299 Retrospective Study of a Low-Risk Chest Pain Protocol in a Socioeconomically Disadvantaged Population

Standardized chest pain (CP) protocols are implemented in emergency departments (EDs) to safely and efficiently assess CP visits and provide the most appropriate disposition without excess resource utilization. However, whether the success of such an approach may be affected by the socioeconomic status of the target population is not known. We sought to determine the effectiveness of a standardized CP protocol in a primarily socioeconomically disadvantaged population. On November 1, 2012, a new CP protocol that utilizes the thrombolysis in myocardial infarction (TIMI) risk score, electrocardiography, and contemporary sensitivity troponin I to triage patients into low, intermediate and high-risk categories was implemented in our Detroit-based ED. Discharged low-risk patients were provided an outpatient cardiology follow-up appointment within 48 hours. We performed a retrospective analysis of patients greater than 18 years of age who presented with a chief complaint of low risk CP (TIMI score 0-1) during a 1-year period (6 months pre- and 6 months post-protocol implementation), comparing the proportion deemed low risk, ED disposition and 30-day ED recidivism rates over time using chi-square. A total of 3613 patients were included (n=1837 pre-protocol versus n=1776 post-protocol). The pre- and post-protocol populations were demographically similar with mean ages of 47.0 and 47.4, respectively. There was no statistical difference in the proportion deemed at low-risk in the pre- versus post-protocol periods (67% pre- versus 68% post-protocol; p=0.167). However, significantly more low-risk patients were discharged post-protocol implementation (55% versus 44%; p<0.001). Of the patients who were discharged, 41.9% kept their appointment with the cardiologist. ED recidivism was also significantly greater in the post-protocol versus pre-protocol (2.98% versus 1.63%; p=0.0035). Post-implementation of a CP protocol, a greater proportion of ED patients with low-risk CP were discharged, yet a higher rate of ED recidivism was seen. Such recidivism may reflect difficulty accessing outpatient follow-up in our socioeconomically disadvantaged population (Detroit has an 82.7% African-American population, and 35.7% of people live below the poverty line), but the precise cause of this important finding is unclear.Tabled 1Comparison Pre- and Post-ProtocolOutcomePre (N=1837)Post (N=1776)Low Risk1227 (67%)1213 (68%)Discharged808 (44%)970 (55%)ED Recidivism30 (1.63%)53 (2.98%) Open table in a new tab