In your practice as an attending - what's your threshold for admitting/obs CP?

[pinipig523]

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So, as an attending (preferably at a community hospital) - what's your threshold for admitting or obs-ing a chest pain patient?

The reason I ask is because it seems like at my gig, we're a little more "lax" on the criteria for admission. At my residency program, if I thought about admitting the patient, we'd OBS him/her if they were low risk w/ normal EKG, send to med short stay for chest pain w/ not a perfect EKG but still low risk, then obviously admit to tele for nstemi/ua... and then unstable ones go to CCU.

But at my current gig - it seems like the prevailing idea is TIMI 0 (I know, not studied for EM), atypical presentation (non-exertional), gets 2 sets q2h of trop and then home w/ cards clinic the next day for a stress test.

 

[Birdstrike]

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[RustedFox]

I have to confess; at my shop - I have the reputation of "Don't even look like you might think that you maybe had chest pain.... Dr. RustedFox will just straight-up admit you."

... and its true. Of course, my average patient age is 60+, and they all have risk factors. I get these suckers admitted in half an hour or so with minimal pushback.

 

[EM_Rebuilder]

So, as an attending (preferably at a community hospital) - what's your threshold for admitting or obs-ing a chest pain patient?

The reason I ask is because it seems like at my gig, we're a little more "lax" on the criteria for admission. At my residency program, if I thought about admitting the patient, we'd OBS him/her if they were low risk w/ normal EKG, send to med short stay for chest pain w/ not a perfect EKG but still low risk, then obviously admit to tele for nstemi/ua... and then unstable ones go to CCU.

But at my current gig - it seems like the prevailing idea is TIMI 0 (I know, not studied for EM), atypical presentation (non-exertional), gets 2 sets q2h of trop and then home w/ cards clinic the next day for a stress test.

Read my post in the Texas Malpractice Thread...

You are in Texas, consultants take CP a little less serious. That has a been one of the biggest adjustments for me from residency in MS to attending in TX.

As others pointed out, its a risk/benefit... You might end up sending someone home that infarcts later. You were not 'willful and wantful' and therefore there is likely not a malpractice suit... However, if you get them admitted, and the trop barely went up, or you have a cath happy Cardio, and the patient ends up with renal failure because of the dye load yet had a clean cath. Which is worse? I dont know, and I dont know that its ever been studied closely.

You are seeing the 'negative effects' of Tort Reform.. Which I am very hestiant to say they are truthfully negative effects and I would MUCH rather be in this situation than the alternative...

 

[Arcan57]

Read my post in the Texas Malpractice Thread...

You are in Texas, consultants take CP a little less serious. That has a been one of the biggest adjustments for me from residency in MS to attending in TX.

As others pointed out, its a risk/benefit... You might end up sending someone home that infarcts later. You were not 'willful and wantful' and therefore there is likely not a malpractice suit... However, if you get them admitted, and the trop barely went up, or you have a cath happy Cardio, and the patient ends up with renal failure because of the dye load yet had a clean cath. Which is worse? I dont know, and I dont know that its ever been studied closely.

You are seeing the 'negative effects' of Tort Reform.. Which I am very hestiant to say they are truthfully negative effects and I would MUCH rather be in this situation than the alternative...

EMRAP had an interesting discussion for November that basically eviscerated any evidence basis for admitting low risk chest pain. Most low-risk chest pain admits get dc'ed by the cardiologist after the 2nd set is negative. Pretty much nobody is getting stressed unless they have a great story + concerning EKG or they have pre-existing CAD and multiple risk factors for badness if cath'd.

 

[RustedFox]

EMRAP had an interesting discussion for November that basically eviscerated any evidence basis for admitting low risk chest pain. Most low-risk chest pain admits get dc'ed by the cardiologist after the 2nd set is negative. Pretty much nobody is getting stressed unless they have a great story + concerning EKG or they have pre-existing CAD and multiple risk factors for badness if cath'd.

That's cool... let the cardiologist DC them. This way, we don't hear the attorney say:

"So... DOCTOR... was there a cardiologist available to evaluate the patient ?"

 

[Mighty Mouse]

Exactly. Never want to be the last one holding the hot potato in my opinion.

I contend that there's pretty much nothing to be gained by us sending a chest pain patient home. If they're 35ish (arbitrary), with remotely decent story, watch 'em overnight.

I don't practice evidence based medicine all the time. I practice reality based medicine

 

[Arcan57]

That's cool... let the cardiologist DC them. This way, we don't hear the attorney say:

"So... DOCTOR... was there a cardiologist available to evaluate the patient ?"

