A new high sensitivity troponin T assay was tested in the ED setting to rapidly assess for acute coronary syndrome. Internal medicine and ED implemented an updated triage and diagnostic pathway which reduced the ED length of stay (LOS) by 2.8 hours per patient, expanded ED capacity by saving 25 patient hours per day through the LOS reduction, and increased discharges by 13%.

Background: In 2017, a High-sensitivity Troponin T (hsTropT) test was approved in the United States to better facilitate diagnosis of acute coronary syndromes. The new test was introduced in the ED at Michigan Medicine in conjunction with an updated triage and diagnostic pathway to identify which patients with chest pain could safely be assessed in the ED and discharged home. In February 2018, a new diagnostic algorithm for the evaluation of chest pain using hsTropT was established. This was then used through a multi-year, multidisciplinary quality improvement project led by Internal Medicine and the ED. Following the design & initial implementation of this QI project, MPrOVE was engaged for quantitative & qualitative analytic support.

MPrOVE Role: MPrOVE provided post-intervention evaluation support by developing a probabilistic process model to understand & predict select impacts following the introduction of hsT and the chest-pain pathway on admissions, stress testing, imaging, and ED length of stay. MPrOVE also collected qualitative measures through post-implementation clinician interviews and ED observations. From these methods, common themes emerged such as:

• confusion on when to order hsT and how to interpret indeterminate values

• lack of availability of CTCA and stress testing after hours

• impact of implementing the hsT test only in the ED (as compared to the entire hospital)

Adjustments to the intervention were made to address these issues such as using multiple methods for pathway education over a continuous period of time, providing additional clarification on how to manage patients with indeterminate values, incorporating audit processes related to pathway outcomes such as reduced ED length of stay, use of hsT across the entire hospital for adult patients.

Outcomes:

• Reduced the amount of time each chest-pain patient spent in the ED by 2.8 hours.

• Expanded ED capacity by saving 25 patient hours/day, through the LOS reduction.

• Increased the rate of chest-pain patients discharged by 13%.

Additional Information:

Emergency Department Clinician Perceptions of Implementing High-Sensitivity Troponin T Assay in an Academic Hospital Emergency Department

Diagnostic patterns and stress testing trends after implementing high-sensitivity troponin assay