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Use of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) To Assist with Triage of Patients with Chest Pain or Other Symptoms Suggestive of Acute Cardiac Ischemia: A Multicenter, Controlled Clinical Trial

Harry P. Selker, MD, MSPH; Joni R. Beshansky, RN, MPH; John L. Griffith, PhD; Tom P. Aufderheide, MD; Daniel S. Ballin, MD; Sheilah A. Bernard, MD; Steven G. Crespo, MD; James A. Feldman, MD; Susan S. Fish, PharmD, MPH; W. Brian Gibler, MD; Debra A. Kiez, MD; Robert A. McNutt, MD; Anne W. Moulton, MD; Joseph P. Ornato, MD; Philip J. Podrid, MD; J. Hector Pope, MD; Deeb N. Salem, MD; Michael R. Sayre, MD; and Robert H. Woolard, MD
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From New England Medical Center/Tufts University School of Medicine, Boston City Hospital, and Boston University Medical Center, Boston, Massachusetts; Medical College of Wisconsin, Milwaukee, Wisconsin; Newton-Wellesley Hospital, Wellesley, Massachusetts; Baystate Medical Center, Springfield, Massachusetts; University of Cincinnati Medical Center, Cincinnati, Ohio; University of North Carolina Hospitals, Chapel Hill, North Caro lina; Rhode Island Hospital, Providence, Rhode Island; and Medical College of Virginia, Richmond, Virginia. Acknowledgments: This study was made possible by the commitment and cooperation of the emergency department staff at each participating hospital and the following research coordinators, research assistants, and medical and nursing staff: Baystate Medical Center: Del Blank, RN, MBA, Brian Hession; Boston City Hospital: Tracy Kerl, RN; Boston University Medical Center: Richard Caggiano, MD, Margo Mitchell, RN; Medical College of Virginia: Patricia Wright, RN, Edgar Gonzalez, PharmD; Medical College of Wisconsin: Sarah Lawrence, RN; New England Medical Center: Bonnie MacLeod, Teresa Pazdral, Diane Pietraskiewicz, RN, Fred Breen, RN; Newton-Wellesley Hospital: Carmel Brodeur, RN, Assad Sayah, MD; Rhode Island Hospital: Emily Connolly, RN, Donna Cimini, RN; University of Cincinnati Medical Center: Julie Gerlach, RN, MPH; and University of North Carolina Hospitals: David Egner, Grant Fletcher. The authors thank Jane Scott, ScD, for her tireless support of this trial as its AHCPR Project Officer, Julie Sullivan for expert manuscript preparation, and Robin Ruthazer and Stacy Supran for statistical assistance. Grant Support: By the Agency for Health Care Policy and Research (RO1 HS07360). Requests for Reprints: Harry P. Selker, MD, Division of Clinical Care Research, New England Medical Center, #63, 750 Washington Street, Boston, MA 02111. Current Author Addresses: Dr. Selker: Division of Clinical Care Research, New England Medical Center, #63, 750 Washington Street, Boston, MA 02111. Ms. Beshansky, Dr. Griffith, Dr. Ballin, and Dr. Salem: New England Medical Center/Tufts University School of Medicine, 750 Washington Street, Boston, MA 02111. Dr. Aufderheide: John Doyne Hospital, 9200 West Wisconsin Avenue, Froedtert East Milwaukee, WI 53226. Drs. Bernard, Crespo, Feldman, Fish, and Podrid: Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118. Dr. Kiez: 1650 Mathers Bay West, Winnipeg, Manitoba R3N OT7, Canada. Dr. Pope: Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199. Drs. Gibler and Sayre: University of Cincinnati Medical Center, 231 Bethesda Avenue, Cincinnati, OH 45267. Dr. McNutt: Chicago Cook County Hospital, 1900 West Polk Street, Chicago, IL 60612. Drs. Moulton and Woolard: Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903. Dr. Ornato: Medical College of Virginia, 401 North 12th Street, Richmond, VA 23298.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1998;129(11_Part_1):845-855. doi:10.7326/0003-4819-129-11_Part_1-199812010-00002
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Background: Approximately 6 million U.S. patients present to emergency departments annually with symptoms suggesting acute cardiac ischemia. Triage decisions for these patients are important but remain difficult.

Objective: To test whether computerized prediction of the probability of acute ischemia, used with electrocardiography, improves the accuracy of triage decisions.

Design: Controlled clinical trial.

Setting: 10 hospital emergency departments in the midwestern, southeastern, and northeastern United States.

Patients: 10 689 patients with chest pain or other symptoms suggestive of acute cardiac ischemia.

Intervention: The probability of acute ischemia predicted by the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI), either automatically printed or not printed on patients' electrocardiograms.

Measurements: Emergency department triage to a coronary care unit (CCU), telemetry unit, ward, or home. Other measurements were the bed capacity of the CCU relative to that of the telemetry unit; training or supervision status of the triaging physician; and patient diagnoses and outcomes based on clinical, electrocardiographic, and creatine kinase data.

Results: For patients without cardiac ischemia, in hospitals with high-capacity CCUs and relatively low-capacity cardiac telemetry units, use of ACI-TIPI was associated with a reduction in CCU admissions from 15% to 12%, a change of −16% (95% CI, −30% to 0%), and an increase in emergency department discharges to home from 49% to 52%, a change of 6% (CI, 0% to 14%; overall P = 0.09). Across all hospitals, for patients evaluated by unsupervised residents, use of ACI-TIPI was associated with a reduction in CCU admissions from 14% to 10%, a change of −32%(CI, −55% to 3%); a reduction in telemetry unit admissions from 39% to 31%, a change of −20%(CI, −34% to −2%);and an increase in discharges to home from 45% to 56%, a change of 25% (CI, 8% to 45%; overall P = 0.008).Among patients with stable angina, in hospitals with high-capacity CCUs, use of ACI-TIPI was associated with a reduction in CCU admissions from 26% to 13%, a change of −50%(CI, −70% to −17%),and an increase in discharges to home from 20% to 22%, a change of 10% (CI, −29% to 71%; overall P = 0.02). At hospitals with high-capacity telemetry units, use of ACI-TIPI was associated with a reduction in telemetry unit admissions from 68% to 59%, a change of −14%(CI, −27% to 1%), and an increase in emergency department discharges to home from 10% to 21%, a change of 100% (CI, 22% to 230%; overall P = 0.02).Among patients with acute myocardial infarction or unstable angina, use of ACI-TIPI did not change appropriate admission (96%) to the CCU or telemetry unit at hospitals with high-capacity CCUs or telemetry units.

Conclusions: Use of ACI-TIPI was associated with reduced hospitalization among emergency department patients without acute cardiac ischemia. This result varied as expected according to the CCU and cardiac telemetry unit capacities and physician supervision at individual hospitals. Appropriate admission for unstable angina or acute infarction was not affected. If ACI-TIPI is used widely in the United States, its potential incremental impact may be more than 200 000 fewer unnecessary hospitalizations and more than 100 000 fewer unnecessary CCU admissions.

Figures

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Figure 1.
Example of an acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) electrocardiogram printed by conventional electrocardiograph for the trial.

BP = blood pressure.

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Figure 2.
Comparison of the acute cardiac ischemia time-insensitive predictive instrument's predicted rates of acute cardiac ischemia with proportions of patients with acute ischemia.

Data are displayed in equal size-ordered deciles of predicted risk over a probability range of 0% to 100%. White bars represent observed proportion of patients with acute cardiac ischemia; striped bars represent predicted proportion of patients with acute cardiac ischemia.

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