Exactly. Never want to be the last one holding the hot potato in my opinion.

I contend that there's pretty much nothing to be gained by us sending a chest pain patient home. If they're 35ish (arbitrary), with remotely decent story, watch 'em overnight.

I don't practice evidence based medicine all the time. I practice reality based medicine

I was trained that sending home low-risk chest pain was the devil's work and condemned both you and the patient to an eternity of being entombed in flaming ice. The basis of this was that none of our tests accurately predicted badness. Of course the badness that was mostly missed was patients getting stented. And those stents don't actually improve mortality in the abscence of a STEMI. I still admit most chest pain patients, but there are an increasing number of no-risk patients that I'm sending home with outpatient f/u. I haven't found a good way to reconcile admitting patients for unnecessary tests that will cause more problems then they'll solve. It's easy currently since none of my cardiologists are doing additional testing, but it's morally difficult to admit someone knowing you're actually increasing their risk of morbidity without effecting mortality.

 

[gutonc]

I don't practice evidence based medicine all the time. I practice reality based medicine

One of my attendings in fellowship called this EBM...Emotion Based Medicine.

I think that we (and by we I mean attendings in all specialties, EM, FM, Cards, Surgery, whatever) are kidding ourselves if we don't admit that we practice this form of EBM as much as the other "EBM."

 

[RustedFox]

it's morally difficult to admit someone knowing you're actually increasing their risk of morbidity without effecting mortality.

Not for me. It'd be morally difficult for me to accept that I (like Birdstrike so eloquently put) sacrificed years of life and hundreds of thousands of dollars to serve my fellow man, only to turn around and be sued for everything I own by that same fellow man.

Until we get sweeping tort reform, I'm not sticking my neck out on the line.

Admit 'em.

Scan 'em.

Whatev.

 

[DO3]

Been rotating with a doc at an approximately 45,000 visit ER, and I've been surprised at how few chest pains he admits. There have only been two (out of about 20)...a STEMI that went straight to the cath lab, and a patient who had a couple of contigous leads with ST depression. Everything else has been sent home. Been nice to see someone who is confident in his exam skills, trusts his lab results, and will only admit patients when it is truly needed.

 

[ERDude]

Been rotating with a doc at an approximately 45,000 visit ER, and I've been surprised at how few chest pains he admits. There have only been two (out of about 20)...a STEMI that went straight to the cath lab, and a patient who had a couple of contigous leads with ST depression. Everything else has been sent home. Been nice to see someone who is confident in his exam skills, trusts his lab results, and will only admit patients when it is truly needed.

No, you're missing the point.

While I definitely don't take as medico-legally defensive of a position as some of the other posters (I often send low-risk chest pain patients home, I just have a frank discussion about risks/benefits of home vs admission), the decision has very little to do with exam skills or trusting lab results.

Yeah, admitting patients with STEMI, concerning history or ischemic changes on EKG is straight forward and certainly nothing to brag about.

Given enough low risk, atypical chest pain patients with normal ekgs and negative initial troponin, there will be those that rule in or have UA. Right now I don't know of a reliable way to pick those patients out from the masses of non cardiac chest pain with the same presentation, same work up, and ah, same exam.

Also sending home chest pain patients has literally almost nothing to do with "exam skills" unless you mean he has diagnosed pericarditis b/c of a friction rub despite a normal EKG and thus decided to the send the patient home? Or diagnosed pneumomediastinum b/c of hamman's crunch with an occult cxr? In my estimation the physical exam has very little to do with a dispo decision on the vast majority of chest pain patients.

 

[southerndoc]

Been nice to see someone who is confident in his exam skills, trusts his lab results, and will only admit patients when it is truly needed.

Interesting how you choose to word your opinion.

 

[RustedFox]

Been rotating with a doc at an approximately 45,000 visit ER, and I've been surprised at how few chest pains he admits. There have only been two (out of about 20)...a STEMI that went straight to the cath lab, and a patient who had a couple of contigous leads with ST depression. Everything else has been sent home. Been nice to see someone who is confident in his exam skills, trusts his lab results, and will only admit patients when it is truly needed.

Wooooow.


See you tomorrow. G'night.

 

[dchristismi]

Um, yeah.

I admit a lot of chest pain. My average patient is 80 and already has 2 stents. I love nothing more than to activate the cath lab.

