An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO)
MA Gomez,
JL Anderson,
LA Karagounis,
JB Muhlestein,
and
FB Mooers
LDS Hospital, Salt Lake City, Utah 84143, USA.
OBJECTIVES: We tested the hypothesis that an emergency department-based protocol for rapidly ruling out myocardial ischemia would reduce hospital time and expense but maintain diagnostic accuracy. BACKGROUND: Patients with a missed diagnosis of myocardial infarction have a high mortality rate; however, providing routine hospital care to low risk patients may not be time- or cost-effective. METHODS: One hundred low risk patients were entered into the study and randomized either to an emergency department-based rapid rule-out protocol (n = 50) or to routine hospital care (n = 50). Patients receiving routine care were managed by their attending physicians. The rapid protocol included serum enzyme testing at 0, 3, 6 and 9h, serial electrocardiograms with continuous ST segment monitoring and, if results were negative, a predischarge graded exercise test. Study patients were also compared with 160 historical control subjects. RESULTS: Myocardial infarction or unstable angina occurred in 6% of patients within 30 days; no diagnoses were missed. By intention to treat analysis (n = 50 in each group), the hospital stay was shorter and charges were lower with the rapid protocol than with routine care (p = 0.001). Among patients in whom ischemia was ruled out, those assigned to the rapid protocol had a shorter hospital stay (median 11.9 vs. 22.8 h, p = 0.0001) and lower initial ($893 vs $1,349, p = 0.0001) and 30-day ($898 vs. $1,522, p = 0.0001) hospital charges than did patients given routine care. In historical control subjects, the hospital stay was longer (median 34.5 h, p = 0.001 vs. either group) and charges greater (median $2,063, p = 0.001, vs rapid protocol, p = 0.02, vs. routine care group). CONCLUSIONS: In low risk patients who present to the emergency department with chest pain, the rapid protocol ruled out myocardial infarction and unstable angina more quickly and cost-effectively than did routine hospital care.
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U Ekelund and J L Forberg
New methods for improved evaluation of patients with suspected acute coronary syndrome in the emergency department
Postgrad. Med. J.,
February 1, 2008;
84(988):
83 - 86.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
U Ekelund and J L Forberg
New methods for improved evaluation of patients with suspected acute coronary syndrome in the emergency department
Emerg. Med. J.,
December 1, 2007;
24(12):
811 - 814.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Clancy
Effectiveness of chest pain units
BMJ,
September 29, 2007;
335(7621):
623 - 624.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Goodacre, E. Cross, C. Lewis, J. Nicholl, S. Capewell, and ESCAPE Research Team
Effectiveness and safety of chest pain assessment to prevent emergency admissions: ESCAPE cluster randomised trial
BMJ,
September 29, 2007;
335(7621):
659 - 659.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al.
ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine
J. Am. Coll. Cardiol.,
August 14, 2007;
50(7):
e1 - e157.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Arnold, S. Goodacre, F. Morris, and on behalf of the ESCAPE Research Team
Structure, process and outcomes of chest pain units established in the ESCAPE Trial
Emerg. Med. J.,
July 1, 2007;
24(7):
462 - 466.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. M. Bulgiba and M. H. Fisher
Using neural networks and just nine patient-reportable factors of screen for AMI.
Health Informatics Journal,
September 1, 2006;
12(3):
213 - 225.
[Abstract]
[PDF]
|
|
|
|
|
|
|
M. Jahrsdoerfer, K. Giuliano, and D. Stephens
Clinical Usefulness of the EASI 12-Lead Continuous Electrocardiographic Monitoring System
Crit. Care Nurse,
October 1, 2005;
25(5):
28 - 37.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S Goodacre and S Dixon
Is a chest pain observation unit likely to be cost effective at my hospital? Extrapolation of data from a randomised controlled trial
Emerg. Med. J.,
June 1, 2005;
22(6):
418 - 422.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. J. Drew, R. M. Califf, M. Funk, E. S. Kaufman, M. W. Krucoff, M. M. Laks, P. W. Macfarlane, C. Sommargren, S. Swiryn, and G. F. Van Hare
Practice Standards for Electrocardiographic Monitoring in Hospital Settings: An American Heart Association Scientific Statement From the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses
Circulation,
October 26, 2004;
110(17):
2721 - 2746.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Christenson, G. Innes, D. McKnight, B. Boychuk, E. Grafstein, C. R. Thompson, F. Rosenberg, A. H. Anis, K. Gin, J. Tilley, et al.
