This article has three things I like – information graphics, informed patients, and an attempt to reduce low-yield chest pain admissions. Unfortunately, in the end, I’m not sure about the strategy.
This is a prospective study in which the authors developed an information graphic attempting to illustrate the outcome risks for low-risk chest pain presentations. They use this information graphic as the intervention in their study population to help educate patients regarding the decision whether to be observed in the hospital with potential provocative stress testing, or whether they would like to be discharged from the Emergency Department to follow-up for an outpatient provocative test. They were attempting to show that use of this decision aid would lead to increased patient knowledge and satisfaction, as well as reduce observation admissions for low-risk chest pain.
The good news: it definitely works. Patients reported increased knowledge, most were happy with the decision instrument, and a significantly increased proportion elected to be discharged from the Emergency Department – 58% of the decision aid group wanted to stay vs. 77% of the “usual care” arm wanted to stay.
My only problem: this study truly exposes the invalidity of our current management of chest pain. If these patients are low-risk and they’re judged safe enough for the outpatient strategy in this study – why are any of them being offered admission? Of course, it’s probably because they don’t have timely follow-up, and AHA guidelines dictate stress testing urgently following the index visit. But, truly, in an ideal world, few (if any) of these low-risk patients – such as the one who ruled in by enzymes – should be offered admission.
But, other than that, I’m all for information graphics and patient education techniques to include them in a shared decision-making process!
“The Chest Pain Choice Decision Aid : A Randomized Trial”
www.ncbi.nlm.nih.gov/pubmed/22496116
I am sure I am misunderstanding your statement.
Only patients that rule in should be admitted?
What about all the unstable angina patients that are at high risk for morbidity and mortality?
Are you advocating for a two set 6 hour rule out for all patients with chest pain? One set does not rule out anything. Two sets backs up my ED tremendously with patients being there for 6-8 hours. We do NOT have a chest pain observation area.
Chest pain is a big problem in my ED as I am sure it is in many.
What's probably not clear from the statement above is that, of the 200 patients selected for this intervention, only one patient had a cardiac event within 30 days. Specifically, one patient in the decision aid group elected to stay and subsequently ruled in by enzymes. So, essentially, I'm simply lamenting that this very low risk group in which only one true cardiac event occurred – although 5 patients eventually had revascularization as well – was offered admission. Ideally, and, perhaps in an ACO with the correct financial incentives, this entire cohort would be managed as an outpatient rather than being offered admission but also given the option to go home. Higher-risk patients with risk factors, true unstable angina, etc. should still be managed as inpatients/observation – but perhaps not the group of patients selected for this intervention.
ACEP guidelines do allow for 2-hour delta cardiac markers – you don't need 6-8 hours to rule someone out for NSTEMI in the ED. I do it routinely.