Impact of a Clinical Decision Rule on Hospital Triage of Patients With Suspected Acute Cardiac Ischemia in the Emergency Department
JAMAPublished 17 July 2002
Brendan M. Reilly
Citations100
SJR quartileQ1
SJR score5.35
SNIP10.71
Generate an AI Snapshot to get a quick, structured summary of this paper.
Study Snapshot
ObjectiveStudy objective
MethodsResearch methodology
PopulationPopulation studied
Sample sizeSample sizes
OutcomesStudy outcomes here
ResultsStudy results comes here
LimitationsResearch study limitations comes here
A concise AI-generated summary of the paper will appear here once you click Generate AI Snapshot.
TL;DR
Use of a previously validated clinical decision rule had a favorable impact on physicians' hospital triage decisions and improved efficiency was explained solely by different triages for very low-risk patients.
Abstract
Use of the clinical decision rule had a favorable impact on physicians' hospital triage decisions. Efficiency improved without compromising safety.
Keywords
Medicine
CirculationACC/AHA Guidelines for the Management of Patients With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction: Executive Summary and Recommendations
4,509 Citations2000Eugene Braunwald, Elliott M. Antman +22 more
JAMAThe TIMI Risk Score for Unstable Angina/Non–ST Elevation MI
3,246 Citations2000Elliott M. Antman, Marc Cohen +8 more
In patients with UA/NSTEMI, the TIMI risk score is a simple prognostication scheme that categorizes a patient's risk of death and ischemic events and provides a basis for therapeutic decision making.
New England Journal of MedicineAnalysis of Probability as an Aid in the Clinical Diagnosis of Coronary-Artery Disease
2,683 Citations1979George Diamond, James S. Forrester
This work reviewed the literature to estimate the pretest likelihood of disease and the sensitivity and specificity of four diagnostic tests and integrates fundamental pretest clinical descriptors with many varying test results to summarize reproducibly and meaningfully the probability of angiographic coronary-artery disease.
New England Journal of MedicineMissed Diagnoses of Acute Cardiac Ischemia in the Emergency Department
1,805 Citations2000Jennifer Pope, Tom P. Aufderheide +6 more
Clinical data from a multicenter, prospective clinical trial of all patients with chest pain or other symptoms suggesting acute cardiac ischemia who presented to the emergency departments of 10 U.S. hospitals found that 19 patients with acute myocardial infarction were mistakenly discharged from the emergency department.
New England Journal of MedicineCardiac-Specific Troponin I Levels to Predict the Risk of Mortality in Patients with Acute Coronary Syndromes
1,767 Citations1996Elliott M. Antman, Milenko J. Tanasijevic +9 more
In patients with acute coronary syndromes, cardiac troponin I levels provide useful prognostic information and permit the early identification of patients with an increased risk of death.
New England Journal of MedicineThe Prognostic Value of B-Type Natriuretic Peptide in Patients with Acute Coronary Syndromes
1,302 Citations2001James A. de Lemos, David A. Morrow +7 more
A single measurement of B-type natriuretic peptide, obtained in the first few days after the onset of ischemic symptoms, provides powerful information for use in risk stratification across the spectrum of acute coronary syndromes, and suggests that cardiac neurohormonal activation may be a unifying feature among patients at high risk for death after acute coronary syndrome.
New England Journal of MedicineCardiac Troponin T Levels for Risk Stratification in Acute Myocardial Ischemia
1,128 Citations1996E. Magnus Ohman, Paul W. Armstrong +11 more
The usefulness of base-line levels of cardiac troponin T and CK-MB and the electrocardiographic category assigned at admission and the presence of confounding factors that impair the detection of ischemia were assessed to assess the usefulness of outcome.
Statistics in MedicineComparative analysis of two rates
1,107 Citations1985Olli S. Miettinen, Markku Nurminen
This paper examines comparative analysis of rates with a view to each of the usual comparative parameters-rate difference, rate ratio and odds ratio with particular reference to first principles, and stresses the need for restricted estimation of variance in the chi-square function underlying interval estimation.
