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A Critical Pathway for Management of Patients with Acute Chest Pain Who Are at Low Risk for Myocardial Ischemia: Recommendations and Potential Impact

Graham Nichol, MD; Ron Walls, MD; Lee Goldman, MD; Steven Pearson, MD; L. Howard Hartley, MD; Elliott Antman, MD; Mark Stockman, MD; Jonathan M. Teich, MD; Christopher P. Cannon, MD; Paula A. Johnson, MD; Karen M. Kuntz, ScD; and Thomas H. Lee, MD
[+] Article, Author, and Disclosure Information

From Brigham and Women's Hospital, Harvard Medical School, and Harvard Community Health Plan, Boston, Massachusetts; and the University of California, San Francisco, School of Medicine, San Francisco, California. Grant Support: In part by the Agency for Health Care Policy and Research (RO1 HS06452), Rockville, Maryland. Requests for Reprints: Thomas H. Lee, MD, Partners Community HealthCare, Inc., Prudential Tower Suite 1150, 800 Boylston Street, Boston, MA 02199-8001. Current Author Addresses: Dr. Nichol: Clinical Epidemiology, Loeb Medical Research Institute, University of Ottawa, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;127(11):996-1005. doi:10.7326/0003-4819-127-11-199712010-00009
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Background: Use of resources for patients with acute chest pain may be improved with clinical strategies that integrate research, Bayesian analysis, and expert opinion.

Objectives: To 1) develop a critical pathway for management of patients with acute chest pain who are at low risk for complications of ischemic heart disease and 2) assess the potential effects of implementation of the pathway on patient safety and resource use.

Design: Evidence-based consensus and prospective cohort study.

Setting: Urban teaching hospital.

Patients: Patients at least 30 years of age who were seen in the emergency department for chest pain and who did not have a history of trauma or abnormalities on radiologic study.

Intervention: Physician-opinion leaders defined criteria for patient inclusion in the pathway and for remaining on the pathway after 6 or 12 hours of observation. Criteria were defined for appropriateness of direct admission, direct discharge, or 6 hours of observation followed by exercise treadmill testing.

Measurements: Number of patients admitted to the hospital, number of days that patients were hospitalized, and clinical outcome.

Results: 2898 of 4585 patients (63%) were admitted to the hospital; of the 2898, 1152 (40%) were classified as potentially eligible for the pathway and 1068 (93%) had a benign clinical course during the initial observation period. The 1068 patients had a mean length of stay of 2.8 ± 4.8 days. If 47% of these patients had been discharged after observation and exercise testing, implementation of the pathway would have reduced the number of admissions by 505 (17%) and days of hospitalization by 1407 (11%).

Conclusions: Retrospective analysis suggests that a critical pathway for patients with acute chest pain may substantially reduce resource use. Prospective study is needed to ensure increased efficiency without increased adverse outcomes.


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Figure 1.
Critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia.
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Figure 2.
Classification of patients by application of criteria for 12-hour observation period.
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Figure 3.
Classification of patients by application of criteria for 6-hour observation period.
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