Abstract and Introduction
Abstract
Introduction: Millions of people present to the emergency department (ED) with chest pain annually. Accurate and timely risk stratification is important to identify potentially life-threatening conditions such as acute coronary syndrome (ACS). An ED-based observation unit can be used to rapidly evaluate patients and reduce ED crowding, but the practice is not universal. We estimated the number of current hospital admissions in the United States (US) eligible for ED-based observation services for patients with symptoms of ACS.
Methods: In this cross-sectional analysis we used data from the 2011–2015 National Hospital Ambulatory Medical Care Survey (NHAMCS). Visits were included if patients presented with symptoms of ACS (eg, chest pain, dyspnea), had an electrocardiogram (ECG) and cardiac markers, and were admitted to the hospital. We excluded patients with any of the following: discharge diagnosis of myocardial infarction; cardiac arrest; congestive heart failure, or unstable angina; admission to an intensive care unit; hospital length of stay > 2 days; alteplase administration, central venous catheter insertion, cardiopulmonary resuscitation or endotracheal intubation; or admission after an initial ED observation stay. We extracted data on sociodemographics, hospital characteristics, triage level, disposition from the ED, and year of ED extracted from the NHAMCS. Descriptive statistics were performed using sampling weights to produce national estimates of ED visits. We provide medians with interquartile ranges for continuous variables and percentages with 95% confidence intervals for categorical variables.
Results: During 2011–2015 there were an estimated 675,883,000 ED visits in the US. Of these, 14,353,000 patients with symptoms of ACS and an ED order for an ECG or cardiac markers were admitted to the hospital. We identified 1,883,000 visits that were amenable to ED observation services, where 987,000 (52.4%) were male patients, and 1,318,000 (70%) were White. Further-more, 739,000 (39.2%) and 234,000 (12.4%) were paid for by Medicare and Medicaid, respectively. The majority (45.1%) of observation-amenable hospitalizations were in the Southern US.
Conclusion: Emergency department-based observation unit services for suspected ACS appear to be underused. Over half of potentially observation-amenable admissions were paid for by Medicare and Medicaid. Implementation of ED-based observation units would especially benefit hospitals and patients in the American South.
Introduction
Over six million adults present to the emergency department (ED) with chest pain in the United States annually.[1,2] While there are multiple etiologies of chest pain, including non-cardiac and benign disorders, accurate and timely risk stratification is important to identify potentially life-threatening conditions such as acute coronary syndrome (ACS). Several objective measures (ie, electrocardiography [ECG], cardiac biomarkers, noninvasive imaging of the myocardium)[3] and decision-support tools[4] have been developed for ACS risk stratification. Yet 2–4% of patients with ACS are inadvertently discharged from the ED.[5–7] Of those patients with chest pain admitted for further evaluation, less than half will be diagnosed with ACS.[8] One factor contributing to these discrepancies in the ED is that ACS symptoms are often non-specific.[9] Additionally, multiple non-ACS conditions are associated with elevated troponin levels.[10] Emerging evidence suggests that ED-based observation units (EDOU) for chest pain may overcome these limitations by enabling implement-ation of a rapid risk-stratification protocol (eg, cardiac biomarker testing, telemetry monitoring, stress testing, echocardiogram) over a short period of time.[1,11]
The use of EDOUs has been described since the 1980s. In 2006 an Institute of Medicine report, The Future of Emergency Care in the United States Health System, supported the use of EDOUs as a tool to reduce ED crowding, improve patient care, and reduce cost.[12] Although these units are diverse, a defining feature is the use of protocolized care with the goal of rapidly discharging the patient back home within 24 hours. Despite documented financial and patient benefits, their adoption has not been universal.[13] Recent estimates suggest that 39% of EDs have a separate observation or clinical decision unit.[2] While the utility of EDOUs for chest pain has been reported,[4,14] it is not fully known to what degree ED-based observation services could expand in the United States.
In this study we used a publicly available, de-identified, and unlinked survey database of nationwide ED visits to determine the number of patients admitted to the hospital from the ED for symptoms of ACS who could potentially have been evaluated in an EDOU. We also sought to determine which patient factors were most associated with patients being admitted despite meeting our derived observation-eligible criteria. Our goal was to corroborate the potential for more EDOUs nationwide as a means to significantly reduce unnecessary hospital admissions and related expenses.
Western J Emerg Med. 2022;23(2):134-140. © 2022 Western Journal of Emergency Medicine