Truly low risk (and young) but a good story? Repeat enz and outpt f/u. No followup? Not so "young?" (Lots of snowbirds in my practice) Yep, you get to spend the night for repeat levels and a cardiology consult to get you into our system, because your cardiologist in Michigan can't really help me. Damning family history? Diabetic since you were a little kid? Yep, let me just get you a bed upstairs.

I send home more than many of my partners. However, your chest pain, unfortunately, is not worth my livelihood.

 

[DB2013EM]

I would like to ask the attendings of the board this.

I've seen one physician where if it was a "borderline" patient, aka youngish, no risk factors, not clear MSK but doesnt sound very cardiac-ish, basically make it the patient's choice. He would say "I will gladly admit you, and it's what I recommend, but you have to make the call. So what do you want?"
Is this useful to do from a medicolegal standpoint? Or will an attorney say WHY DID YOU LET THAT PATIENT GO HOME? SO WHAT IF HE WAS 37 WITH A CLEAN BILL OF HEALTH? You get my point.
If I'm not being clear, I will gladly elaborate more. Thanks.

 

[RustedFox]

Um, yeah.

I admit a lot of chest pain. My average patient is 80 and already has 2 stents. I love nothing more than to activate the cath lab.

Truly low risk (and young) but a good story? Repeat enz and outpt f/u. No followup? Not so "young?" (Lots of snowbirds in my practice) Yep, you get to spend the night for repeat levels and a cardiology consult to get you into our system, because your cardiologist in Michigan can't really help me. Damning family history? Diabetic since you were a little kid? Yep, let me just get you a bed upstairs.

I send home more than many of my partners. However, your chest pain, unfortunately, is not worth my livelihood.

This.

They're all from Michigan/Ohio at my shop, too.

 

[Doctor Bob]

I would like to ask the attendings of the board this.

I've seen one physician where if it was a "borderline" patient, aka youngish, no risk factors, not clear MSK but doesnt sound very cardiac-ish, basically make it the patient's choice. He would say "I will gladly admit you, and it's what I recommend, but you have to make the call. So what do you want?"
Is this useful to do from a medicolegal standpoint? Or will an attorney say WHY DID YOU LET THAT PATIENT GO HOME? SO WHAT IF HE WAS 37 WITH A CLEAN BILL OF HEALTH? You get my point.
If I'm not being clear, I will gladly elaborate more. Thanks.

I would phrase that a little bit differently with a patient. When I go to disposition them I tell them my recommendations and plan. At that point they can refuse and after a discussion of risks/benefits they are free to go home. But I don't present it as "here are your treatment options; pick one". Instead I present it as "here is my recommendation for treatment; if you don't like it here are your alternatives". The difference is somewhat semantic I suppose.

As for my threshold of admitting CP; even though I work at a big hospital with every consulting service under the sun I still have the same mental process. When deciding if I want to admit a CP I ask myself "if I was at a small hospital with no consultants and no available IP beds would I transfer this person to another hospital for further workup?" If the answer is yes then I admit them. If the answer is no, then I do a delta-troponin and send them home. (ok it's a little bit more involved of a train of thought but that's the pared down generalization).

 

[southerndoc]

As for my threshold of admitting CP; even though I work at a big hospital with every consulting service under the sun I still have the same mental process. When deciding if I want to admit a CP I ask myself "if I was at a small hospital with no consultants and no available IP beds would I transfer this person to another hospital for further workup?" If the answer is yes then I admit them. If the answer is no, then I do a delta-troponin and send them home. (ok it's a little bit more involved of a train of thought but that's the pared down generalization).

I rarely do repeat troponins in the ED. My philosophy is that if it's concerning enough to warrant a repeat troponin, it usually warrants admission. It's lost revenue to the hospital by doing repeat troponins in the ED, and it's not the best thing to be tying up a bed in the ED if the waiting room is packed (we have pretty good door-to-floor times).

Occasionally I do repeat troponins, but it's rare. My practice has changed in the last few years since we are now measured on turnaround times.

 

[Arcan57]

I rarely do repeat troponins in the ED. My philosophy is that if it's concerning enough to warrant a repeat troponin, it usually warrants admission. It's lost revenue to the hospital by doing repeat troponins in the ED, and it's not the best thing to be tying up a bed in the ED if the waiting room is packed (we have pretty good door-to-floor times).

Occasionally I do repeat troponins, but it's rare. My practice has changed in the last few years since we are now measured on turnaround times.

I can see that as a strategy. The problem is that if it's recent or stuttering pain and you were concerned enough to send off one marker, you haven't ruled out MI.

