AEM: ER docs have good gut instincts for chest pain patients

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Emergency physicians should trust their judgment when evaluating patients who report with chest pain symptoms, based on research published in this month's issue of Academic Emergency Medicine.

The study suggests that emergency physicians should counsel with other physicians against discharge when they feel strongly about a patient for whom there is no compelling data, other than their evaluation and judgment, according to lead researcher Abhinav Chandra, MD, at Duke University Medical Center in Durham, N.C.

"There is evidence for emergency room physicians to trust their gut instinct when they have to make a quick decision about a potential heart patient, before lab results are even returned," said Chandra, director of acute-care research and of the clinical evaluation unit in Duke's division of emergency medicine. "Sometimes these patients could be better served by staying at the hospital and having more tests rather than being treated and released or discharged."

Chandra and colleagues found that for patients who lacked obvious initial evidence of a cardiac event, the emergency physicians' estimates of risk in the first 30 days correlated with their actual outcomes. The patients were from nine hospitals, including two non-teaching hospitals and a hospital in Singapore. They collected data between June 1999 and August 2001.

"Based on these data, I believe significant advances in both optimal patient care and cost-effective patient management can result from improved and increased communication between emergency room physicians and admitting physicians," Chandra said. "Our primary concern has to be a central focus on making the best possible decision about which patients should stay, and which should go home, and continually analyzing the factors that would lead to either approach.

"I was surprised by the magnitude of the good instincts," Chandra said. "Of the 10,713 patients who met the criteria for our study, 604 were diagnosed with unstable angina. A total of 133, or 22 percent, had an adverse outcome in the first 30 days." The researchers defined adverse outcomes as death, MI or revascularization.

Chandra and colleagues also evaluated data on the 24 subjects who were discharged from the emergency department who had major adverse cardiac events. They found a total of 524 were discharged to home from the group assessed as high risk, and five had a major adverse outcome within 30 days.

"While only 1 percent had a bad outcome in the first 30 days, that is unsettling, because we see them and express concern about their risk level, yet so many are sent home," he said. "We don't know what influenced the ultimate decision by the admitting or ER doctor to send the patients home, and that would be an important variable to study further."

According to the authors, one way to formalize the value of ‘gut instinct' concerning chest pain patients would be to introduce objective tools, like those that already exist for risk stratification of patients with pneumonia and for venous thrombus embolism. For example, the emergency physician could use an objective tool to categorize a patient with potential acute coronary syndrome and then add their judgment and determine the final probability of acute coronary syndrome, they wrote.

Chandra noted that good independent judgment takes experience to attain, but thinks it begins to be very sound about one to two years after formal training ends. "Emergency medicine is unique in that you have a very limited amount of time and data to make decisions," he said. "Emergency physicians are very good at operating under these circumstances."

"When we examine cost and efficiency of healthcare, I think that emergency physicians can make an impact. If we release patients who end up needing further care, costs go up," Chandra concluded. "Our decisions are better than we might give ourselves credit for."