Early "step-down" transfer of low-risk patients with chest pain. A controlled interventional trial.

OBJECTIVE: To determine whether providing private practitioners with triage criteria for their low-risk chest pain patients would safely enhance bed utilization efficiency in coronary and intermediate care units. DESIGN: Prospective, controlled, interventional trial using an alternate month study design. SETTING: A large teaching community hospital. PATIENTS: Cohort of 404 low-risk patients with chest pain for whom a diagnosis of myocardial infarction has been excluded and who have not sustained complications, required interventions, or developed unstable comorbidity. INTERVENTIONS: During intervention months, private practitioners caring for low-risk patients in the coronary and intermediate care units were contacted 24 hours after admission. Physicians were informed that the transfer of low-risk patients to nonmonitored beds could probably be done safely, based on the results of a pilot study. The practitioner had the option of agreeing to or deferring patient transfer. During control months, physicians were not contacted in this way. MEASUREMENTS AND MAIN RESULTS: Use of the triage criteria by private practitioners reduced lengths of stay in the intermediate and coronary care units by 36% and 53%, respectively. Bed availability increased by 744 intermediate and 372 coronary care unit bed-days per year. Charges decreased by $2.6 million per year and profits improved by $390,000 per year. There were not significant differences in complications between control and intervention patients and in no case (95% CI, 0% to 1.6%) did the triage criteria adversely affect quality of care. CONCLUSIONS: The early transfer triage criteria may be a safe and efficacious decision aid for improving bed utilization in intermediate and coronary care units. In addition, this study shows the feasibility of and potential benefits from applying practice guidelines at a community hospital.

Selecting the best triage rule for patients hospitalized with chest pain.

PURPOSE: During an observational study, we investigated the potential benefits and risks of the use of admission and early transfer triage rules in 498 patients hospitalized with chest pain. PATIENTS AND METHODS: Appropriateness of triage decisions was measured using explicit and implicit judgments. RESULTS: Application of an admission triage rule (partially based on the Brush electrocardiographic criteria) would have increased coronary care unit (CCU) admissions by 3%, whereas application of a triage rule 24 hours after admission would have reduced bed utilization by 860 intermediate care and 82 CCU bed-days per year when compared with actual patient triage. Although 9.5% of patients who underwent triage according to the early transfer triage rule would have experienced a minor complication after transfer, the medical care of none would have been adversely affected. CONCLUSION: Our results show that application of a triage rule 24 hours after admission may have the potential to shorten length of stay in the CCU and intermediate care unit without significantly compromising patient care. However, use of the admission triage rule would have increased CCU bed utilization. The failure of the admission triage rule to improve bed utilization illustrates the potential hazards of ignoring patient complications, interventions, and co-morbidity when predicting the efficacy of a triage rule.