New England Journal of MedicineEmergency Room Triage of Patients with Acute Chest Pain by Means of Rapid Testing for Cardiac Troponin T or Troponin I
1,046 Citations1997Christian W. Hamm, Britta Goldmann +4 more
Bedside tests for cardiac-specific troponins are highly sensitive for the early detection of myocardial-cell injury in acute coronary syndromes and allow rapid and safe discharge of patients with an episode of acute chest pain from the emergency room.
JAMAUsers' Guides to the Medical Literature
1,003 Citations2000Thomas McGinn, Gordon Guyatt +5 more
Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction.
JAMAPrevalence, Clinical Characteristics, and Mortality Among Patients With Myocardial Infarction Presenting Without Chest Pain
786 Citations2000John G. Canto
It is suggested that patients without chest pain on presentation represent a large segment of the myocardial infarction population and are at increased risk for delays in seeking medical attention, less aggressive treatments, and in-hospital mortality.
New England Journal of MedicineA Computer Protocol to Predict Myocardial Infarction in Emergency Department Patients with Chest Pain
661 Citations1988Lee Goldman, E. Francis Cook +17 more
Although this protocol should not be used to override careful clinical judgment in individual cases, the computer protocol for the most part yields accurate estimates of the probability of myocardial infarction.
The American Journal of CardiologyClinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room
654 Citations1987Thomas H. Lee, Gregory W. Rouan +15 more
Patients in whom AMI was missed were significantly younger, had less typical symptoms and were less likely to to have had prior AMI or angina or to have electrocardiographic evidence of ischemia or infarction not known to be old.
New England Journal of MedicineA Predictive Instrument to Improve Coronary-Care-Unit Admission Practices in Acute Ischemic Heart Disease
606 Citations1984Michael W. Pozen, Ralph B. D’Agostino +3 more
A predictive instrument for use in a hand-held programmable calculator, which requires only 20 seconds to compute a patient's probability of having acute cardiac ischemia, could reduce the number of CCU admissions in this country by more than 250,000 per year.
New England Journal of MedicinePregnancy-Associated Plasma Protein A as a Marker of Acute Coronary Syndromes
556 Citations2001Antoni Bayés‐Genís, Cheryl A. Conover +7 more
PAPP-A is present in unstable plaques, and circulating levels are elevated in acute coronary syndromes; these increased levels may reflect the instability of atherosclerotic plaques.
New England Journal of MedicineA Clinical Trial of a Chest-Pain Observation Unit for Patients with Unstable Angina
520 Citations1998Michael E. Farkouh, Peter A. Smars +9 more
A CPU located in the emergency department can be a safe, effective, and cost-saving means of ensuring that patients with unstable angina who are considered to be at intermediate risk for cardiovascular events receive appropriate care.
Annals of Emergency MedicineMissed diagnoses of acute myocardial infarction in the emergency department: Results from a multicenter study
473 Citations1993Bruce D. McCarthy, Joni R. Beshansky +2 more
The rate of missed acute myocardial infarction in the emergency department was only 1.9%, but death or potentially lethal complications occurred in 25% of missed AMI patients, and another 25% might have been prevented had patients who were recognized to have ischemic heart disease by the physician in the ED been admitted.
Annals of Emergency MedicineComprehensive Strategy for the Evaluation and Triage of the Chest Pain Patient
408 Citations1997James L. Tatum, Robert L. Jesse +5 more
Rapid perfusion imaging plays a key role in the risk stratification of low-risk patients, allowing discrimination of unsuspected high risk patients who require prompt admission and possible intervention from those who are truly at low risk.
ACC Current Journal ReviewThe TIMI risk score for unstable angina/non–ST-elevation MI: a method for prognostication and therapeutic decision making
400 Citations2001Elliott M. Antman, Marc Cohen +1 more
New England Journal of MedicinePrediction of the Need for Intensive Care in Patients Who Come to Emergency Departments with Acute Chest Pain
361 Citations1996Lee Goldman, E. Francis Cook +4 more
The risk of major complications in patients with acute chest pain can be estimated on the basis of the clinical presentation and new clinical observations made during the hospital course, and these estimates of risk help in making rational decisions about the appropriate level of medical care for patients with severe chest pain.
