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Emergency Physicians Can Trust Their Judgment on Chest Pain Patients

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Now we have evidence that emergency room physicians should trust their gut instinct when they have to make a quick decision about a potential heart patient, before lab results are even returned. Sometimes these patients could be better served by staying at the hospital and having more tests rather than being treated and released or discharged.

The findings, published in the August issue of Academic Emergency Medicine, are important in today's health care climate. When we examine cost and efficiency of health care, I think that emergency physicians can make an impact. If we release patients who end up needing further care, costs go up.

Now it looks as if emergency physicians should counsel against discharge with other physicians when they feel strongly about a chest pain patient for whom there is no compelling data, other than our evaluation and judgment. Based on data I reviewed with colleagues, on a group of more than 10,000 patients, 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.

Sometimes the initial tests we see in the emergency setting don't indicate anything serious, but I think, based on my experience and the sum of my judgment, there is something more.

I was curious and wondered if I might be out of line or if there would be validity in this gut instinct. I recalled the existing data from a large registry on coronary outcomes and learned that there might be evidence to support our judgment.

Examining a robust database, I and other emergency medicine colleagues found that, for patients who lacked obvious initial evidence of a cardiac event, the 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, and the data was collected between June 1999 and August 2001.)

In this database were results of how emergency physicians had estimated the risk of symptoms suggesting an acute coronary syndrome. The physicians had classified them into four categories: unstable angina, high risk for cardiac event, low risk, and non-cardiac chest pain. In the current study, the researchers wanted to learn how these categories tracked with later outcomes.

I was really surprised by the magnitude of the good instincts. 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. I think that is pretty substantial. The adverse outcomes included death, heart attack (myocardial infarction), or the need to open blood vessels for blood flow.

Likewise, we evaluated data on the 24 subjects who were discharged from the emergency department who had major adverse cardiac events. A total of 524 were discharged to home from the high-risk group, and five had a major adverse outcome within 30 days.

While only one 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.

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. My hope is that we can share these findings with a wide group of physicians, because we all have the same goal of keeping our patients healthy.

One way to formalize the value of the gut instinct about 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 his/her judgment and determine the final probability of acute coronary syndrome. In this way, we could check to see if we were right and improve care.

Emergency medicine is unique in that we have a very limited amount of time and data to make decisions. Emergency physicians are very good at operating under these circumstances. Bottom line: Our decisions are better than we might give ourselves credit for.

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