Chest pain: a rapid evaluation unit may save money.

Clinical bottom line (level 1b-)

  1. Patients who were admitted to a rapid evaluation chest pain unit possibly have fewer infarcts or episodes of unstable angina than patients receiving normal care.
  2. Patients spent fewer hours in hospital (39 less), consequently money was saved.
Gomez et al: Journal of the American College of Cardiology 1996; 28 (1): 25-33
Expires July 2003

The study

Unblinded concealed randomised trial without intention-to-treat
Setting: emergency department, USA

100 patients (aged mean 51 years, 61%% male) presenting to ED with suspected ischaemic chest pain, or with symptoms suggestive of acute myocardial ischaemia or infarction

Excluded if
  • <30 years old
  • SVT/VT/numerous ectopics/ second or third degree heart block, new left bundle branch block
  • blood pressure >220/120
  • CC needing monitoring or medication
  • other conditions needing iv medication
  • risk >7% by Goldman criteria
  • ECG changes- ST elevation >0.1 mV; new Q waves; ST decrease >0.08 seconds after J point; deep symmetrical T wave inversion


Note:
  • Patients were randomised following evaluation by ED physician.


Control Group: (n = 50, 50 analysed): normal care- admitted to hospital under internal medicine team
Experimental Group: (n = 50, 50 analysed): admitted to chest pain evaluation unit. Had CK and CK-MB at 0, 3, 6, 9 hours, and ECG every 15 minutes or if significant ST elevation. If all tests negative, had cardiac stress test (treadmill or dobutamine) 9-12 hours after admission. If any test positive, transferred to coronary care unit. If negative, discharged.

100% followed for 30 days

The evidence

Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
acute MI or unstable angina 30 days 5
(10.0%)		 1
(2.00%)		 80%
(-65% to 98%)		 8.00%
(-1.18% to 17.2%)		 13
(NNT = 6 to infinity;
NNH = 85 to infinity)

Outcome Control Group
(SD)		 Experimental Group
(SD)		 Mean Difference
(95% CI)
length of stay after randomisation (hours) 54.6
(126) 		15.4
(12.2) 		39
(3.6 to 75)
cost at 30 days ($) 5860
(14638) 		1424
(1735) 		4440
(300 to 8570)

Comments

  1. Some patients with chest pain were already discharged by ER physicians- what criteria did they use?
  2. Study was too small to detect small differences.

Citation

  1. Gomez MA, Anderson JL, Karagounis LA, et al: An emergency department-based protocol for rapidly ruling out myocardial ischemia decreases hospital time and expense: results of a randomized study (ROMIO). Journal of the American College of Cardiology 1996; 28 (1): 25-33
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Contributor: Chris Ball and Clare Wotton, July 2000
Reviewer:

Clinical Question.
Patient chest pain
Intervention or Exposure rapid evaluation chest pain unit
Outcome length of hospitalisation, MI, angina