Annals of Internal MedicineUse of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) To Assist with Triage of Patients with Chest Pain or Other Symptoms Suggestive of Acute Cardiac Ischemia: A Multicenter, Controlled Clinical Trial
356 Citations1998H P Selker, Joni R. Beshansky +17 more
A clinical trial is reported to test the effect of electrocardiogram-based ACI-TIPI on emergency department triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia and whether its use would reduce unnecessary hospital and CCU admission for emergency department patients without cardiac ischemic disease or with stable angina pectoris while not reducing hospitalization.
JAMAIs This Patient Having a Myocardial Infarction?
284 Citations1998Akbar Panju
Computer-derived algorithms that depend on clinical examination and ECG findings might improve the classification of patients according to the probability that an MI is causing their chest pain.
ACC Current Journal ReviewPrediction of the need for intensive care in patients who come to emergency departments with acute chest pain
266 Citations1996
Clinical factors used to predict whether patients who come to an emergency department with acute chest pain are having an acute myocardial infarction or have acute ischemic heart disease 1-7 serve as surrogate criteria for another important issue: deciding whether a patient will benefit from hospitalization and, if so, determining the appropriate level of care.
Annals of Emergency MedicineLitigation against the emergency physician: Common features in cases of missed myocardial infarction
263 Citations1989Robert A. Rusnak, Thomas O. Stair +2 more
Adverse outcome data from two insurance companies were retrospectively studied to determine whether a constellation of clinical circumstances, data-gathering behaviors, or physician variables were common to cases of missed acute myocardial infarction (AMI) and, if so, to formulate quality assurance recommendations to decrease future occurrences of misdiagnosis.
JAMARisk Stratification in Unstable Angina
156 Citations1995James E. Calvin, Lloyd W. Klein +6 more
The classification of unstable angina proposed by Braunwald includes four factors that predict risk of major in-hospital cardiac complications and can be combined with diabetes and age to better stratify risk ofmajor cardiac complications in this disorder using a simpler model.
JAMADisposition of Presumed Coronary Patients From an Emergency Room
150 Citations1976Stanley S. Schor
All patients with presumed coronary problems seen at the Chaim Sheba Medical Center during a one-year period were followed up and the fate of those who were not hospitalized and the factors contributing to the two types of erroneous decisions were evaluated.
Survey of AnesthesiologyMissed Diagnoses of Acute Cardiac Ischemia in the Emergency Department
142 Citations2000Hector J. Pope, Tom P. Aufderheide +6 more
The percentage of patients who present to the emergency department with acute myocardial infarction or unstable angina who are not hospitalized is low, but the discharge of such patients is associated with increased mortality.
Archives of Internal MedicineAn Evaluation of a Chest Pain Diagnostic Protocol to Exclude Acute Cardiac Ischemia in the Emergency Department
134 Citations1997Robert J. Zalenski
A chest pain diagnostic protocol achieved high sensitivity and improved specificity over the standard emergency department workup and there were no adverse advents associated with early ExECG.
The American Journal of CardiologyA National Survey of Emergency Department Chest Pain Centers in the United States
100 Citations1998Robert J. Zalenski, Robert J. Rydman +3 more
Annals of Internal MedicineA Critical Pathway for Management of Patients with Acute Chest Pain Who Are at Low Risk for Myocardial Ischemia: Recommendations and Potential Impact
100 Citations1997Graham Nichol, Ron Walls +10 more
The specific goals of the critical pathway were to reduce admission rates and total days of hospitalization among patients who were at low risk for complications of ischemic disease and to limit adverse outcomes.
Annals of Emergency MedicineAn Evaluation of Technologies for Identifying Acute Cardiac Ischemia in the Emergency Department: Executive Summary of a National Heart Attack Alert Program Working Group Report
97 Citations1997Harry P. Selker, Robert J. Zalenski +14 more
An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: Executive Summary of a National Heart Attack Alert Program Working Group report.
