Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study

• Published in: The Journal of emergency medicine Vol. 54; no. 4; pp. 549 - 557
• Main Authors: Hyams, Jessica M., Streitz, Matthew J., Oliver, Joshua J., Wood, Richard M., Maksimenko, Yevgeniy M., Long, Brit, Barnwell, Robert M., April, Michael D.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2018
• Subjects: accelerated disposition pathway; Age Factors; Chest Pain - diagnosis; chest pain discharge; chest pain in the emergency department; clinical decision rule; Cohort Studies; Electrocardiography - methods; Emergency Service, Hospital - organization & administration; Emergency Service, Hospital - statistics & numerical data; Female; HEART pathway; HEART score; Hospitalization - statistics & numerical data; Humans; low-risk chest pain; Male; Middle Aged; Outcome Assessment (Health Care) - statistics & numerical data; Risk Factors; Severity of Illness Index; Treatment Outcome; Troponin - analysis; Troponin - blood; Validation Studies as Topic; HEART pathway; HEART score; low-risk chest pain; clinical decision rule; chest pain in the emergency department; accelerated disposition pathway; chest pain discharge
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2017.12.038

Chest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful. To compare admission rates prior to and after implementation of an accelerated disposition pathway for ED patients with low-risk chest pain based upon the HEART (History, ECG, Age, Risk factors, Troponin) score (HEART pathway). We conducted an impact analysis of the HEART pathway. Patients with a HEART score ≥ 4 underwent hospital admission for cardiac risk stratification and monitoring. Patients with a HEART score ≤ 3 could opt for discharge with 72-h follow-up in lieu of admission. We collected data on cohorts prior to and after implementation of the new disposition pathway. For each cohort, we screened the charts of 625 consecutive chest pain patients. We measured patient demographics, past medical history, vital signs, HEART score, disposition, and 6-week major adverse cardiac events (MACE) using chart review methodology. We compared our primary outcome of hospital admission between the two cohorts. The admission rate for the preintervention cohort was 63.5% (95% confidence interval [CI] 58.7–68.2%), vs. 48.3% (95% CI 43.7–53.0%) for the postintervention cohort. The absolute difference in admission rates was 15.3% (95% CI 8.7–21.8%). The odds ratio of admission for the postintervention cohort in a logistic regression model controlling for demographics, comorbidities, and vital signs was 0.48 (95% CI 0.33–0.66). One postintervention cohort patient leaving the ED against medical advice (HEART Score 4) experienced 6-week MACE. The HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.