CHEST PAIN TRIAGE ‑- OUTCOME AFTER INAPPROPRIATE DISCHARGE. MA. Fitzpatrick*, M. Dodd, E. Hutchings,
D. Schoevers, A. Grouse. Cardiology and Emergency Depts, Nepean
Hospital, NSW. Introduction: Chest pain (CP) patients (pts) with an intermediate
risk (IntRisk) of short-term adverse events are frequently discharged
inappropriately (InDis) without exclusion of MI at 8 hrs or exercise
testing (EST) contrary to national Guidelines (NGL) (MJA 1997; 166:644). Aim: To compare the outcomes (death, MI or recurrent CP admission)
of InDis pts with those managed by a chest pain unit surgery (CPU
‑- exclude MI + EST + discharge in <24 hrs). Methods:
Prospective cohort study of 1,013 patients presenting for the first time
to the NH ED with CP between 29/6/98 and 28/2/99. Of 370 IntRisk pts, 173 were discharged <24 hrs: 75 CPU; 100
InDis (43 <6 hrs, 57 No EST). Of 205
high risk or ST elevation MI pts, 20 of the high risk pts were discharged
<24 hrs: 6 CPU; 14 InDis (5 <6 hrs, 9 No EST). Of the CPU pts, 27 participated in a randomised study comparing
outcomes with usual care. Of the
remaining CPU pts, 36/54 would have met inclusion criteria for the study, while
51/106 InDis pts met these criteria.
Outcomes were determined by chart review and telephone at 4 months. Results: At entry, the CPU & InDis pts had a similar
age and sex distribution and frequency of CAD risk factors.
However, InDis pts had a higher prevalence of prior CAD (43% v 7%,
p<0.01). Outcome data in table (P<0.05 * Chi-sq): CPU
Strategy Inapprop
Disch P Number
of pts 81 Lost
to Followup 1 7 Death 0 1 NS a
Myocardial Infarct (MI) 1 4 NS b
CP readmission 2 8 NS c
Composite (a+b+c) 3 13 * Revascularisation 2 6 NS For InDis pts, the death occurred <24
hrs after discharge from the ED, while 4/12 other events occurred in the first
week. For CPU pts, 1/3 events occurred
<1 week. Conclusions: ED staff are less likely to refer pts with prior CAD for EST
prior to early discharge. Compared to
pts managed with the CPU strategy, InDis pts have worse outcomes which may be
improved by resourcing and implementing the CPU strategy at NH.