New England Journal of MedicineMissed Diagnoses of Acute Coronary Syndromes in the Emergency Room — Continuing Challenges
93 Citations2000Rajendra H. Mehta, Kim A. Eagle
Patients with suspected acute coronary syndromes, or acute cardiac ischemia, account for nearly 1.7 million hospital admissions per year in the United States and between 2 and 8 percent of patients with myocardial infarction are mistakenly released from the emergency department.
Annals of Internal MedicinePatient-Specific Predictions of Outcomes in Myocardial Infarction for Real-Time Emergency Use: A Thrombolytic Predictive Instrument
85 Citations1997H P Selker, John L. Griffith +10 more
A time-insensitive predictive instrument that would predict, for an individual patient, the effect of thrombolysis on the likelihood of key clinical outcomes: acute mortality, long-term mortality, cardiac arrest, and serious complications of thRombolytic therapy [hemorrhagic stroke and major bleeding].
Emergency Medicine JournalShould we establish chest pain observation units in the UK? A systematic review and critical appraisal of the literature
74 Citations2000Steve Goodacre
There is no strong evidence that a CPOU will improve outcomes if routine practice is good and cost savings have been shown when compared with routine care in the United States but may not be reproduced the UK.
The American Journal of MedicineEmergency department admissions to inpatient cardiac telemetry beds: a prospective cohort study of risk stratification and outcomes
59 Citations2001Lakshmi Durairaj, Brendan M. Reilly +8 more
Patients with or without chest pain were risk-stratified using a prediction rule and observed for in-hospital cardiac complications, acute myocardial infarction, and transfer to an intensive care unit (ICU).
The American Journal of MedicineThe observation unit: a new interface between inpatient and outpatient care
59 Citations2001Enrique Martinez, Brendan M. Reilly +2 more
Observation units can serve patients with diverse clinical syndromes and may reduce inpatient admissions and this novel "point of care" deserves further evaluation.
The American Journal of MedicineTriage of patients with chest pain in the emergency department: a comparative study of physicians’ decisions
47 Citations2002Brendan M. Reilly, Arthur T. Evans +2 more
In simulated cases, physicians' triage decisions varied widely and their predictions of patient outcomes differed markedly from that of the validated prediction rule, suggesting that use of the prediction rule in the emergency department could improve physicians' decisions and patients' outcomes.
JAMARisk stratification in unstable angina. Prospective validation of the Braunwald classification
29 Citations1995J. E. Calvin
The American Journal of MedicinePerformance and potential impact of a chest pain prediction rule in a large public hospital
23 Citations1999Brendan M. Reilly, Lakshmi Durairaj +6 more
Independent validation of the prediction rule suggests that it can improve triage decisions for patients admitted with suspected acute ischemic heart disease and its acceptance by clinicians, and its cost effectiveness.
Academic Emergency MedicineObservation Medicine in Emergency Medicine Residency Programs
20 Citations2002Sharon E. Mace, Jatin Shah
This survey describes current OM education strategies to teach OM, and nearly two-thirds of EM programs have or are planning an OU.
JAMADisposition of presumed coronary patients from an emergency room. A follow-up study
19 Citations1976Stanford Schor
Academic Emergency MedicineObservation Medicine in Emergency Medicine Residency Programs
14 Citations2002Sharon E. Mace, Jatin Shah
Archives of Internal MedicineNew Approaches to Diagnosis and Management of Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction
12 Citations2001Robert A. O’Rourke, Judith S. Hochman +4 more
Clinical studies evaluating a conservative, ischemia-guided approach vs an early aggressive approach to patients with unstable angina pectoris/non-ST-segment elevation MI are presented, with a practical algorithm for treating such patients.
The American Journal of MedicineTelemetry or not telemetry: a great leap forward or a waste of resources?
5 Citations2001Lee Goldman
In this issue of the American Journal of Medicine, Durairaj and colleagues report on a prospective study of 1,033 consecutive patients admitted from the emergency department to an in-patient telemetry unit at Cook County Hospital and the yield of telemetry for detecting important arrhythmias was low.