 

[EM_Rebuilder]

I would like to ask the attendings of the board this.

I've seen one physician where if it was a "borderline" patient, aka youngish, no risk factors, not clear MSK but doesnt sound very cardiac-ish, basically make it the patient's choice. He would say "I will gladly admit you, and it's what I recommend, but you have to make the call. So what do you want?"
Is this useful to do from a medicolegal standpoint? Or will an attorney say WHY DID YOU LET THAT PATIENT GO HOME? SO WHAT IF HE WAS 37 WITH A CLEAN BILL OF HEALTH? You get my point.
If I'm not being clear, I will gladly elaborate more. Thanks.

I do that. See my other post above; I like to do whats best for the patient (which is not always the best medico-legally) and sometimes that means giving the patient advice and allowing them to make a decision.

I council them on low risk CP, CT scans on belly pain, LPs on headaches, CTs on little kids that fell.. thats probably the big ones I usually have 'the talk' on. Obviously if its overwhelmingly clearly indicated, we dont talk, its just done. I used to try to talk them out of XRays, but thats more time than its often worse and honestly an ankle film is not a huge amount of radiation. I question how much my documentation and 'patient educated about doing CT scan, they state they have great FU and will return if worsening".. if its truly a missed appy and became a court case. But, I feel more comfortable doing the above because I am in Texas. I'd rather be in a court of law with the above documented, than not documented and not done, and I can feel warm and fuzzy thinking I dont scan everyone.

 

[Daiphon]

I play the game like this:

Good "story" = admit
Crap "story" but + risk factors = admit
Crap "story" + no RFs = 2 sets & home for follow-up.

I do 2 sets, too, based on Erlanger... most defensible position I have in my armamentarium.

Exceptions happen, such as second-visit syndrome & others, but this is the general approach.

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

 

[deleted109597]

All you can do is tell people what their risk factors are.
If they're not in ACS, I don't like to admit them unless they've got dynamic EKG changes.
Normal EKG, negative enzymes, low risk? You can go home.
Abnormal EKG that isn't changed from the last 15 and negative enzymes? You can go home too.
EKG changes or positive trops? You can stay.
Obviously there are some patients who sound like ticking time bombs that I encourage to stay, but it is less than I used to in residency.

Even if you admit every single patient with chest pain, you're going to miss the people who don't have actual pain.
We can't save all of them, and we certainly don't have room to admit them all.
Sometimes I can send them to cards to get a stress test during the same day as an outpatient (word to the wise, present early in the day with chest pain).

 

[dotcb]

STEMI - cath lab
NSTEMI - admit +/- heparin and maybe urgent cath
intermittent CP and high risk profile - admit
intermittent CP and moderate or low risk profile - 2 trops, with 2nd 6 hrs from onset of CP, home w/ expedited cardiology or stress test F/U
constant CP - with 2 negative trops at 6 hrs, ACS is ruled out. I feel pretty comfortable that the pain is non-cardiac at that point. I do any other investigation warranted (pursuing other causes of CP like PE or dissection), but I would likely talk to the patient and either admit them (for unexplained pain?) or discharge them with follow up.

Overall, I admit about 1/3 of chest pain patients.

 

[keeping-it-real]

Absence of ACS doesn't mean absence of CAD. And if/when the discharged patient has 'the big one' nobody is going to care if they were acutely ischemic or not when they were at the ER a month ago. it'll be considered a miss and you'll be held accountable for whatever happened as a result.

CP should be simple and straightforward. If it's possible they could have CAD, admit them and stress them. Our medicolegal climate doesn't permit much else and there's no reason to be a cowboy about it. And for every doc that thinks they can r/o by story, we all have stories of our own about that "low risk" CP that we admitted to Obs who ended up ruling in.

And to echo southerndoc, I'm not a fan of repeat troponins. The main ER isn't the place to be performing observation medicine. And for those performing a 2 hour troponin, what's the sensitivity of these? It has to be in the neighborhood of 90-95%.

 

[Mighty Mouse]

here's my thing...

we don't miss (we hope) STEMIs.
NSTEMIs have +troponin, so problem solved.

