Aim To compare the length of stay, efficacy and safety of a new 0h/1h algorithm, utilising a high sensitivity troponin T (HsTnT) assay, with the previous standard 3 hour troponin at the Brighton and Sussex University Hospitals NHS Trust (BSUH) Emergency Departments (ED).
Methods The 2015 ESC guidelines approved a 1 hour algorithm used in conjunction with a HsTnT assay and clinical assessment to safely “rule-out” an NSTEMI in patients presenting to the ED with suspected ACS. We collected data on all patients attending the ED with suspected ACS in April 2017-pre and April 2018-post pathway implementation. The pathway triages patients into “rule-in”, “rule-out” and “observation” groups. The initial pathway we developed included a lower cut-off than the ESC algorithm, <3 versus (v) <5 ng/L for the initial troponin value (To) in order to allocate a patient to the “rule-out” group. 30-day all-cause mortality and major adverse cardiovascular events (MACE) were collected for both years. The final diagnosis was collected from discharge summaries for those admitted from the ED.
Results In April 2017 v April 2018 there were 391 v 491 patients who presented to the ED with suspected ACS. Mean age of 61 v 57 years and 59.3% v 58.5% male.
There was a reduction with the new pathway in the median time from ED arrival to discharge for all discharged patients 3.92 hours [IQR = 3.18–6.23] v 3.78 hours [IQR = 3.2–5.17]. In patients triaged to the “rule-out” group, 281 v 392, the median time from ED arrival to discharge was 3.82 hours [IQR = 3–5.87] v 3.63 hours [IQR = 3.07–3.98] (see figure 1). In those who had a To value > 12ng/L, 63 v 71 patients, and subsequently discharged home, there was a significant reduction in the median time from ED arrival to discharge from 4.67 hours [IQR = 3.27–8.83] to 3.93 hours [IQR = 3.55–5.18] (see figure 2).
In April 2018 65.6%, 24.4% and 10% of patients with a suspected ACS were triaged to the “rule-out”, “observation” and “rule-in” groups respectively. A diagnosis of ACS was made in 10.83% and 63.3% of patients in the “observation” and “rule-in” groups respectively.There was a significant reduction in the proportion of patients admitted 27.9% v 20% with an increase in those admitted being given a primary cardiac diagnosis at discharge 52.4% v 71.7%. For patients triaged to the “rule out” group and discharged home from the ED there were no MACE (1 MACE in the rule in group appropriately discharged after cardiology review) and no deaths in April 2018 compared with 2 MACE and no deaths in April 2017. For patients in April 2018 with an initial troponin <5ng/L and discharged home there were no MACE or deaths at 30 days.
Conclusion Our results have shown a significant reduction in the median time from ED arrival to discharge, a benefit greatest seen in those presenting with a To value > 12ng/L. A greater number of patients were discharged from the ED. In those admitted there was an increased PPV for a cardiac diagnosis on discharge. The new pathway was also shown to be safe.
In an NHS era of overwhelmed EDs, 4 hour targets and high inpatient bed occupancy our results have shown the new 0/1h troponin pathway to be more efficacious than our previous care. Patients were safely triaged to a quicker discharge, with a reduced proportion of admissions. To continue improving the efficacy of the new pathway we have increased the cut off for To to 5ng/L in January 2019 and plan to further reassess this pathway.
Conflict of Interest None
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