Effect of Implementation of HEART Chest Pain Protocol on Emergency Department Disposition, Testing and Cost.

BACKGROUND: Symptoms concerning for acute coronary syndromes (ACS) such as chest pain and dyspnea are some of the most common reasons for presenting to an emergency department (ED). The HEART score (history, electrocardiogram, age, risk factors and troponin) was developed and has been externally validated in an emergency setting to determine which patients with chest pain are at increased risk for poor outcomes. Our hospital adopted a HEART score-based protocol in late 2015 to facilitate the management and disposition of these patients. In this study we aimed to analyze the effects of the adoption of this protocol. Prior studies have included only patients with chest pain. We included both patients with chest pain and patients with only atypical symptoms. METHODS: This was a retrospective chart review of two cohorts. We identified ED charts from six-month periods prior to and after adoption of our HEART score-based protocol. Patients in whom an electrocardiogram and troponin were ordered were eligible for inclusion. We analyzed data for patients with typical symptoms (chest pain) and atypical symptoms both together and separately. RESULTS: We identified 1546 charts in the pre-adoption cohort and 1623 in the post-adoption cohort that met criteria. We analyzed the first 900 charts in each group. Discharges from the ED increased (odds ratio [OR[1.56, P<.001), and admissions for cardiac workup decreased (OR 0.46, P <.001). ED length of stay was 17 minutes shorter (P = .01). Stress testing decreased (OR 0.47, P<.001). We estimate a cost savings for our hospital system of over $4.5 million annually. There was no significant difference in inpatient length of stay or catheterization rate. When analyzing typical and atypical patients separately, these results held true. CONCLUSION: After adoption of a HEART score-based protocol, discharges from the ED increased with a corresponding decrease in admissions for cardiac evaluations as well as cost. These effects were similar in patients presenting without chest pain but with presentations concerning for ACS.

Semimembranosus tendinopathy: one cause of chronic posteromedial knee pain.

CONTEXT: Semimembranosus tendinopathy (SMT) is an uncommon cause of chronic knee pain that is rarely described in the medical literature and may be underdiagnosed or inadequately treated owing to a lack of understanding of the condition. EVIDENCE ACQUISITION: A search of the entire PubMed (MEDLINE) database using the terms knee pain semimembranosus and knee tendinitis semimembranosus, returned only 5 references about SMT-4 case series and 1 case report-and several relevant anatomical or imaging references. RESULTS: The incidence of SMT is unknown in the athletic population and is probably more common in older patients. The usual presentation for SMT is aching posteromedial knee pain. Physical examination can usually localize the area of tenderness to the distal semimembranosus tendon or its insertion on the medial proximal tibia. In unclear cases, bone scan, magnetic resonance imaging, or ultrasound may distinguish SMT from other causes of posteromedial knee pain. Treatment should begin with relative rest, ice, nonsteroidal anti-inflammatory drugs, and rehabilitative exercise. In the minority of cases that persist greater than 3 months, a corticosteroid injection at the tendon insertion site may be effective. Surgery to reroute and reattach the tendon is rarely needed but may be effective. CONCLUSION: SMT is an uncommon cause of knee pain, but timely diagnosis can lead to effective treatments.