Unstable angina is the part of the ACS umbrella I have issues with. who gets missed in ACS?
1) extremities of age -- so the younger patient we think is fine, might not be
2) diabetics -- the silent MI, the vague symptoms
3) Lupus patients (Mattu argues worse than diabetes)
4) psych patients
5) frequent fliers
6) language barriers
7) atypical symptoms -- which unfortunately we can turn into anything a patient says

i know that a majority of my patient's i admit aren't having the big one. i'm just not willing to bet the house on it. i try to not be complacent on my history. chest pain + sob, nausea, diaphoresis and its a slam dunk. but what about the vague weak, dizzy, sob ones?

and if i think there's a hint that they actually fall under the ACS umbrella, the only thing that really distinguishes the 2 are the trops. so you can have eleventybillion neg trops and still technically be UA/ACS.

in addition, outpatient follow up sounds great, but it doesn't always work. story about a guy who had great follow up...

63 male, syncopizes. his wife is a nurse at our huge 1000 bed hospital. he sees his pcp. pcp says yeah, i'm concerned. lets refer you to cardiologist. cardiologist says, yeah, i'm concerned, lets get you some tests like an echo and a stress test. takes a week or so to make it happen. in the meantime, dude comes in having "the big one" huge inferior STEMI, and dies on cath lab table.

better to stress them when you have ready access to it. if the cardiologist decides to do serial trops, or just an echo, thats on their conscience and their license, not mine.

 

[deleted109597]

If it's possible they could have CAD, admit them and stress them. Our medicolegal climate doesn't permit much else and there's no reason to be a cowboy about it. And for every doc that thinks they can r/o by story, we all have stories of our own about that "low risk" CP that we admitted to Obs who ended up ruling in.

A few issues.
1. Everyone could possibly have CAD, so you basically just said to admit every one of them.
2. Stress tests fail pretty commonly, so just stressing them also isn't the answer.
3. You are basically just advocating to toss the "hot potato" to someone else so that they're holding onto it when it happens. This is why tort reform is important.
4. Nobody is advocating being a cowboy. Not one of us has said not to perform any tests. However, we cannot continue to admit every single patient. Hell, at my last hospital, if I admitted every chest pain patient we would have a 75% admit rate. Not feasible.
5. Plural of anecdote does not make fact.

 

[keeping-it-real]

here's my thing...

we don't miss (we hope) STEMIs.
NSTEMIs have +troponin, so problem solved.

Unstable angina is the part of the ACS umbrella I have issues with. who gets missed in ACS?
1) extremities of age -- so the younger patient we think is fine, might not be
2) diabetics -- the silent MI, the vague symptoms
3) Lupus patients (Mattu argues worse than diabetes)
4) psych patients
5) frequent fliers
6) language barriers
7) atypical symptoms -- which unfortunately we can turn into anything a patient says

i know that a majority of my patient's i admit aren't having the big one. i'm just not willing to bet the house on it. i try to not be complacent on my history. chest pain + sob, nausea, diaphoresis and its a slam dunk. but what about the vague weak, dizzy, sob ones?

and if i think there's a hint that they actually fall under the ACS umbrella, the only thing that really distinguishes the 2 are the trops. so you can have eleventybillion neg trops and still technically be UA/ACS.

in addition, outpatient follow up sounds great, but it doesn't always work. story about a guy who had great follow up...

63 male, syncopizes. his wife is a nurse at our huge 1000 bed hospital. he sees his pcp. pcp says yeah, i'm concerned. lets refer you to cardiologist. cardiologist says, yeah, i'm concerned, lets get you some tests like an echo and a stress test. takes a week or so to make it happen. in the meantime, dude comes in having "the big one" huge inferior STEMI, and dies on cath lab table.

better to stress them when you have ready access to it. if the cardiologist decides to do serial trops, or just an echo, thats on their conscience and their license, not mine.

The problem is our system. People act like we have no idea what we're doing and just order a bunch of tests and admit people. The reality is that we can usually do a pretty job using our experience and 'gestalt.'

The other reality, though, is that we are held to a "zero" miss rate for the high-risk diagnoses. Missing an MI or a SAH that leads to death or major morbidity is potentially career ending and can even lead to bankruptcy. Until the system changes it's not worth it to take unnecessary risk.

Also, I just listened to that EM:RAP 2-hour troponin discussion with Mattu...and this is basically exactly what he highlights.

 

[dotcb]

Absence of ACS doesn't mean absence of CAD. And if/when the discharged patient has 'the big one' nobody is going to care if they were acutely ischemic or not when they were at the ER a month ago. it'll be considered a miss and you'll be held accountable for whatever happened as a result.

CP should be simple and straightforward. If it's possible they could have CAD, admit them and stress them. Our medicolegal climate doesn't permit much else and there's no reason to be a cowboy about it. And for every doc that thinks they can r/o by story, we all have stories of our own about that "low risk" CP that we admitted to Obs who ended up ruling in.

