Background:
Approximately 6 million U.S. patients present to emergency departments annually with symptoms suggesting acute cardiac ischemia. Triage decisions for these patients are important but remain difficult.
Objective:
To test whether computerized prediction of the probability of acute ischemia, used with electrocardiography, improves the accuracy of triage decisions.
Design:
Controlled clinical trial.
Setting:
10 hospital emergency departments in the midwestern, southeastern, and northeastern United States.
Patients:
10 689 patients with chest pain or other symptoms suggestive of acute cardiac ischemia.
Intervention:
The probability of acute ischemia predicted by the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI), either automatically printed or not printed on patients' electrocardiograms.
Measurements:
Emergency department triage to a coronary care unit (CCU), telemetry unit, ward, or home. Other measurements were the bed capacity of the CCU relative to that of the telemetry unit; training or supervision status of the triaging physician; and patient diagnoses and outcomes based on clinical, electrocardiographic, and creatine kinase data.
Results:
For patients without cardiac ischemia, in hospitals with high-capacity CCUs and relatively low-capacity cardiac telemetry units, use of ACI-TIPI was associated with a reduction in CCU admissions from 15% to 12%, a change of −16% (95% CI, −30% to 0%), and an increase in emergency department discharges to home from 49% to 52%, a change of 6% (CI, 0% to 14%; overall P = 0.09). Across all hospitals, for patients evaluated by unsupervised residents, use of ACI-TIPI was associated with a reduction in CCU admissions from 14% to 10%, a change of −32%(CI, −55% to 3%); a reduction in telemetry unit admissions from 39% to 31%, a change of −20%(CI, −34% to −2%);and an increase in discharges to home from 45% to 56%, a change of 25% (CI, 8% to 45%; overall P = 0.008).
Among patients with stable angina, in hospitals with high-capacity CCUs, use of ACI-TIPI was associated with a reduction in CCU admissions from 26% to 13%, a change of −50%(CI, −70% to −17%),and an increase in discharges to home from 20% to 22%, a change of 10% (CI, −29% to 71%; overall P = 0.02). At hospitals with high-capacity telemetry units, use of ACI-TIPI was associated with a reduction in telemetry unit admissions from 68% to 59%, a change of −14%(CI, −27% to 1%), and an increase in emergency department discharges to home from 10% to 21%, a change of 100% (CI, 22% to 230%; overall P = 0.02).
Among patients with acute myocardial infarction or unstable angina, use of ACI-TIPI did not change appropriate admission (96%) to the CCU or telemetry unit at hospitals with high-capacity CCUs or telemetry units.
Conclusions:
Use of ACI-TIPI was associated with reduced hospitalization among emergency department patients without acute cardiac ischemia. This result varied as expected according to the CCU and cardiac telemetry unit capacities and physician supervision at individual hospitals. Appropriate admission for unstable angina or acute infarction was not affected. If ACI-TIPI is used widely in the United States, its potential incremental impact may be more than 200 000 fewer unnecessary hospitalizations and more than 100 000 fewer unnecessary CCU admissions.
References
- 1. Pozen MW, D'Agostino RB, Selker HP, Sytkowski PA, Hood WB Jr. A predictive instrument to improve coronary-care-unit admission practices in acute ischemic heart disease. A prospective multicenter clinical trial. N Engl J Med. 1984; 310:1273-8. Google Scholar
- 2. Fineberg HV, Scadden D, Goldman L. Care of patients with a low probability of acute myocardial infarction. Cost effectiveness of alternatives to coronary-care-unit admission. N Engl J Med. 1984; 310:1301-7. Google Scholar
- 3. McCarthy BD, Beshansky JR, D'Agostino RB, Selker HP. Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study. Ann Emerg Med. 1993; 22:579-82. Google Scholar
- 4. Lee TH, Rouan GW, Weisberg MC, Brand DA, Acampora D, Stasiulewicz C, et al. Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Cardiol. 1987; 60:219-24. Google Scholar
- 5. Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, et al. An evaluation of technologies for detecting acute cardiac ischemia in the emergency department: a report from a National Heart Attack Alert Program Working Group. Ann Emerg Med. 1997; 29:13-87. Google Scholar
- 6. McCarthy BD, Wong JB, Selker HP. Detecting acute cardiac ischemia in the emergency department: a review of the literature. J Gen Intern Med. 1990; 5:365-73. Google Scholar
- 7. Jayes RL Jr, Larsen GC, Beshansky JR, D'Agostino RB, Selker HP. Physician electrocardiogram reading in the emergency department-accuracy and effect on triage decisions: findings from a multicenter study. J Gen Intern Med. 1992; 7:387-92. Google Scholar
- 8. Selker HP, Griffith JL, D'Agostino RB. A tool for judging coronary care unit admission appropriateness, valid for both real-time and retrospective use. A time-insensitive predictive instrument (TIPI) for acute cardiac ischemia: a multicenter study. Med Care. 1991; 29:610-27. Google Scholar
- 9. Selker HP, D'Agostino RB, Laks MM. A predictive instrument for acute ischemic heart disease to improve coronary care unit admission practices: a potential on-line tool in a computerized electrocardiograph. J Electrocardiol. 1988; 21 Suppl:S11-7. Google Scholar
