Expunging “Zero-Miss” from Chest Pain Evaluation

The admit rate for chest pain from the Emergency Department varies widely.  In some instances, the rule “chest pain = admit” is the norm – or, at the least, observation and provocative or anatomic radiology from the Emergency Department.  Indeed, such studies exhorting the advantages of CCTA in the ED included those aged as low as 30 years – patients in whom the false positives from testing far outweigh the true.

The typical motivating factor for such aggressive admission rates has been a culture of “zero miss”, motivated by huge settlements for missed MI.  Accordingly, this brief study followed Emergency Physicians and asked – what if there were no legal liability?  What if there was an acceptable miss rate of 1 or 2% in chest pain?  How many of these people would be discharged instead of admitted?

Based on 259 surveys completed regarding a convenience sample of admitted chest pain patients, the answer from this single-center study is: 30%.

With over 5 million ED visits for chest pain annually, cutting the current 35% admission rate by 30% turns into a massive reduction in resource utilization.  And, frankly, it’s not as daunting to implement such thresholds as one might imagine: ED physicians set the standard of care, not lawyers.  As Jeff Kline has alluded to the possibility, it’s time for domain experts to set reasonable practice variation and resource utilization, rather than leave it up to lawyers and their hired guns:

Some argue that “standard of care” is only determined by a jury. I disagree. Physician topic experts should write the standard of care.

— jeffrey kline (@klinelab) July 12, 2015

This definitely should be done.

“The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates”
http://www.ncbi.nlm.nih.gov/pubmed/26118834

2 thoughts on “Expunging “Zero-Miss” from Chest Pain Evaluation”

  1. Holy crumbles !
    Did'nt know the gold standard (as per the temple case uou linked) was to order a "lipid profile" for chest pain patients. In addition to the cardiac markers that are not supposed to rule out risk 3 months later in the first place.

  2. Our prospective study in chest pain patients in the NZMJ this year we showed a greater than 70% discharge from ED rate and feel that probably more could have been dischrged if it weren't for EDphysician gestalt! See NZMJ vol 128 number 1408 Jan 2015 'Use of an Accelerated Diagnostic Pathway allows rapid and safe discharge of 70% of chest pain patients from the Emergency Department'
    We powered this study to a miss rate of 1%

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