rule was 98.8% sensitive and 32.5% specific. This means that of all the ED patients identified over a 30-day period who developed acute coronary syndrome (ACS), the rule would identify 98.8% of those at risk for deterioration if sent home early. "This is a lower [error rate] than anywhere else in the literature," asserts James Christenson, MD, research director and clinical emergency physician at St. Paul’s Hospital Department of Emergency Medicine and clinical professor at the University of British Columbia, both in Vancouver (Christenson led the team of researchers). But being that sensitive, he adds, it is relatively nonspecific, and keeps additional patients for work-up that do not have acute coronary syndrome. In attempting to identify patients with a potentially deadly disease, say emergency medicine experts, it is best for a rule to have a high sensitivity.
The rule basically says chest pain patients under the age of 40 with normal initial electrocardiogram (EKG) and no prior history of ischemic chest pain are suitable for early discharge. For older patients with low-risk pain characteristics, a few additional test results, including initial creatine kinase (CK)-MB under 3.0, or initial CK-MB over 3.0, but no change in EKG or rise in CK-MB within two hours of arrival, would qualify them for early discharge.
Christenson says he wanted to create such a tool because his ED had noted they were sending home some patients with ACS in error "and the realization that we did not have an organized structure on which to base the decision to discharge patients or keep them for further observation." This was coupled, he says, with his own research into U.S. models of chest pain units where, he claims, patients with a very low probability of ACS were kept in the units and given expensive work-ups.
"This is not practical for us," he says. "We set out to find, from a busy ED’s point of view, if we could define a group of patients within a couple of hours who we thought were safe to go home."
Christenson claims that earlier tools were "not commonly developed from a clinical perspective; most were founded on statistical methodologies to identify probability of disease."
These models, he says, can identify patients with a 4% or 5% chance of disease, "But a clinician can’t act on this. Our tool looks for patients who should be discharged or not — not a percentage."
Results not a surprise
The findings are not a surprise to Jesse DiRando, MD, FACEP, director of emergency services, Parma (OH) Community General Hospital/EMP of Cuyahoga, and director of the chest pain observation Unit at Parma Community.
"It intuitively validates what we already suspected: that patients between the ages of 25 and 40 with no major risk factors and normal EKGs have a very low instance of acute coronary syndrome," he says. As far as the actual protocol being suggested, "what I will tell you is that what we do with our chest pain observation unit is just about the same thing, without applying the Vancouver Rule’ by name," he says.
DiRando adds, however, that while the findings would not change clinical practices at his facility, "if you were in an ED that had no chest pain observation ability, it might change your approach slightly." In such an ED, he notes, "You’d be presented with the option of either admitting the patient or sending him home. If you didn’t have the ability to do what we do in rule-out observation, [the older low-risk patients] probably would have been admitted." In his facility, such patients would be put in observation. "If we followed the rule, we might not admit some for observation," he concedes. "If you ask me retrospectively which is more comprehensive, it’s ours. But their point is, there is a lot of unnecessary testing."
Even Christenson says it is too early to call for clinical adoption of the rule. "This rule has been developed in a population of 769, which we think is reasonably representative, but it has not yet been validated [by a more detailed prospective study]," he emphasizes. "ED managers may want to educate their physicians about the rule and let them make individual judgments, but it should not be incorporated into a clinical pathway."
Reference
- Christenson J, Innes G, McKnight D, et al. A clinical prediction rule for early discharge of patients with chest pain. Doi:10.10.16/ j.annemergmed.2005.08.0078.
Sources
For more information on assessing chest pain patients, contact:
- James Christenson, MD, Research Director, Clinical Emergency Physician, St. Paul’s Hospital Department of Emergency Medicine, Clinical Professor, University of British Columbia, Vancouver. Phone: (604) 660-6910.
- Jesse DiRando, MD, FACEP, Director, Emergency Services, Parma (OH) Community General Hospital/ Emergency Medicine Physicians of Cuyahoga. E-mail: [email protected].
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