Safety and efficiency of emergency department assessment of chest discomfort
Can. Med. Assoc. J.,
June 8, 2004;
170(12):
1803 - 1807.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Goodacre, J. Nicholl, S. Dixon, E. Cross, K. Angelini, J. Arnold, S. Revill, T. Locker, S. J Capewell, D. Quinney, et al.
Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care
BMJ,
January 31, 2004;
328(7434):
254.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Goldman and A. J. Kirtane
Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia: The Elusive Search for Diagnostic Perfection
Ann Intern Med,
December 16, 2003;
139(12):
987 - 995.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. A. Spertus, M. J. Radford, N. R. Every, E. F. Ellerbeck, E. D. Peterson, and H. M. Krumholz
Challenges and opportunities in quantifying the quality of care for acute myocardial infarction: Summary from the acute myocardial infarction working group of the American heart association/American college of cardiology first scientific forum on quality of care and outcomes research in cardiovascular disease and stroke
J. Am. Coll. Cardiol.,
May 7, 2003;
41(9):
1653 - 1663.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. A. Spertus, M. J. Radford, N. R. Every, E. F. Ellerbeck, E. D. Peterson, and H. M. Krumholz
Challenges and Opportunities in Quantifying the Quality of Care for Acute Myocardial Infarction: Summary From the Acute Myocardial Infarction Working Group of the American Heart Association/American College of Cardiology First Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke
Circulation,
April 1, 2003;
107(12):
1681 - 1691.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T B Hassan
Clinical decision units in the emergency department: old concepts, new paradigms, and refined gate keeping
Emerg. Med. J.,
March 1, 2003;
20(2):
123 - 125.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. J. Gibbons
Chest Pain Triage--Another Step Forward
JAMA,
December 4, 2002;
288(21):
2745 - 2746.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Committee Members, R. J. Gibbons, G. J. Balady, J. Timothy Bricker, B. R. Chaitman, G. F. Fletcher, V. F. Froelicher, D. B. Mark, B. D. McCallister, A. N. Mooss, et al.
ACC/AHA 2002 guideline update for exercise testing: summary article: A report of the American college of cardiology/American heart association task force on practice guidelines (committee to update the 1997 exercise testing guidelines)
J. Am. Coll. Cardiol.,
October 16, 2002;
40(8):
1531 - 1540.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. J. Gibbons, G. J. Balady, J. Timothy Bricker, B. R. Chaitman, G. F. Fletcher, V. F. Froelicher, D. B. Mark, B. D. McCallister, A. N. Mooss, M. G. O'Reilly, et al.
ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines)
Circulation,
October 1, 2002;
106(14):
1883 - 1892.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C Taylor, A Forrest-Hay, and S Meek
ROMEO: a rapid rule out strategy for low risk chest pain. Does it work in a UK emergency department?
Emerg. Med. J.,
September 1, 2002;
19(5):
395 - 399.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S W Goodacre, F M Morris, S Campbell, J Arnold, and K Angelini
A prospective, observational study of a chest pain observation unit in a British hospital
Emerg. Med. J.,
March 1, 2002;
19(2):
117 - 121.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. V. Williams, S. D. Fihn, and R. J. Gibbons
Guidelines for the Management of Patients with Chronic Stable Angina: Diagnosis and Risk Stratification
Ann Intern Med,
October 2, 2001;
135(7):
530 - 547.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. F. Fletcher, G. J. Balady, E. A. Amsterdam, B. Chaitman, R. Eckel, J. Fleg, V. F. Froelicher, A. S. Leon, I. L. Pina, R. Rodney, et al.
Exercise Standards for Testing and Training: A Statement for Healthcare Professionals From the American Heart Association
Circulation,
October 2, 2001;
104(14):
1694 - 1740.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. H. Christenson, S. H. Duh, W. R. Sanhai, A. H.B. Wu, V. Holtman, P. Painter, E. Branham, F. S. Apple, M. Murakami, and D. L. Morris
Characteristics of an Albumin Cobalt Binding Test for Assessment of Acute Coronary Syndrome Patients: A Multicenter Study
Clin. Chem.,
March 1, 2001;
47(3):
464 - 470.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
British Cardiac Society Guidelines and Medical Pra and Royal College of Physicians Clinical Effectiveness
Guideline for the management of patients with acute coronary syndromes without persistent ECG ST segment elevation
Heart,
February 1, 2001;
85(2):
133 - 142.