And to echo southerndoc, I'm not a fan of repeat troponins. The main ER isn't the place to be performing observation medicine. And for those performing a 2 hour troponin, what's the sensitivity of these? It has to be in the neighborhood of 90-95%.

CAD is the domain of cardiology and the PCP. CAD is not an emergency condition. ACS is what we need to rule out. I think we can be more discriminating than admitting every patient with chest pain. ACS takes about 6 hours +/- a provocative test to rule out. There's really no need for a 23 or 24+ hour admission if you can get expedited outpatient tests and follow-up visits. Admitting all these patients is kind of a waste of inpatient beds.

Our job is to risk stratify the patient, rule out emergency conditions, and if something bad is going to happen, ensure appropriate return precautions and (ideally) a health care visit between seeing us and the patient's event. I'm serious.

While I'm not a fan of observation medicine, I think our domain is completing work-ups focused around ruling out emergency conditions that can be done in the ballpark of ~6 hours. Otherwise, a 23 hr obs admit should be done.

 

[xaelia]

Unstable angina is the part of the ACS umbrella I have issues with. who gets missed in ACS?

The European Society of Cardiology has eliminated the diagnosis of unstable angina:
http://www.internalmedicinenews.com...knew-ye/1c5d13ac11d3702a6b69ba7710813d5b.html

The premise: the "stuttering" chest pain from thrombosis/thrombolysis associated with an unstable plaque ought to result in a non-negative troponin using one of the newer, highly-sensitive troponin assays.

 

[keeping-it-real]

CAD is the domain of cardiology and the PCP. CAD is not an emergency condition. ACS is what we need to rule out. I think we can be more discriminating than admitting every patient with chest pain. ACS takes about 6 hours +/- a provocative test to rule out. There's really no need for a 23 or 24+ hour admission if you can get expedited outpatient tests and follow-up visits. Admitting all these patients is kind of a waste of inpatient beds.

Our job is to risk stratify the patient, rule out emergency conditions, and if something bad is going to happen, ensure appropriate return precautions and (ideally) a health care visit between seeing us and the patient's event. I'm serious.

While I'm not a fan of observation medicine, I think our domain is completing work-ups focused around ruling out emergency conditions that can be done in the ballpark of ~6 hours. Otherwise, a 23 hr obs admit should be done.

The problem with risk stratifying is that even a Timi score of 0 still has a ~5% risk of adverse cardiac event at 14 days. The other problem is that even if you arrange timely follow-up, the patient may choose to disregard your instructions; and when an adverse event happens, you can still be liable.

The 6 hour troponin is separate issue. From a logistical standpoint, it's a complete time-sink.

Chest pain should be a very easy ER visit. Our history and ED work-up with a single troponin/ekg are not good enough to have a near zero miss rate. And when you start turning every chest pain into a potential 6 hour visit, this is unnecessarily inefficient. It should not be the expectation that you routinely anticipate such lengthy visits. That's what observation and inpatient is for.

 

[deleted109597]

The problem with risk stratifying is that even a Timi score of 0 still has a ~5% risk of adverse cardiac event at 14 days. The other problem is that even if you arrange timely follow-up, the patient may choose to disregard your instructions; and when an adverse event happens, you can still be liable.

You're saying 1/20 all comers have a risk of adverse cardiac event at 14 days? Are you mad?

Chest pain should be a very easy ER visit. Our history and ED work-up with a single troponin/ekg are not good enough to have a near zero miss rate. And when you start turning every chest pain into a potential 6 hour visit, this is unnecessarily inefficient. It should not be the expectation that you routinely anticipate such lengthy visits. That's what observation and inpatient is for.

How can you sit there with a straight face and say a 6 hour troponin (not a 6 hour delta, just a 6 hours after pain started) is inefficient, but observation and admission is better? How many places do you know where an admission takes more than 6 hours to get upstairs? Especially one that now has to go to cardiac tele because you've labelled them as ACS.

 

[Rendar5]

TIMI scores can only really be used once someone's actually been diagnosed as having unstable angina as far as I understood. Not a really great tool for the ED since it doesn't apply to "rule out" cases.

 

[Arcan57]

The problem with risk stratifying is that even a Timi score of 0 still has a ~5% risk of adverse cardiac event at 14 days. The other problem is that even if you arrange timely follow-up, the patient may choose to disregard your instructions; and when an adverse event happens, you can still be liable.

The 6 hour troponin is separate issue. From a logistical standpoint, it's a complete time-sink.

