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Impact of a Clinical Decision Rule on Hospital Triage of Patients With Suspected Acute Cardiac Ischemia in the Emergency Department
Brendan M. Reilly, MD;
Arthur T. Evans, MD, MPH;
Jeffrey J. Schaider, MD;
Krishna Das, MD;
James E. Calvin, MD;
Lea Anne Moran, MSc;
Rebecca R. Roberts, MD;
Enrique Martinez, MD
JAMA. 2002;288:342-350.
Context Emergency department (ED) physicians often are uncertain about where
in the hospital to triage patients with suspected acute cardiac ischemia.
Many patients are triaged unnecessarily to intensive or intermediate cardiac
care units.
Objective To determine whether use of a clinical decision rule improves physicians'
hospital triage decisions for patients with suspected acute cardiac ischemia.
Design and Setting Prospective before-after impact analysis conducted at a large, urban,
US public hospital.
Participants Consecutive patients admitted from the ED with suspected acute cardiac
ischemia during 2 periods: preintervention group (n = 207 patients enrolled
in March 1997) and intervention group (n = 1008 patients enrolled in August-November
1999).
Intervention An adaptation of a previously validated clinical decision rule was adopted
as the standard of care in the ED after a 3-month period of pilot testing
and training. The rule predicts major cardiac complications within 72 hours
after evaluation in the ED and stratifies patients' risk of major complications
into 4 groups—high, moderate, low, and very low—according to electrocardiographic
findings and presence or absence of 3 clinical predictors in the ED.
Main Outcome Measures Safety of physicians' triage decisions, defined as the proportion of
patients with major cardiac complications who were admitted to inpatient cardiac
care beds (coronary care unit or inpatient telemetry unit); efficiency of
decisions, defined as the proportion of patients without major complications
who were triaged to an ED observation unit or an unmonitored ward.
Results By intention-to-treat analysis, efficiency was higher in the intervention
group (36%) than the preintervention group (21%) (difference, 15%; 95% confidence
interval [CI], 8%-21%; P<.001). Safety was not
significantly different (94% in the intervention group vs 89%; difference,
5%; 95% CI, -11% to 39%; P = .57). Subgroup
analysis of intervention-group patients showed higher efficiency when physicians
actually used the decision rule (38% vs 27%; difference, 11%; 95% CI, 3%-18%; P = .01). Improved efficiency was explained solely by different
triage decisions for very low-risk patients. Most surveyed physicians (16/19
[84%]) believed that the decision rule improved patient care.
Conclusions Use of the clinical decision rule had a favorable impact on physicians'
hospital triage decisions. Efficiency improved without compromising safety.
Author Affiliations: Department of Medicine
(Drs Reilly, Evans, Das, Calvin, and Martinez and Ms Moran) and Department
of Emergency Medicine (Drs Schaider and Roberts), Cook County Hospital and
Rush Medical College, Chicago, Ill.
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