J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 3 7 5 e3 8 3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Original Research Article
Safe and rapid disposition of low-to-intermediate risk patients presenting to the emergency department with chest pain: A 1-year high-volume single-center experience Ronald L. Jones MDa, Dustin M. Thomas MDa, Megan L. Barnwell MDa, Emilio Fentanes MDa, Adam N. Young MDa, Robert Barnwell MDb, Austin T. Foley MDb, Michael Hilliard MDb, Edward A. Hulten MDc, Todd C. Villines MDc, Ricardo C. Cury MDd, Ahmad M. Slim MDa,* a
Cardiology Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, Texas 782346200, USA b Emergency Department, San Antonio Military Medical Center, San Antonio, TX, USA c Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA d Department of Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
article info
abstract
Article history:
Background: Coronary CT angiography (CTA) is a powerful tool for the evaluation of chest
Received 24 July 2014
pain in the emergency department (ED). Some debate persists regarding its cost-
Received in revised form
effectiveness in a low-to-intermediate risk population.
2 August 2014
Objective: This study sought to evaluate the safety and cost-effectiveness of coronary CTA
Accepted 5 August 2014
for low-to-intermediate risk patients presenting to the ED with chest pain in a closed-loop referral system. Methods: Chest pain patients were evaluated in the ED via a local rapid coronary CTA
Keywords:
protocol and tracked prospectively for ED throughput, disposition, chest pain recidivism,
Coronary computed tomography
and cost utilization as compared with an age-matched cohort evaluated for chest pain
angiography
treated with usual care.
Computed tomography
Results: One hundred eighty-three patients underwent the rapid coronary CTA protocol
Acute chest pain
compared with an age-matched cohort of 184 patients treated with usual care. The median
Emergency disposition
follow-up period for major adverse cardiovascular events in the coronary CTA group was 9.0 months (range, 1.8e14.5 months) and 11.1 months (range, 0e14.0 months) for the agematched cohort. The median ED length of stay (LOS) was 5.8 hours (range, 2.6e12.3 hours) for the rapid coronary CTA cohort and 12.2 hours (range, 1.7e40.3 hours) for the age-matched cohort (P < .001). The median time to performance of coronary CTA was 2.5 hours (range, 0.4
Conflict of interest: The authors declare no conflicts of interest. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, and the Department of Defense, or the US Government. * Corresponding author. E-mail address: [email protected] (A.M. Slim). 1934-5925/$ e see front matter Published by Elsevier Inc. on behalf of Society of Cardiovascular Computed Tomography. http://dx.doi.org/10.1016/j.jcct.2014.08.003
376
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 3 7 5 e3 8 3
e8.7 hours) with a median time from coronary CTA performance to disposition of 2.9 hours (range, 0.8e8.6 hours). Total median hospital LOS was 5.9 hours (range, 2.7e124 hours) in the rapid coronary CTA cohort compared with 25.0 hours (range, 1.2e208 hours) in the agematched cohort (P < .001). Hospital admission was more common in the age-matched cohort (98.9% vs 9.3%; P < .001). There was a significant reduction in total payer cost in coronary CTA group when compared to usual care ($182,064.55 vs $685,190.77; P < .001). Conclusions: Coronary CTA for ED risk stratification and disposition within a closed referral system resulted in the shortest ED LOS published to date while being safe and costeffective. Published by Elsevier Inc. on behalf of Society of Cardiovascular Computed Tomography.
1.
Introduction
Cardiac CT angiography (coronary CTA) is emerging as a useful tool for evaluation of chest pain in low-to-intermediate risk patients presenting to the emergency room.1,2 Coronary CTA has been demonstrated to be safe and effective. It is a better predictor of coronary artery disease (CAD) than traditional risk factors or scoring systems that emergency departments (EDs) have used.3 In a study of predominantly low-risk possible acute coronary syndrome (ACS) patients, coronary CTA was also able to prognosticate very low events with no significant major adverse cardiovascular events (MACE) over the course of 2 years.4 As an emerging tool for diagnosis of coronary disease and risk stratification, it is necessary for this test to be able to be equivalent to or better than current diagnostic tests in terms of cost-effectiveness, prognosis, or diagnosis. There is some debate as to whether this is a more cost-effective or less resource-intense strategy in a low-to-intermediate risk population.5e7 As part of process improvement and patient safety, we sought to evaluate the efficacy and safety of our expedited coronary CTA ED chest pain protocol which incorporated algorithm-based patient selection parameters for coronary CTA as well as disposition recommendations based on CAD burden.
2.
Methods
2.1.