[Full Text]
|
|
|
|
|
|
|
R Bholasingh, R J de Winter, J C Fischer, R W Koster, R J G Peters, and G T Sanders
Safe discharge from the cardiac emergency room with a rapid rule-out myocardial infarction protocol using serial CK-MBmass
Heart,
February 1, 2001;
85(2):
143 - 148.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
S. Goodacre, F. Morris, J. Arnold, and K. Angelini
Is a chest pain observation unit likely to be cost saving in a British hospital?
Emerg. Med. J.,
January 1, 2001;
18(1):
11 - 14.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
R. A. Stein, B. R. Chaitman, G. J. Balady, J. L. Fleg, M. C. Limacher, I. L. Pina, M. A. Williams, and T. Bazzarre
Safety and Utility of Exercise Testing in Emergency Room Chest Pain Centers : An Advisory From the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association
Circulation,
September 19, 2000;
102(12):
1463 - 1467.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. Braunwald, E. M. Antman, J. W. Beasley, R. M. Califf, M. D. Cheitlin, J. S. Hochman, R. H. Jones, D. Kereiakes, J. Kupersmith, T. N. Levin, et al.
ACC/AHA guidelines for the management of patients with unstable angina and non-st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina)
J. Am. Coll. Cardiol.,
September 1, 2000;
36(3):
970 - 1062.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Quin
Chest pain evaluation units
Emerg. Med. J.,
July 1, 2000;
17(4):
237 - 240.
[Full Text]
|
|
|
|
|
|
|
T. H. Lee and L. Goldman
Evaluation of the Patient with Acute Chest Pain
N. Engl. J. Med.,
April 20, 2000;
342(16):
1187 - 1195.
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. R. Every, J. Hochman, R. Becker, S. Kopecky, and C. P. Cannon
Critical Pathways : A Review
Circulation,
February 1, 2000;
101(4):
461 - 465.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. W Goodacre
Should we establish chest pain observation units in the UK? A systematic review and critical appraisal of the literature
Emerg. Med. J.,
January 1, 2000;
17(1):
1 - 6.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
T. Jernberg, B. Lindahl, and L. Wallentin
ST-segment monitoring with continuous 12-lead ECG improves early risk stratification in patients with chest pain and ECG nondiagnostic of acute myocardial infarction
J. Am. Coll. Cardiol.,
November 1, 1999;
34(5):
1413 - 1419.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. J. Gibbons, K. Chatterjee, J. Daley, J. S. Douglas, S. D. Fihn, J. M. Gardin, M. A. Grunwald, D. Levy, B. W. Lytle, R. A. O'Rourke, et al.
ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina)
J. Am. Coll. Cardiol.,
June 1, 1999;
33(7):
2092 - 2197.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. E. Farkouh, P. A. Smars, G. S. Reeder, A. R. Zinsmeister, R. W. Evans, T. D. Meloy, S. L. Kopecky, M. Allen, T. G. Allison, R. J. Gibbons, et al.
A Clinical Trial of a Chest-Pain Observation Unit for Patients with Unstable Angina
N. Engl. J. Med.,
December 24, 1998;
339(26):
1882 - 1888.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. K. Newby and D. B. Mark
The Chest-Pain Unit -- Ready for Prime Time?
N. Engl. J. Med.,
December 24, 1998;
339(26):
1930 - 1932.
[Full Text]
|
|
|
|
|
|
|
C. A. Polanczyk, T. H. Lee, E. F. Cook, R. Walls, D. Wybenga, G. Printy-Klein, L. Ludwig, G. Guldbrandsen, and P. A. Johnson
Cardiac troponin I as a predictor of major cardiac events in emergency department patients with acute chest pain
J. Am. Coll. Cardiol.,
July 1, 1998;
32(1):
8 - 14.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. R. Hedges
Cardiac Enzyme Availability and Hospital Length of Stay
Clin. Chem.,
February 1, 1997;
43(2):
249 - 250.
[Full Text]
[PDF]
|
|
|
|
