Association between an educational intervention and a reduction in inappropriate troponin testing in patients presenting to an adult emergency department.

BACKGROUND: High-sensitivity troponin replaced the fourth generation assay at our institution in July 2010. Prior experience suggested that the number of positive tests with the new assay may double, and that many troponin requests were inappropriate. AIM: Primarily, this study aims to design and measure the effect of an educational intervention to reduce the number of inappropriate troponin tests. Second, other objectives are to compare weekly totals of troponin tests before and after the intervention, to note patients with missed acute coronary syndrome (ACS) during the study period and to survey clinicians regarding their likely troponin ordering practices in certain clinical scenarios. METHODS: A staff survey informed the content of the educational intervention. Criteria for inappropriate testing were defined prior to the study. Retrospective notes review of pre-and post-intervention cohorts were used to determine the reduction in inappropriate troponin tests. RESULTS: Ninety-six patients were in each cohort. The proportion of inappropriate tests fell from 43% (95% confidence interval (CI) 33-53) pre-intervention to 22% (95% CI 14-31) post-intervention, P = 0.002. Weekly total of troponin tests performed decreased from a mean of 298 (95% CI, 290-307) pre-intervention to 244 (95% CI 232-255) post-intervention, P < 0.001. No cases of missed ACS were found; all cause mortality was unchanged following the intervention. CONCLUSION: Our educational intervention was associated with a reduction in inappropriate use of troponin tests and a reduction in the total number of tests requested, with no known missed ACS. Others faced with a change to a high-sensitivity assay should consider a similar intervention.

Impact of a decision rule on duration of continuous cardiac monitoring of patients with suspected acute coronary syndrome in an emergency department.

BACKGROUND/AIMS: To determine the effect of introducing a decision rule on the duration of continuous cardiac monitoring (CCM) for patients with suspected acute coronary syndrome in an adult emergency department (ED). METHODS: This was a retrospective observational study of 220 patients with suspected acute coronary syndrome made up of two consecutive cohorts collected before and after introduction in July 2010 of a decision rule that made use of a new high-sensitivity troponin T assay. The primary outcome was median CCM duration in the ED (CCMED). Secondary outcomes were median duration of CCM in the first 24 h, rate of adverse events, proportion of patients after the intervention who had the rule adhered to, and estimated median CCMED had the decision rule been adhered to by all patients. RESULTS: The decision rule was adhered to in 59.3% (95% confidence interval 49.8-68.1) of patients post-intervention. There was no statistically or clinically significant difference in median CCMED before (240 min, interquartile range 156-313) and after (230 min interquartile range 145-353) introduction of the decision rule (P = 0.74) nor in CCM in the first 24 h (908 min vs 929 min). Seven (3.2%, 95% confidence interval 1.4-6.6) adverse events occurred overall. All three patients with adverse events after the intervention were monitored in ED according to the decision rule. CONCLUSION: Introduction of this decision rule did not decrease the median CCMED. All adverse events after the intervention occurred in appropriately monitored patients, including patients with initially negative high-sensitivity troponin T, suggesting that the decision rule would not compromise patient safety.

Notification of random hyperglycaemia to general practitioners by an emergency medicine team: impact of a simple intervention plan.

AIM: To determine whether general practitioners (GPs) were being appropriately notified of patients' elevated random glucose levels by emergency medicine (EM) staff, and to investigate whether two simple interventions improved the notification rate. METHODS: Patients were included if their random venous plasma glucose (RVPG) at presentation to the Emergency Department (ED) was >or= 7.8 mmol/l and if they were discharged directly to their GP. Patients with known impaired glucose metabolism (IGM) were excluded. Patient discharge summaries were reviewed over a 5-month period before and a 5-week period after two simple interventions: first, a targeted educational session for EM staff and second, modifications to the automated message accompanying laboratory results. RESULTS: Before intervention, the GPs of 120 out of 178 patients received no notification of an elevated RVPG compared with 23 of 62 patients after intervention (P < 0.00001). Notification met a predefined standard in 25 of 178 patients before, and 34 of 62 patients after intervention (P < 0.01). CONCLUSIONS: EM staff education, together with an automated laboratory message, significantly improved the rate and quality of notification of elevated RVPG levels to GPs. These simple measures have the potential to hasten implementation of preventive and therapeutic measures in patients with IGM.

Meeting report of the International Society of Hypertension Conference on Hypertension and Diabetes.

Points of agreement: (1) In IDDM, hypertension occurs in patients who have already developed nephropathy, probably in the microalbuminuric phase. (2) Hypertension is an important accelerator of the development of diabetic nephropathy. (3) Hypertension, obesity and NIDDM are often associated, and insulin resistance is commonly observed in all three states. (4) Antihypertensive therapy retards the development of diabetic nephropathy in IDDM and reduces proteinuria in NIDDM. (5) The choice of antihypertensive agent in the diabetic patient must be based upon the efficacy of the drug as well as avoidance of side effects including deleterious influence on glucose, insulin and lipid levels and renoprotection. (6) Carefully conducted long-term comparative trials between different classes of antihypertensive drugs in microalbuminuric IDDM and NIDDM patients are essential. Points of major controversy: (1) Detection of IDDM patients prone to the development of diabetic nephropathy can be performed by measuring specific parameters such as erythrocyte Na(+)-Li+ countertransport activity. (2) Insulin resistance is a pathogenic mechanism rather than purely an association with hypertension and obesity. (3) A certain class of antihypertensive agents--ACE inhibitors--confers a specific renoprotective effect in diabetic nephropathy, in addition to its effects upon systemic blood pressure. (4) Reduction of blood pressure should be considered in the normotensive microalbuminuric diabetic patient. (5) Microalbuminuria is a sufficient 'surrogate endpoint' for the progression of renal failure.