Can chest pain patients be evaluated in the ER waiting room?

by John Gever

Emergency department patients with chest pain may safely be evaluated in the waiting room when necessary, researchers said.

Among 303 patients triaged to waiting-room evaluation in a prospective study, no acute coronary syndromes were missed and adverse event rates overall were lower than among 804 patients who were assessed in conventional monitored beds, reported Frank Scheuermeyer, MD, of St. Paul’s Hospital in Vancouver, British Columbia, and colleagues online in Annals of Emergency Medicine.

“Although waiting room evaluation is not ideal, it is a feasible contingency strategy for periods when ED crowding or volume surges lead to compromised access and delays to stretcher placement,” the researchers wrote.

They also noted that the alternative to waiting-room evaluation — delaying evaluation until a monitored bed opens up — is “associated with a variety of negative outcomes,” especially for patients who may be suffering myocardial infarction.

The report described the experience at St. Paul’s Hospital with a triage system in which patients with chest pain of potentially cardiac origin were evaluated in the emergency department waiting room when no monitored beds were available.

The waiting room was equipped with three curtained stretchers and a physician order-entry terminal, with some tests such as electrocardiography possible there as well.

Scheuermeyer and colleagues prospectively followed all patients with chest pain presenting at the emergency department from February to September 2006, a total of 1,107 after excluding patients under 25 years of age, patients with clearly non-cardiac causes of chest pain, and those who were lost to follow-up.

The study’s primary outcome was the rate of acute coronary syndrome missed in the emergency department but subsequently diagnosed within 30 days according to well-defined criteria. Other outcomes included adverse events, time to physician evaluation and ECG, revascularizations, and admission rate.

Among the 303 patients evaluated in the waiting room, 102 were never placed on a stretcher during their entire stay in the emergency department.

The researchers found that the evaluations were perfect in detecting acute coronary syndrome, whether conducted in the waiting room or in monitored beds. No cases were missed during the study period, they reported.

Overall, 7.6% of those evaluated in the waiting room and 11.7% of those assessed in monitored beds were diagnosed with acute coronary syndrome (P>0.05).

Median times to physician assessment were 28 minutes for patients assigned to beds versus 25 minutes for those evaluated in the waiting room.

Scheuermeyer and colleagues observed that, because waiting-room assessment only occurred during periods of extreme crowding, “it is likely that chest pain patients would have waited substantially longer in the absence of a waiting room assessment option.”

There was more of a difference in door-to-ECG times, the researchers noted: median 37 minutes for the monitored bed group versus 50 minutes for those evaluated in the waiting room.

“Times to physician and times to ECG exceeded targets for both groups, but failure to achieve these standards did not appear to cause deleterious outcomes in our study,” Scheuermeyer and colleagues wrote.

Adverse events were significantly less common among those assessed in the waiting room. Two of the 303 waiting-room patients had adverse events (both tachyarrhythmias), compared with 32 among those evaluated in monitored beds (P<0.05).

Other measures also suggested the waiting-room group generally had better outcomes:

* Rate of discharge within three hours: 17.2% monitored bed group, 28.0% waiting room group
* Admission during index visit: 19.7% monitored bed, 11.8% waiting room
* Admission during follow-up: 24.9% monitored bed, 12.9% waiting room
* Revascularization at index visit: 5.6% monitored bed, 4.3% waiting room
* Revascularization during follow-up: 7.3% monitored bed, 5.0% waiting room

Scheuermeyer and colleagues pointed out that patients were not randomized to the two groups, but were triaged to prioritize higher-risk patients for beds. In some cases, they noted, patients were taken out of beds and put in hallways to make room for more acutely ill patients.

Nevertheless, they concluded that evaluating chest pain in the waiting room does not compromise patients’ treatment or ultimate outcomes.

If anything, they added, the findings show that their triage system, “combined with rapid clinical evaluation, can identify a subgroup of chest pain patients who do not require continuous cardiac monitoring and that limited ED resources can be diverted to patients with greater need and at higher clinical risk.”

But they did acknowledge some downsides to waiting room evaluations, including less patient comfort and lack of privacy.

“Further work is required to clarify which patients are safe to assess and treat in a nontraditional setting and identify optimal systems and processes for doing so,” they wrote.

John Gever is a MedPage Today Senior Editor.

Originally published in MedPage Today. Visit MedPageToday.com for more emergency medicine news.

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