IMPACT OF THE ACUTE CARDIAC ISCHEMIA TIME-INSENSITIVE PREDICTIVE INSTRUMENT (ACI-TIPI) ON THE SPEED OF TRIAGE DECISION-MAKING FOR EMERGENCYDEPARTMENT PATIENTS PRESENTING WITH CHEST PAIN - A CONTROLLED CLINICAL-TRIAL

Objective: Emergency department (ED) triage for acute cardiac ischemia in the primary teaching hospital in Geneva, Switzerland, is very accu rate, but at the cost of very long ED stays. Thus, the authors sought: 1) to determine the impact of the acute cardiac ischemia time-insensi tive predictive instrument (ACI-TIPI), incorporated into a computerize d electrocardiograph, on length of stay and speed of triage decision m aking for ED patients presenting with symptoms suggesting acute cardia c ischemia, and 2) to study the ACI-TIPI's impact on physicians of dif ferent training levels. Design: A seven-month prospective clinical tri al with alternating-month experimental and control periods. Setting: A n urban major teaching hospital in Geneva, Switzerland. Participants: Patients over the age of 18 years presenting to the ED with chest pain or other symptoms suggesting acute cardiac ischemia (acute myocardial infarction or unstable angina pectoris). Emergency department physici ans, classified as novice (those in their first ED rotations) and expe rienced (those in their second or later ED rotations). Patients stayin g overnight in die ED (n = 111) were excluded from the analysis. Inter vention: During the experimental months, the computerized electrocardi ograph printed the ACI-TIPI probability of acute cardiac ischemia at t he top of each subject's electrocardiogram. During control months, the probability was not provided. Measurements and main results: Among th e 418 study subjects, for patients with acute ischemia seen by novice clinicians, the use of the ACI-TIPI decreased ED time from presentatio n to triage decision and ED release by 0.7 hour (19%) (p = 0.007). Sub group analyses for patients with acute myocardial infarction, patients with unstable angina pectoris, and patients given thrombolytic therap y also showed analogous decreases in ED time consistent with this find ing. Other key determinants of ED length of stay included: age, whethe r the coronary care unit was full, whether patients received thromboly tic therapy, and whether admission was during the night shift. The exp erimental and control groups did not differ in triage disposition appr opriateness or mortality. Conclusions: For ED patients with acute card iac ischemia evaluated by novice clinicians, the ACI-TIPI substantiall y speeded ED decision making and triage. The suggestion of an impact o n different cardiac ischemia subgroups and mortality deserves further larger clinical trials.