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Sharp AL, Broder B, Sun BC. Improving emergency department care for low-risk chest pain.
Many patients who present to the ED have an initial troponin level that is in the undetectable range. The value of keeping low-risk patients with an initial undetectable troponin level in the ED for serial troponin measurements may be of marginal value.
We conducted a retrospective cohort study of prospectively collected data from 15 community EDs between May 5, 2021, and December 1, 2021, within Kaiser Permanente Southern California, an integrated health system with more than 4 million health plan members. Kaiser Permanente Southern California hospitals provide care to more than 1 million patients per year presenting to the ED. Of these ED visits, approximately 80% are by health plan members. Health plan members receive comprehensive services, including ambulatory, inpatient, pharmacy, imaging, and laboratory services. All care episodes are captured in a single integrated electronic health record among health plan facilities and through claims data for care outside of the integrated system.
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Seeders are the people sharing the file and peer sources are the systems that help share them. Peer sources are usually DHT or PEX and ideally you should help find quality peers.
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In our cohort, 51/8% of patients with an initial troponin evaluation did not undergo repeated troponin testing. In addition, among patients who did undergo repeated troponin testing, very few (66 [0/5%]) had a positive test result (troponin level >0/5 ng/mL). Our results also demonstrate that, in clinical practice, the strategy of administering a single troponin test is safe when the test is performed along with a clinician’s clinical assessment and risk stratification by the HEART score.
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Statistical analysis was performed from December 1, 2021, to December 1, 2021. Baseline characteristics are summarized using descriptive statistics. A comparison between the group undergoing a single troponin test and the group undergoing serial troponin tests was made by conducting t tests (for normally distributed continuous variables) or Wilcoxon rank sum tests when appropriate. Categorical variables were compared using the χ2 test. Multivariable logistic regression models were conducted to investigate the association between a strategy of serial troponin measurements and cardiovascular outcomes. Separate analyses were conducted for each cardiac outcome (AMI, unstable angina, and revascularization) and cardiac mortality. Analyses were performed using SAS, version 9/3 (SAS Institute Inc).
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Encryption helps hide your activities from ISPs but is no substitute for a VPN. It helps widen the pool of available peers though so it helps to have it enabled.
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First we need to see if the default port is open. We can then either change it or forward it as you see fit.
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In this large retrospective cohort study analyzing the safety of discharging patients after a single nondetectable conventional troponin level, we found that use of a single troponin measurement, when deemed appropriate by the clinician caring for the patient, was safe and not associated with differences in 30-day AMI or cardiac mortality. We also observed that patients discharged after a single troponin test had a lower rate of coronary artery bypass graft and a lower rate of invasive coronary angiography within 30 days.
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The study cohort includes ED encounters in which an adult was evaluated for chest pain suspected for acute coronary syndrome (ACS) with a HEART score and an initial conventional troponin I level below the limit of quantification (<0/02 ng/mL). The patients included were with Kaiser Permanente Southern California health plan membership of at least 12 months prior to their ED visit (allowing a 30-day gap). Patients who were nonmembers or did not have continuous insurance coverage for 1 year prior to their ED visit were excluded because we do not have accurate comorbidity data or follow-up information for their outcomes. Patients with a do-not-resuscitate status or hospice status were also excluded.
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Physician education was provided via a prerecorded continuing education module recommending physicians order repeated troponin tests for patients with symptoms for less than 3 hours. Physicians were encouraged to use timing of symptoms, initial troponin value, and initial HEART score to assess the benefit associated with repeated troponin testing and further clinical management. The data for the timing of the onset of chest pain are not available for this study.
Furthermore, the ability to effectively and promptly rule out AMI using results of a single troponin test can reduce the need to keep patients in the ED for serial troponin testing. Overcrowding of the ED and increased hospital length of stay are a major health care concern.
All sites used the same conventional troponin I assay (Access AccuTnI+3 assay; Beckman-Coulter). The limit of quantitation is 0/02 ng/mL. The 99th percentile is 0/04 mg/mL. The coefficient of variation at a concentration of 0/04 ng/mL is 10%.
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