Patient selection
This is a prospective study assessing patients who presented to the ED with acute chest pain who underwent 128-slice coronary CTA between January 2013 through December 2013 at a single-center tertiary referral hospital (San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, TX). Patients included in the rapid coronary CTA protocol (Fig. 1) were low-to-intermediate risk adults aged at least 18 years based on Thrombolysis In Myocardial Infarction risk calculator with a score of 2. Patients were evaluated for acute chest pain, as defined in prior analysis as symptoms suspicious of angina based on the ED physician’s assessment.1,8 Onset of chest pain was within 24 hours of ED presentation with a normal or nondiagnostic electrocardiogram (ECG) without dynamic changes concerning for ischemia or injury
and normal cardiac biomarkers, typically troponin T. The rapid coronary CTA protocol was available to the ED between 0800 hours and 1500 hours on weekdays. Patient throughput in the ED was tracked prospectively in the rapid coronary CTA protocol cohort. Exclusion criteria for the rapid coronary CTA protocol were patients with known CAD, elevated initial serum biomarkers, dynamic ECG changes concerning for ischemia or injury, known or suspected iodinated contrast allergy or other contraindication to receiving iodinated contrast, impaired renal function defined as a serum creatinine level 1.5 mg/dL, and normal cardiac risk stratification within the preceding 12 months or a normal coronary CTA within the preceding 24 months. An age, gender, and cardiac risk factorematched historic cohort of patients evaluated in the ED for acute chest pain during the same time period (January 2013 through December 2013) who underwent evaluation and disposition with usual care were retrospectively abstracted for ED length of stay (LOS), ED disposition, hospital LOS (if admitted to the hospital), and downstream ischemic testing, whether performed in the inpatient setting or within 3 days of ED evaluation. Age-matched cohort patients met the same definition of acute chest pain as the rapid coronary CTA group. Patients with known CAD, definite ACS, or definite noncardiac etiology of chest pain were excluded from the usual care cohort. The patient’s outcomes and coronary CTA results were then retrospectively abstracted and compared to a retrospective cohort of age, gender, and cardiac risk factorematched chest pain patients evaluated in the ED during the same time period. Institutional review board approval to present the data from the process improvement project was obtained.
2.2. CTA
Noninvasive coronary artery analysis by coronary
All scans were analyzed by a cardiologist with level-III American College of Cardiology or American College of Radiology-certified imaging expertise in accordance with Society of Cardiovascular Computed Tomography (SCCT) guidelines. Scans were performed in accordance with SCCT guidelines.9 Studies were obtained using a 128-slice dualsource scanner with a high-pitch single heart beat image acquisition capabilities (SOMATOM Definition Flash CT; Siemens, Erlagen, Germany). Patients were treated before scan acquisition with metoprolol tartrate based on an internal protocol. Patients with heart rate (HR) 100 mm Hg were given 50 mg orally and 100 mg orally for HR >70 beats/min and SBP >100 mm Hg. Beta blocker was not given for patients with HR
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Original Research Article
Safe and rapid disposition of low-to-intermediate risk patients presenting to the emergency department with chest pain: A 1-year high-volume single-center experience Ronald L. Jones MDa, Dustin M. Thomas MDa, Megan L. Barnwell MDa, Emilio Fentanes MDa, Adam N. Young MDa, Robert Barnwell MDb, Austin T. Foley MDb, Michael Hilliard MDb, Edward A. Hulten MDc, Todd C. Villines MDc, Ricardo C. Cury MDd, Ahmad M. Slim MDa,* a
Cardiology Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive, San Antonio, Texas 782346200, USA b Emergency Department, San Antonio Military Medical Center, San Antonio, TX, USA c Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA d Department of Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
article info
abstract
Article history:
Background: Coronary CT angiography (CTA) is a powerful tool for the evaluation of chest
Received 24 July 2014
pain in the emergency department (ED). Some debate persists regarding its cost-
Received in revised form
effectiveness in a low-to-intermediate risk population.
2 August 2014
Objective: This study sought to evaluate the safety and cost-effectiveness of coronary CTA
Accepted 5 August 2014
for low-to-intermediate risk patients presenting to the ED with chest pain in a closed-loop referral system. Methods: Chest pain patients were evaluated in the ED via a local rapid coronary CTA
Keywords:
protocol and tracked prospectively for ED throughput, disposition, chest pain recidivism,
Coronary computed tomography
and cost utilization as compared with an age-matched cohort evaluated for chest pain
angiography
treated with usual care.
Computed tomography
Results: One hundred eighty-three patients underwent the rapid coronary CTA protocol
Acute chest pain
compared with an age-matched cohort of 184 patients treated with usual care. The median
Emergency disposition
follow-up period for major adverse cardiovascular events in the coronary CTA group was 9.0 months (range, 1.8e14.5 months) and 11.1 months (range, 0e14.0 months) for the agematched cohort. The median ED length of stay (LOS) was 5.8 hours (range, 2.6e12.3 hours) for the rapid coronary CTA cohort and 12.2 hours (range, 1.7e40.3 hours) for the age-matched cohort (P < .001). The median time to performance of coronary CTA was 2.5 hours (range, 0.4
Conflict of interest: The authors declare no conflicts of interest. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, and the Department of Defense, or the US Government. * Corresponding author. E-mail address: [email protected] (A.M. Slim). 1934-5925/$ e see front matter Published by Elsevier Inc. on behalf of Society of Cardiovascular Computed Tomography. http://dx.doi.org/10.1016/j.jcct.2014.08.003
376
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 3 7 5 e3 8 3
e8.7 hours) with a median time from coronary CTA performance to disposition of 2.9 hours (range, 0.8e8.6 hours). Total median hospital LOS was 5.9 hours (range, 2.7e124 hours) in the rapid coronary CTA cohort compared with 25.0 hours (range, 1.2e208 hours) in the agematched cohort (P < .001). Hospital admission was more common in the age-matched cohort (98.9% vs 9.3%; P < .001). There was a significant reduction in total payer cost in coronary CTA group when compared to usual care ($182,064.55 vs $685,190.77; P < .001). Conclusions: Coronary CTA for ED risk stratification and disposition within a closed referral system resulted in the shortest ED LOS published to date while being safe and costeffective. Published by Elsevier Inc. on behalf of Society of Cardiovascular Computed Tomography.
