Development of a Clinical Care Pathway for Patients with Suspected Acute Coronary Syndromes in the Emergency Department
Date
2020-04-30
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Abstract
Chest pain is a predominant reason for emergency department (ED) visits and hospitalizations in Canada. ED physicians use diagnostic tools (e.g., biomarkers) to identify patients with myocardial infarction (MI) requiring intervention, and prognostic tools (e.g., risk scores) to determine which patients without MI are eligible for discharge. While clinical guidelines recommend that these two portions of the assessment occur sequentially, the evidence for each has emerged in isolation. There is also a paucity of evidence on risk score use in the era of high-sensitivity cardiac troponin (hs-cTn) assays, adverse event risk factors for patients without MI, and appropriate timelines for follow-up. This project had three complimentary objectives: (1) Synthesize available evidence on prognostic prediction score performance when hs-cTn assays are incorporated; (2) Quantify the time course of major adverse cardiac events (MACE) in patients without index MI and identify characteristics with potential predictive value for MACE, and; (3) Develop a sequential clinical pathway for the assessment of chest pain in the ED and measure the impacts on diagnostic and prognostic accuracy as well as ED patient flow. A systematic review was conducted to synthesize evidence on the chest pain risk scores to be prioritized for integration into the clinical pathway. A time-to-event analysis was then conducted to measure timing of MACE in patients without index MI, as well as a stratified analysis to identify characteristics with predictive value for 30-day MACE to be used in the pathway for clinical stratification. Trial clinical pathways were developed and quantitatively compared. Pathways combined a validated 2-hour hs-cTn diagnostic algorithm with variable clinical pre-stratification, risk score types, and low-risk cut-offs. A sequential clinical pathway using a validated hs-cTn algorithm and the HEART score can identify nearly 40% of ED chest pain patients as eligible for discharge without the need for further testing with no missed MI or 30-day MACE. This thesis project contributed evidence necessary for the updating and advancing of the ED chest pain assessment and presents an evidence-based sequential clinical pathway that maximizes the efficiency of the ED chest pain assessment.
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Keywords
Emergency Department, Chest Pain, Clinical Pathway, High-Sensitivity Cardiac Troponin Assays
Citation
O'Rielly, C. M. (2020). Development of a Clinical Care Pathway for Patients with Suspected Acute Coronary Syndromes in the Emergency Department (Master's thesis, University of Calgary, Calgary, Canada). Retrieved from https://prism.ucalgary.ca.