FAILURE OF A CHEST PAIN CLINICAL POLICY TO MODIFY PHYSICIAN EVALUATION AND MANAGEMENT

Study objective: To assess the effectiveness of a specific, targeted clinical policy regarding the evaluation of nontraumatic chest pain in the emergency department (ED) to modify physician evaluation and management. Design: Retrospective, blinded chart review. Setting: Twelve metropolitan EDs. Participants: All males older than 35 years and females older than 45 years who presented with nontraumatic chest pain during one of the two study periods-1 year before (1989) or 1 year after (1991) dissemination of the American College of Emergency Physicians' (ACEP) chest pain clinical policy. Measurements: Physician's compliance with various documentation rules regarding history and physical examination were compared between the two periods with chi2 analysis. Fisher's exact test was used when any one cell value was less than five. The physician's compliance with the rules and guidelines of management (Actions) were compared between the two periods with chi2 analysis. Results: Rates of compliance for 1989 and 1991 were as follows: history documentation, 368 (82%) vs. 255 (78%) (P=.22); physical examination documentation, 397 (88%) vs. 287 (88%) (P=.94); Action rules, 292 (65%) vs. 208 (64%) (P=.76); and Action guidelines, 247 (55%) vs. 172 (53%) (P=.55). Conclusion: We conclude that the dissemination of the ACEP chest pain clinical policy has not significantly modified the behavior of our metropolitan area emergency physicians regarding the evaluation and management of patients who present to the ED with a chief complaint of nontraumatic chest pain.