- 10. Cairns CB, Niemann JT, Selker HP, Laks MM. Computerized version of the time-insensitive predictive instrument. Use of the Q wave, ST-segment, T wave, and patient history in the diagnosis of acute myocardial infarction by the computerized ECG. J Electrocardiol. 1991; 24 Suppl:46-9. Google Scholar
- 11. Sarasin FP, Reymond JM, Griffith JL, Beshansky JR, Schifferli JA, Unger PF, et al. Impact of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) on the speed of triage decision making for emergency department patients presenting with chest pain: a controlled clinical trial. J Gen Intern Med. 1994; 9:187-94. Google Scholar
- 12. Aufderheide TP, Rowlandson I, Lawrence SW, Kuhn EM, Selker HP. A test of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) for prehospital use. Ann Emerg Med. 1996; 27:193-8. Google Scholar
- 13. Selker HP. Systems for comparing actual and predicted mortality rates: characteristics to promote cooperation in improving hospital care [Editorial]. Ann Intern Med. 1993; 118:820-2. Google Scholar
- 14. Jayes RL Jr, Beshansky JR, D'Agostino RB, Selker HP. Do patients' coronary risk factor reports predict acute cardiac ischemia in the emergency room? A multicenter study. J Clin Epidemiol. 1992; 45:621-6. Google Scholar
- 15. Selker HP, Griffith JL, Dorey FJ, D'Agostino RB. How do physicians adapt when the coronary care unit is full? A prospective multicenter study. JAMA. 1987; 257:1181-5. Google Scholar
- 16. Gillum RF, Fortmann SP, Prineas RJ, Kottke TE. International diagnostic criteria for acute myocardial infarction and acute stroke. Am Heart J. 1984; 108:150-8. Google Scholar
- 17. Campeau L. Grading of angina pectoris [Letter]. Circulation. 1976; 54:522-3. Google Scholar
- 18. Cochrane AL. Effectiveness and Efficiency. Random Reflections on Health Services. Cambridge Univ Pr; 1971. Google Scholar
- 19. Braunwald E, Mark DB, Jones RH, Cheitlin MD, Fuster V, McCaulery KM, et al. Unstable angina: diagnosis and management. In: Unstable Angina: Diagnosis and Management. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, National Heart, Lung, and Blood Institute; 1994. AHCPR publication 94-0602. Google Scholar
- 20. Selker HP. Coronary care unit triage decision aids: how do we know when they work? [Editorial] Am J Med. 1989; 87:491-3. Google Scholar
- 21. Lee TH, Pearson SD, Johnson PA, Garcia TB, Weisberg MC, Guadagnoli E, et al. Failure of information as an intervention to modify clinical management. A time-series trial in patients with acute chest pain. Ann Intern Med. 1995; 122:434-7. Google Scholar
Author, Article, and Disclosure Information
From New England Medical Center/Tufts University School of Medicine, Boston City Hospital, and Boston University Medical Center, Boston, Massachusetts; Medical College of Wisconsin, Milwaukee, Wisconsin; Newton-Wellesley Hospital, Wellesley, Massachusetts; Baystate Medical Center, Springfield, Massachusetts; University of Cincinnati Medical Center, Cincinnati, Ohio; University of North Carolina Hospitals, Chapel Hill, North Caro lina; Rhode Island Hospital, Providence, Rhode Island;
and Medical College of Virginia, Richmond, Virginia.
Medical College of Wisconsin: Sarah Lawrence, RN; New England Medical Center: Bonnie MacLeod, Teresa Pazdral, Diane Pietraskiewicz, RN, Fred Breen, RN; Newton-Wellesley Hospital: Carmel Brodeur, RN, Assad Sayah, MD; Rhode Island Hospital: Emily Connolly, RN, Donna Cimini, RN; University of Cincinnati Medical Center: Julie Gerlach, RN, MPH; and University of North Carolina Hospitals: David Egner, Grant Fletcher.
The authors thank Jane Scott, ScD, for her tireless support of this trial as its AHCPR Project Officer, Julie Sullivan for expert manuscript preparation, and Robin Ruthazer and Stacy Supran for statistical assistance.
Ms. Beshansky, Dr. Griffith, Dr. Ballin, and Dr. Salem: New England Medical Center/Tufts University School of Medicine, 750 Washington Street, Boston, MA 02111.
Dr. Aufderheide: John Doyne Hospital, 9200 West Wisconsin Avenue, Froedtert East Milwaukee, WI 53226.
Drs. Bernard, Crespo, Feldman, Fish, and Podrid: Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118.
Dr. Kiez: 1650 Mathers Bay West, Winnipeg, Manitoba R3N OT7, Canada.
Dr. Pope: Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199.
Drs. Gibler and Sayre: University of Cincinnati Medical Center, 231 Bethesda Avenue, Cincinnati, OH 45267.
Dr. McNutt: Chicago Cook County Hospital, 1900 West Polk Street, Chicago, IL 60612.
Drs. Moulton and Woolard: Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.
Dr. Ornato: Medical College of Virginia, 401 North 12th Street, Richmond, VA 23298.
Acknowledgments: This study was made possible by the commitment and cooperation of the emergency department staff at each participating hospital and the following research coordinators, research assistants, and medical and nursing staff: Baystate Medical Center: Del Blank, RN, MBA, Brian Hession; Boston City Hospital: Tracy Kerl, RN; Boston University Medical Center: Richard Caggiano, MD, Margo Mitchell, RN; Medical College of Virginia: Patricia Wright, RN, Edgar Gonzalez, PharmD;
Grant Support: By the Agency for Health Care Policy and Research (RO1 HS07360).
Corresponding Author: Harry P. Selker, MD, Division of Clinical Care Research, New England Medical Center, #63, 750 Washington Street, Boston, MA 02111.
Current Author Addresses: Dr. Selker: Division of Clinical Care Research, New England Medical Center, #63, 750 Washington Street, Boston, MA 02111.
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