Do management algorithms improve chest pain triage?

Objective: To audit the use of management algorithms for chest pain in an emergency department. Design and setting: Prospective study of all patients with chest pain presenting to the emergency department of an urban teaching hospital between 12 January and 4 May 1997. Staff were asked to complete a standardised admission form that incorporated the risk stratification algorithms for managing patients with suspected acute coronary syndrome. Main outcome measures: Compliance with the use of management algorithms; concordance with a cardiologist's review of the triage grouping and admission/discharge decision; and major cardiovascular events over four months. Results: Emergency department staff documented the triage group in 223 of 503 cases (45%). Concordance with the group assigned by a cardiologist was 70% (kappa=0.73; SEkappa=0.04). When the management algorithm was applied correctly, 92% of triage decisions were correct (95% confidence interval [CI], 87%-96%). The triage decision was less often correct when risk stratification was not done (78% [73%-83%], P<0.001), overestimated (77% [66%-88%], P < 0.01), or underestimated (50% [18%-82%], P < 0.001). The proportion of patients free of major cardiovascular events at four-month follow-up was 50% for those with myocardial infarction with ST-segment elevation, 47% for those with a high short-term risk of an adverse cardiac event, 82% for those with intermediate risk, and 99% for those with a low risk or non-coronary chest pain (P < 0.001). Conclusions: Use of management algorithms by emergency staff was poor. When used, triage decisions were more likely to be correct. Subsequent outcome confirms that the NHMRC risk stratification algorithms are useful for prognostic stratification of patients with suspected acute coronary syndrome.