1.
Introduction
Cardiac CT angiography (coronary CTA) is emerging as a useful tool for evaluation of chest pain in low-to-intermediate risk patients presenting to the emergency room.1,2 Coronary CTA has been demonstrated to be safe and effective. It is a better predictor of coronary artery disease (CAD) than traditional risk factors or scoring systems that emergency departments (EDs) have used.3 In a study of predominantly low-risk possible acute coronary syndrome (ACS) patients, coronary CTA was also able to prognosticate very low events with no significant major adverse cardiovascular events (MACE) over the course of 2 years.4 As an emerging tool for diagnosis of coronary disease and risk stratification, it is necessary for this test to be able to be equivalent to or better than current diagnostic tests in terms of cost-effectiveness, prognosis, or diagnosis. There is some debate as to whether this is a more cost-effective or less resource-intense strategy in a low-to-intermediate risk population.5e7 As part of process improvement and patient safety, we sought to evaluate the efficacy and safety of our expedited coronary CTA ED chest pain protocol which incorporated algorithm-based patient selection parameters for coronary CTA as well as disposition recommendations based on CAD burden.
2.
Methods
2.1.
Patient selection
This is a prospective study assessing patients who presented to the ED with acute chest pain who underwent 128-slice coronary CTA between January 2013 through December 2013 at a single-center tertiary referral hospital (San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, TX). Patients included in the rapid coronary CTA protocol (Fig. 1) were low-to-intermediate risk adults aged at least 18 years based on Thrombolysis In Myocardial Infarction risk calculator with a score of 2. Patients were evaluated for acute chest pain, as defined in prior analysis as symptoms suspicious of angina based on the ED physician’s assessment.1,8 Onset of chest pain was within 24 hours of ED presentation with a normal or nondiagnostic electrocardiogram (ECG) without dynamic changes concerning for ischemia or injury
and normal cardiac biomarkers, typically troponin T. The rapid coronary CTA protocol was available to the ED between 0800 hours and 1500 hours on weekdays. Patient throughput in the ED was tracked prospectively in the rapid coronary CTA protocol cohort. Exclusion criteria for the rapid coronary CTA protocol were patients with known CAD, elevated initial serum biomarkers, dynamic ECG changes concerning for ischemia or injury, known or suspected iodinated contrast allergy or other contraindication to receiving iodinated contrast, impaired renal function defined as a serum creatinine level 1.5 mg/dL, and normal cardiac risk stratification within the preceding 12 months or a normal coronary CTA within the preceding 24 months. An age, gender, and cardiac risk factorematched historic cohort of patients evaluated in the ED for acute chest pain during the same time period (January 2013 through December 2013) who underwent evaluation and disposition with usual care were retrospectively abstracted for ED length of stay (LOS), ED disposition, hospital LOS (if admitted to the hospital), and downstream ischemic testing, whether performed in the inpatient setting or within 3 days of ED evaluation. Age-matched cohort patients met the same definition of acute chest pain as the rapid coronary CTA group. Patients with known CAD, definite ACS, or definite noncardiac etiology of chest pain were excluded from the usual care cohort. The patient’s outcomes and coronary CTA results were then retrospectively abstracted and compared to a retrospective cohort of age, gender, and cardiac risk factorematched chest pain patients evaluated in the ED during the same time period. Institutional review board approval to present the data from the process improvement project was obtained.
2.2. CTA
Noninvasive coronary artery analysis by coronary
All scans were analyzed by a cardiologist with level-III American College of Cardiology or American College of Radiology-certified imaging expertise in accordance with Society of Cardiovascular Computed Tomography (SCCT) guidelines. Scans were performed in accordance with SCCT guidelines.9 Studies were obtained using a 128-slice dualsource scanner with a high-pitch single heart beat image acquisition capabilities (SOMATOM Definition Flash CT; Siemens, Erlagen, Germany). Patients were treated before scan acquisition with metoprolol tartrate based on an internal protocol. Patients with heart rate (HR) 100 mm Hg were given 50 mg orally and 100 mg orally for HR >70 beats/min and SBP >100 mm Hg. Beta blocker was not given for patients with HR
