Edward Watts Carlton1, Ahmed Khattab2, Kim Greaves3. 1. Emergency Department, Southmead Hospital, Bristol, UK School of Health and Social Care, Bournemouth University, Bournemouth, Dorset, UK. 2. School of Health and Social Care, Bournemouth University, Bournemouth, Dorset, UK. 3. Department of Cardiology, Sunshine Coast Hospital and Health Services, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia.
Abstract
OBJECTIVES: To establish the accuracy of emergency department (ED) nursing staff risk assessment using an established chest pain risk score alone and when incorporated with presentation high-sensitivity troponin testing as part of an accelerated diagnostic protocol (ADP). DESIGN: Prospective observational study comparing nursing and physician risk assessment using the modified Goldman (m-Goldman) score and a predefined ADP, incorporating presentation high-sensitivity troponin. SETTING: A UK District ED. PATIENTS: Consecutive patients, aged ≥18, with suspected cardiac chest pain and non-ischaemic ECG, for whom the treating physician determined serial troponin testing was required. OUTCOME MEASURES: 30-day major adverse cardiac events (MACE). RESULTS: 960 participants were recruited. 912/960 (95.0%) had m-Goldman scores recorded by physicians and 745/960 (77.6%) by nursing staff. The area under the curve of the m-Goldman score in predicting 30-day MACE was 0.647 (95% CI 0.594 to 0.700) for physicians and 0.572 (95% CI 0.510 to 0.634) for nursing staff (p=0.09). When incorporated into an ADP, sensitivity for the rule-out of MACE was 99.2% (95% CI 94.8% to 100%) and 96.7% (90.3% to 99.2%) for physicians and nurses, respectively. One patient in the physician group (0.3%) and three patients (1.1%) in the nursing group were classified as low risk yet had MACE. There was fair agreement in the identification of low-risk patients (kappa 0.31, 95% CI 0.24 to 0.38). CONCLUSIONS: The diagnostic accuracy of ED nursing staff risk assessment is similar to that of ED physicians and interobserver reliability between assessor groups is fair. When incorporating high-sensitivity troponin testing, a nurse-led ADP has a miss rate of 1.1% for MACE at 30 days. TRIAL REGISTRATION NUMBER: Controlled Trials Database (ISRCTN no. 21109279). Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
OBJECTIVES: To establish the accuracy of emergency department (ED) nursing staff risk assessment using an established chest pain risk score alone and when incorporated with presentation high-sensitivity troponin testing as part of an accelerated diagnostic protocol (ADP). DESIGN: Prospective observational study comparing nursing and physician risk assessment using the modified Goldman (m-Goldman) score and a predefined ADP, incorporating presentation high-sensitivity troponin. SETTING: A UK District ED. PATIENTS: Consecutive patients, aged ≥18, with suspected cardiac chest pain and non-ischaemic ECG, for whom the treating physician determined serial troponin testing was required. OUTCOME MEASURES: 30-day major adverse cardiac events (MACE). RESULTS: 960 participants were recruited. 912/960 (95.0%) had m-Goldman scores recorded by physicians and 745/960 (77.6%) by nursing staff. The area under the curve of the m-Goldman score in predicting 30-day MACE was 0.647 (95% CI 0.594 to 0.700) for physicians and 0.572 (95% CI 0.510 to 0.634) for nursing staff (p=0.09). When incorporated into an ADP, sensitivity for the rule-out of MACE was 99.2% (95% CI 94.8% to 100%) and 96.7% (90.3% to 99.2%) for physicians and nurses, respectively. One patient in the physician group (0.3%) and three patients (1.1%) in the nursing group were classified as low risk yet had MACE. There was fair agreement in the identification of low-risk patients (kappa 0.31, 95% CI 0.24 to 0.38). CONCLUSIONS: The diagnostic accuracy of ED nursing staff risk assessment is similar to that of ED physicians and interobserver reliability between assessor groups is fair. When incorporating high-sensitivity troponin testing, a nurse-led ADP has a miss rate of 1.1% for MACE at 30 days. TRIAL REGISTRATION NUMBER: Controlled Trials Database (ISRCTN no. 21109279). Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Entities:
Keywords:
cardiac care, acute coronary syndrome; cardiac care, diagnosis; nursing, emergency departments