Studies: Chest pains, syncope in ED may not necessitate admission
Wednesday, July 08, 2015
When a patient's health is in question, it makes sense to admit them to the hospital and run a few tests — just to be safe — right? Well, a pair of recent studies in JAMA Internal Medicine indicate that may not be the best option.
Roughly half of the 7 million adults arriving at the emergency department with chest pains each year are admitted to hospitals for observation and diagnostic testing. However, a new study says the number of admissions is probably too high and many patients could safely receive follow-up care in another setting.
Researchers at at The Ohio State University Wexner Medical Center and Mount Carmel Health System reviewed more than 45,000 chest-pain-related emergency department visits from 2008-13 as part of a study published in the May edition of JAMA Internal Medicine.
Of those who had normal cardiac blood test, electrocardiograms and vital signs, a small number — only 0.06 percent — were at risk of having a life-threatening cardiac event such as arrhythmia or cardiac or respiratory arrest.
"We wanted to determine the risk to help assess whether this population of patients could safely go home and do further outpatient testing within a day or two," said Dr. Michael Weinstock, a professor of emergency medicine at The Ohio State University College of Medicine and chairman of the Emergency Department at Mt. Carmel St. Ann’s Hospital.
"This data shows routine hospital admission is not the best strategy for this group. We tend to admit a lot of people with chest pain out of concern for missing a heart attack or some other life-ending irregularity," Weinstock said. "To me, this says we can think more about what's best for the patient long term. I've been having these conversations with my patients, and only one wanted to stay in the hospital. Most people want to go home and get tests done the next day."
The research indicates that changes could be made to the current guidelines that call for routinely admitting and testing chest-pain patients following a clean evaluation in the emergency department.
"We'd like to see more emergency medicine physicians having that bedside conversation to ensure the chest-pain patient knows the risks and benefits of hospitalization compared to outpatient evaluation," Weinstock said. "We think continuing evaluation in an outpatient setting is not only safer for the patient, it's a less-costly approach for the healthcare system."
An unrelated study from researchers at Johns Hopkins University School of Medicine and the University of Maryland found low-risk syncope patients who were admitted through the ED experienced actually experienced harm.
"Exposing patients to unnecessary hospital admissions and testing 'just to be on the safe side' is not only wasteful from a financial and resource standpoint, but also puts patients at significant risk for harm with little likelihood of benefit," study investigator Dr. Jenna VanLiere Canzoniero, from Johns Hopkins University School of Medicine.
Researchers reviewed 213 patients who were admitted at a tertiary center over a three-year period. About a third — or 72 patients — were admitted unnecessarily because they had a San Francisco Syncope Rule rating of 0.
Syncope patients had average hospital stays of 1.73 days and underwent about 11 tests such as computed tomography or MRI of the head and Doppler ultrasound. Of low-risk patients, 13 percent experienced an adverse event related to hospital admission, and in 32 percent of cases, a definite cause of syncope could not be determined.
"It can be difficult as clinicians to resist the temptation to do more, especially in the setting of our current training, medicolegal, and reimbursement systems, which often encourage doing more," Canzoniero said. "However, judicious restraint may really be in the best interest of our patients."
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