Article Text
PDF
Abstract
Objectives To determine whether using a point-of-care cardiac biomarker panel would increase the rate of successful discharge home after emergency department assessment, and affect the use of cardiac tests and treatments, subsequent attendance at or admission to hospital and major adverse events.
Design and setting Pragmatic multicentre randomised controlled trial in six acute hospitals in the UK.
Participants Patients attending with acute chest pain due to suspected myocardial infarction (N=2243).
Interventions Diagnostic assessment using a point-of-care biomarker panel consisting of creatine kinase, myocardial type, myoglobin and troponin I measured at baseline and 90 min compared with standard care without the point-of-care panel.
Main outcome measures The primary outcome was successful discharge home, defined as having left hospital or awaiting transport home by 4 h after attendance and no major adverse events up to 3 months. Secondary outcome measures included length of stay, use of coronary care, cardiac interventions and inpatient beds, emergency department attendances, subsequent admissions, outpatient visits and major adverse events.
Results Point-of-care panel assessment was associated with an increased rate of successful discharge (358/1125 (32%) vs 146/1118 (13%); OR 3.81, 95% CI 3.01 to 4.82; p<0.001), reduced median length of initial hospital stay (8.8 vs 14.2 h; p<0.001) and greater use of coronary care (50/1125 (4.0%) vs 31/1118 (3.0%); p=0.041), but no difference in mean length of initial stay (29.6 vs 31.7 h; p=0.462), mean inpatient days over follow-up (1.8 vs 1.7; p=0.815) or major adverse events (36 (3%) vs 26 (2%); OR 1.31, 95% CI 0.78 to 2.20; p=0.313).
Conclusions Point-of-care panel assessment increases successful discharge home and reduces median length of stay, but does not alter overall hospital bed use.
Trial registration Current controlled trials ISRCTN37823923.
- Acute coronary syndrome
- delivery of care
- emergency medicine
Statistics from Altmetric.com
Footnotes
↵* For members of the RATPAC research team see the end of the paper.
The RATPAC Research Team Charlotte Arrowsmith (RATPAC research nurse, Derriford Hospital, Plymouth); Julian Barth (consultant in chemical pathology, Leeds General Infirmary/co-applicant); Jonathan Benger (professor of emergency care, University of the West of England/co-applicant); Mike Bradburn (senior medical statistician, Clinical Trials Research Unit, University of Sheffield); Simon Capewell (professor of epidemiology, University of Liverpool/co-applicant); Tim Chater (database manager, Clinical Trials Research Unit, University of Sheffield); Tim Coats (professor of emergency medicine/co-applicant); Paul Collinson (consultant in chemical pathology, St George's Hospital, London/co-applicant); Cindy Cooper (director, Clinical Trials Research Unit, University of Sheffield); Mandy Cooper (RATPAC research nurse, Leicester Royal Infirmary); Judy Coyle (RATPAC research nurse, Edinburgh Royal Infirmary); Liz Cross (trial manager, Health Services Research, University of Sheffield); Simon Dixon (professor of health economics, health economics and decision science/co-applicant); Patrick Fitzgerald (research fellow, health economics and decision science, University of Sheffield); Emma Gendall (RATPAC research nurse, Frenchay Hospital, Bristol); Steve Goodacre (professor of emergency medicine, Health Services Research, University of Sheffield/chief investigator); Emma Goodwin (RATPAC research nurse, Barnsley Hospital); Alasdair Gray (consultant in emergency medicine, Royal Infirmary of Edinburgh/co-applicant); Alistair Hall (professor of clinical cardiology, University of Leeds/co-applicant); Kevin Hall (RATPAC research nurse, Barnsley Hospital); Taj Hassan (consultant in emergency medicine, Leeds General Infirmary/co-applicant); Julian Humphrey (consultant in emergency medicine, Barnsley Hospital); Steven Julious (senior lecturer in medical statistics, Medical Statistics Group, Health Services Research, University of Sheffield/co-applicant); Jason Kendall (consultant in emergency medicine, Frenchay Hospital, Bristol); Vanessa Lawlor (RATPAC research nurse, Frenchay Hospital, Bristol); Sue Mackness (RATPAC research nurse, Leicester Royal Infirmary); Yvonne Meades (RATPAC research nurse, Leeds General Infirmary); David Newby (professor of cardiology, University of Edinburgh/co-applicant); Dawn Newell (RATPAC research nurse, Leicester Royal Infirmary); Doris Quartey (RATPAC research nurse, Leeds General Infirmary); Karen Robinson (RATPAC research nurse, Leicester Royal Infirmary); Glen Sibbick (RATPAC research nurse, Leicester Royal Infirmary); Jason Smith (consultant in emergency medicine, Derriford Hospital, Plymouth); Roz Squire (RATPAC research nurse, Derriford Hospital, Plymouth).
Trial Steering Committee Simon Carley, consultant in emergency medicine, Manchester Royal Infirmary (independent member); Paul Collinson, consultant in chemical pathology, St George's Hospital, London (co-applicant); Liz Cross, research associate, Health Services Research, University of Sheffield (trial manager); Sue Dodd, CHD emergency and acute care manager (vascular programme) Department of Health (independent member); Marcus Flather, director, Clinical Trials and Evaluation Unit, Royal Brompton Hospital, London (chair); Steve Goodacre, professor of emergency medicine, Health Services Research, University of Sheffield (chief investigator); Sara Hilditch, statistician, director of Statistical Services Unit, Sheffield University (independent member); Enid Hirst (lay representative); Richard Hudson, quality assurance manager, Research Office, Academic Division, University of Sheffield (sponsor representative); Jason Kendall, consultant in emergency medicine, Frenchay Hospital, Bristol (investigator representative); Rebecca Whitlock-Moss, programme manager, National Institute for Health Research Health Technology Assessment (funder representative).
Data Monitoring Committee John Greenwood, senior lecturer/consultant cardiologist, Academic Unit of Cardiovascular Medicine, Leeds General Infirmary (independent clinician); Jon Nicholl, professor of health services research, University of Sheffield (acting chair); Helen Thorpe, principal statistician, Clinical Trials Research Unit, University of Leeds (chair and independent statistician); William Townend, consultant in emergency medicine, Hull Royal Infirmary (independent clinician).
Disclaimer The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the National Institute for Health Research Health Technology Assessment.
Funding The RATPAC trial was funded by the National Institute for Health Research Health Technology Assessment programme (no 06/302/19) and sponsored by the University of Sheffield. The study funders had no role in study design, in the collection, analysis and interpretation of data, in the writing of the report or in the decision to submit the paper for publication. The researchers were independent of the study funders. All authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.
Competing interests None.
Ethics approval The study was granted ethics approval by Leeds East Research Ethics Committee and review was provided by the local research ethics committee at each participating centre.
Provenance and peer review Not commissioned; externally peer reviewed.