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The National Heart Attack Alert Program (NHAAP), which is coordinated by the National Heart, Lung, and Blood Institute (NHLBI), promotes the early detection and optimal treatment of patients with acute myocardial infarction and other acute coronary ischemic syndromes. The NHAAP, having observed the development and growth of chest pain centers in emergency departments with special interest, created a task force to evaluate such centers and make recommendations pertaining to the management of patients with acute cardiac ischemia. This position paper offers recommendations to assist emergency physicians in EDs, including those with chest pain centers, in providing comprehensive care for patients with acute cardiac ischemia.

Context: More than 3 million patients are hospitalized yearly in the United States for chest pain. The cost is over $3 billion just for those found to be free of acute disease. New rapid diagnostic tests for acute myocardial infarction (AMI) have resulted in the proliferation of accelerated diagnostic protocols (ADPs) and chest pain observation units., Objective: To determine whether use of an emergency department (ED)-based ADP can reduce hospital admission rate, total cost, and length of stay (LOS) for patients needing admission for evaluation of chest pain., Design: Prospective randomized controlled trial comparing admission rate, total cost, and LOS for patients treated using ADP vs inpatient controls. Total costs were determined using empirically measured resource utilization and microcosting techniques., Setting: A large urban public teaching hospital serving a predominantly African American and Hispanic population., Patients: A sample of 165 patients was randomly selected from a larger consecutive sample of 429 patients with chest pain concurrently enrolled in an ADP diagnostic cohort trial. Eligible patients presented to the ED with clinical findings suggestive of AMI or acute cardiac ischemia (ACI) but at low risk using a validated predictive algorithm., Main Outcome Measures: Primary outcomes measured for each subject were LOS and total cost of treatment., Results: The hospital admission rate for ADP vs control patients was 45.2% vs 100% (P<.001). The mean total cost per patient for ADP vs control patients was $1528 vs $2095 (P<.001). The mean LOS measured in hours for ADP vs control patients was 33.1 hours vs 44.8 hours (P<.01)., Conclusions: In this trial, ADP saved $567 in total hospital costs per patient treated. Use of ED-based ADPs can reduce hospitalization rates, LOS, and total cost for low-risk patients with chest pain needing evaluation for possible AMI or ACI.

Study Objective: Patient satisfaction is an essential outcome measure in the diagnosis and treatment of acute chest pain in the emergency department. We compared patient satisfaction with the diagnostic protocol of a chest pain observation unit (CPOU) and standard inpatient hospitalization., Methods: We prospectively studied patients who presented to the ED with chest pain and were found to have a low risk of acute myocardial infarction (AMI) but who still might have benefited from a diagnostic protocol to rule out AMI. Consenting patients (N = 104) were randomized to the CPOU (experimental) arm or the hospital inpatient (control) arm and assessed for satisfaction by means of an interview before hospital discharge., Results: The CPOU protocol scored higher on four summary ratings of overall patient satisfaction. Correlations between overall satisfaction, number, and type of problems with care, and patient characteristics demonstrated content validity and revealed strengths and improvements that might be made in CPOUs., Conclusion: Patients were more satisfied with rapid diagnosis in the CPOU than with inpatient stays for acute chest pain. Our findings add important information to the standard practice of weighing clinical and cost outcomes between two medical care alternatives.

Study Objective: To evaluate the applicability of a short-stay protocol for exclusion of acute ischemic heart disease without hospital admission and to analyze these results in the context of a conceptual model., Methods: An observational study of patients who presented with chest pain to the emergency department of an 886-bed inner-city municipal hospital and who needed hospital admission to rule out acute myocardial infarction (AMI). Patients were assessed by ED attending physicians to determine eligibility for an alternative, 12-hour protocol in an ED chest pain observation unit (CPOU) followed by immediate exercise testing. Outcome measures were proportion of patients eligible for the short-stay protocol, risk factor profile, and reasons for exclusion., Results: Of 500 patients screened, 446 had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% confidence interval [CI], 48.7% to 57.9%) were found to have low probability for AMI. After study exclusion criteria were applied to the patient cohort, 63 patients (14.1%; 95% CI, 10.9% to 17.3%) were eligible for the protocol. The most common reasons for exclusion were history of coronary artery disease (46%) and inability to perform an interpretable exercise tolerance test (42%)., Conclusion: Although most admitted patients with chest pain (53%) were at low probability for AMI, only a minority (14%) were eligible for a short-stay protocol that required patients to be free of known coronary artery disease and able to perform an exercise tolerance test. Factors affecting the operations and efficiency of a CPOU include clinical characteristics of the target patient population, protocol tests used, and hospital occupancy and reimbursement patterns.

Introduction: A multitude of life-threatening and nonlife-threatening processes cause chest pain and shortness of breath. Prehospital therapy for these patients may be lifesaving and includes pharmacologic interventions, as well as invasive procedures. Appropriate therapy depends on the diagnostic skills of the paramedic., Objective: This study was undertaken to determine the accuracy of the paramedic diagnosis in patients transported with a chief complaint of pain or shortness of breath., Setting: Multihospital, one large municipal hospital, one community hospital., Design: Prospective, cross-sectional study. Paramedics evaluated the patient and then completed a standard form indicating the diagnosis. The paramedic's and final emergency physician's diagnoses were compared to assess the accuracy of the paramedic diagnosis., Population: All patients who complained of chest pain or shortness of breath, transported to the study centers by the city of Denver paramedics, were eligible for the study. Ninety-nine of the 102 patients enrolled had complete records for analysis and were entered into the study., Results: Diagnostic concordance data were analyzed by organ system (e.g., cardiac, pulmonary, etc.) and for specific diagnoses using the kappa statistic and McNemar's chi-square analysis for discordant pairs. Using the kappa statistic, there was statistically significant concordance between the paramedic and emergency-physician diagnosis for cardiac (p = 0.0001; kappa value = 0.54) and pulmonary organ systems (p = 0.0001; kappa value = 0.61). Overall, for organ system diagnosis, the paramedics had an 82% accuracy (p = 0.05) rating. For specific cardiac and pulmonary diagnosis, paramedics had good concordance with emergency physicians., Conclusions: Overall, paramedics have excellent diagnostic agreement with emergency-physician diagnosis by organ system. They retained good agreement on specific cardiac diagnoses and pulmonary diagnosis.