Chest pain should be a very easy ER visit. Our history and ED work-up with a single troponin/ekg are not good enough to have a near zero miss rate. And when you start turning every chest pain into a potential 6 hour visit, this is unnecessarily inefficient. It should not be the expectation that you routinely anticipate such lengthy visits. That's what observation and inpatient is for.

It's 2012. There's no reason to be doing a 6hr r/o. Pick the 2-hr delta-MB or the 90 min triple marker r/o, they both have pretty solid data. You're preaching exactly what I was taught in residency, but that's the old way. Even the new study that showed the ultra-sensitive troponin isn't perfect (sometime last year in NEJM I believe) was looking at a single enzyme at a single time strategy.

It's absolutely true that we aren't good enough to tell who does or doesn't have CAD, but we're really good at determining who has an MI and really good at dealing with moderate/high risk ACS. The way we deal with low/no-risk ACS is a travesty. If you're in a practice environment where you have no choice then at least have the insight to realize you're doing the wrong thing.

 

[keeping-it-real]

You're saying 1/20 all comers have a risk of adverse cardiac event at 14 days? Are you mad?



How can you sit there with a straight face and say a 6 hour troponin (not a 6 hour delta, just a 6 hours after pain started) is inefficient, but observation and admission is better? How many places do you know where an admission takes more than 6 hours to get upstairs? Especially one that now has to go to cardiac tele because you've labelled them as ACS.

Not all comers with chest pain. But if you're consider a diagnosis of angina, the Timi score would apply.

Observation units are perfect for chest pain. The purpose is to not only get them out of the department while performing repeat enzymes but also to get the stress test performed. The ACC/AHA guidelines are pretty clear in recommending a stress test as part of the work-up, even in low-risk patients. You can be free to deviate from these guidelines, but you are taking on unnecessary risk by doing so.

Also, hopefully no community hospital is taking anywhere near 6 hours to admit a patient from the ED.

It's 2012. There's no reason to be doing a 6hr r/o. Pick the 2-hr delta-MB or the 90 min triple marker r/o, they both have pretty solid data. You're preaching exactly what I was taught in residency, but that's the old way. Even the new study that showed the ultra-sensitive troponin isn't perfect (sometime last year in NEJM I believe) was looking at a single enzyme at a single time strategy.

It's absolutely true that we aren't good enough to tell who does or doesn't have CAD, but we're really good at determining who has an MI and really good at dealing with moderate/high risk ACS. The way we deal with low/no-risk ACS is a travesty. If you're in a practice environment where you have no choice then at least have the insight to realize you're doing the wrong thing.

What's a travesty is the fact that we are held to a "no-miss" standard. Our management of low risk ACS is a direct consequence of this. And if you're not performing any provocative testing as part of your work-up, you are creating potential liability if the patient fails to follow up for their outpatient stress and then goes on to have an adverse cardiac event.

 

[The White Coat Investor]

Been rotating with a doc at an approximately 45,000 visit ER, and I've been surprised at how few chest pains he admits. There have only been two (out of about 20)...a STEMI that went straight to the cath lab, and a patient who had a couple of contigous leads with ST depression. Everything else has been sent home. Been nice to see someone who is confident in his exam skills, trusts his lab results, and will only admit patients when it is truly needed.

That probably isn't far from what I do. I'm blessed with a relatively healthy population (lots of my chest pain patients are in their 20s and 30s) and can get next day stress tests very easily. In fact, you probably get your stress test at about the same time whether I put them in the hospital or out. I also have a department that isn't so busy that I can't hold someone a few hours for a second set.

STEMIs go to the cath lab
EKG changes, positive trops, a really good story where the pain just started, chest pain with a decent story and a history of CAD, someone who seems unreliable, and someone who wants to be admitted get admitted.
Older person with chest pain that doesn't fit the above categories gets a phone consult with cardiology and at least 2 sets of enzymes and EKG
Everyone else goes home for a stress test tomorrow after two sets and an EKG, at least one set 6 hours after onset of pain.

What convinced me to send more patients home as an attending than I did as a resident was to talk to the cardiologists about what they were doing with the patients I admitted to them. There was a fair percentage that got nothing more than one more set of enzymes, watched on a monitor for 12-24 hours, then were scheduled for an outpatient stress test. When I explain to the patients what is likely to happen to them if I admit them, many of them simply choose to go home. I offer admission to nearly everyone, but none of them really want it, especially when I can get an outpatient stress test the next day.

 

[deleted109597]

Not all comers with chest pain. But if you're consider a diagnosis of angina, the Timi score would apply.

