• Jessica M Hyams, Matthew J Streitz, Joshua J Oliver, Richard M Wood, Yevgeniy M Maksimenko, Brit Long, Robert M Barnwell, and Michael D April.
• Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas.
• J Emerg Med. 2018 Apr 1; 54 (4): 549-557.

BackgroundChest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful.ObjectiveTo 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).MethodsWe 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.ResultsThe 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.ConclusionsThe HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.Published by Elsevier Inc.

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