No it doesn't.

Observation units are perfect for chest pain. The purpose is to not only get them out of the department while performing repeat enzymes but also to get the stress test performed. The ACC/AHA guidelines are pretty clear in recommending a stress test as part of the work-up, even in low-risk patients. You can be free to deviate from these guidelines, but you are taking on unnecessary risk by doing so.

Not really. If I refer them for outpatient testing, and am clear in my instructions, I'm not taking any more risk than I am signing out someone AMA. Chest pain isn't a jail sentence.

Also, hopefully no community hospital is taking anywhere near 6 hours to admit a patient from the ED.

Get out in the community more.

What's a travesty is the fact that we are held to a "no-miss" standard. Our management of low risk ACS is a direct consequence of this. And if you're not performing any provocative testing as part of your work-up, you are creating potential liability if the patient fails to follow up for their outpatient stress and then goes on to have an adverse cardiac event.

Just because your personal practice is more conservative doesn't mean we are creating potential liability. Hell, some places have hospital policies that recommend 2 hour delta trops and discharge. Depends completely on the malpractice climate of the area.
If you've got data that states we are having the masses die off due to cardiac disease after ED discharge, feel free to present it. Dogma without data isn't acceptable anymore.

 

[Rendar5]

TIMI applies if you diagnose someone as ACS. If you diagnose chest pain and are admitting to rule out ACS, and they're lower risk (2-5% chance of ACS), then if you want to use the TIMI score, you have to you're gonna have to apply that 5% to the pretest probability of 5%. That leaves you with a 1/400 risk if the TIMI is 0, not a 1/20. I don't use the TIMI score personally though as I was never trained on it and I don't even know if the ED population is the appropriate population to apply it it.

 

[Arcan57]

Not all comers with chest pain. But if you're consider a diagnosis of angina, the Timi score would apply.

Observation units are perfect for chest pain. The purpose is to not only get them out of the department while performing repeat enzymes but also to get the stress test performed. The ACC/AHA guidelines are pretty clear in recommending a stress test as part of the work-up, even in low-risk patients. You can be free to deviate from these guidelines, but you are taking on unnecessary risk by doing so.

Also, hopefully no community hospital is taking anywhere near 6 hours to admit a patient from the ED.

Perhaps your hospital is overburdened with empty tele beds, but this time of year getting someone upstairs is a 6-7 hr procedure. And the guidelines are clear that the provocative testing should be done within 72 hrs. Nevermind that it has no discriminitive value in the majority of patients we're admitting for "chest pain", in most places you can get outpatient f/u within 3 days (Friday afternoons being one of the gray areas). If you absolutely know the patient can't get f/u in your system and that's a routine issue, you need to work on fixing your system. I'd say somewhere around 80% of the patients we admit for chest pain don't get a provocative test and I don't notice our cardiologists getting sued into the Stone Age for missed ACS.

My gut feeling is that we've so distorted the diagnosis of "angina" that the TIMI data, etc. doesn't have validity in our patient population in 2012. Like the diagnostic creep that has occurred with PE, we're working up people that never would have made it into any of the clinical trials because their risk is so low.

 

[Old_Mil]

http://www.epmonthly.com/features/current-features/the-dilemma-of-low-risk-chest-pain/

Here, STEMI = Lytics.

I use two hour troponins and two hour EKGs. If your two hour delta troponin is 0.02 or greater you get shipped *out of the ER*. If your two hour delta is less than 0.02 and you are having symptoms you get admitted for a 6 hour. If that's positive you get shipped out of the tele unit. If your two hour delta is zero, and you are low risk you get sent home with outpatient referral. Not really sure if there's a way to tweak this to make it more sensitive in a community setting without local cards or a real chest pain unit.

So far, I haven't missed or gotten sued for CP. I have had one patient with two negative troponins but with a delta of 0.02 and a lot of risk factors. The consulting cardiologist did accept, the patient developed ST elevations shortly after arrival at the cath lab hospital, was taken to the lab emergently, and had a 100% fresh lesion stented. So I guess you can say that in her case this protocol diagnosed her STEMI before she had it...

In the end, we handle chest pain based on what the field of law tells us, not the medical field.

 

[Apollyon]

http://www.epmonthly.com/features/current-features/the-dilemma-of-low-risk-chest-pain/

and you are low risk you get sent home with outpatient referral.

It seems comprehensive, but what about the high risk pt? Delta is zero, no pain, high risk (4+ RF, hx) - what do you do with them?