News on the Medical Scribe Front

Medical Journal Review: Measuring Outcomes of Early Discharge of Low-Risk Chest Pain Patients

Posted by Holly Case on Jul 10, 2018 8:30:00 AM


Keeping up with current medical research is an important part of any doctor’s life. Actually, that’s something you need to start doing even before you attend medical school. But it can be tough to find time to read the latest medical journals in between your hectic scribe schedule, keeping up with your studies, applying to med school, and having some semblance of a social life. Our goal is to make your life easier as a scribe, which includes helping you keep up with the newest medical research, such as a recent case study about using the HEART score as a criteria for early hospital discharge. (Tip: these are great talking points with your physicians if you happen to have rare breaks between patients!)


The Issue


Chest pain consistently ranks among the top reasons that people visit the ED. Since heart disease is the number-one cause of death in the U.S., it’s a good thing that ED staff takes the issue so seriously.


As a scribe, you’re sure to see patients with this issue so often that you’ll have memorized the series of tests included in a chest pain workup shortly after getting on the floor. But the traditional protocol for patients with chest pain includes both a significant battery of tests as well as an observation period. This practice requires a lot of time and money. This study takes a deeper, evidence-based look at whether the existing protocols are useful and cost-effective.


Obviously as hospital staff, we want to protect the health of our patients. But we also need to eliminate waste in healthcare costs and become as efficient as possible. A case study published in the New England Journal of Medicine looked at whether low-risk chest pain patients could be safely discharged from the ED earlier.


The Study Design


The Kaiser Permanente Southern California (KPSC) health system wanted to improve the standard of practice in its emergency department for patients with possible acute coronary syndrome (ACS) by using a diagnostic tool called the HEART score. (Click here to check out our 90-second video breakdown explaining this score!)

The HEART score is a set of criteria that helps doctors predict the estimated risk of a cardiac event in the next 30 days. This is a diagnostic workup given to all patients who present with chest pain in participating hospitals. The five components of the HEART score are the following:

  • History (the patient’s personal medical history)
  • ECG results
  • Age
  • Risk factors (including obesity, smoking, high cholesterol, family history, previous stroke or TIA)
  • Troponin test results (which is the initial troponin level)

According to the study, KPSC patients with a HEART score of 0-3 and a negative troponin test at arrival and again three hours later would be discharged home with instructions to follow up with their primary care doctors.

The other component of this particular study was to keep track of patient outcomes after discharge to see how many had to return to the ED with follow-up cardiac events.




The Findings

The KPSC study looked at the outcomes for patients after early discharge. Low-risk patients had only a 0.09 percent risk of myocardial infarction or death in the 30 days after discharge. Even the moderate- and high-risk groups had 0.26 percent and 0.68 percent risks of MI or death within 30 days. This group experiencing complications after discharge is referred to as the “miss rate.”

For a point of reference, the overall nationwide “miss rate” for facilities using the HEART score is 2.1 percent. The miss rate means that hospital staff weren’t able to successfully prevent tragedies, and that’s the kind of outcome that nobody wants.


Previous Results Confirm Savings and Safety


This study incorporates the results of a different2017 study, the Henry Ford HEART Study, that found significant savings on healthcare costs following early discharge of low-risk patients. The majority of chest pain visits to the emergency department do not indicate that the patient is indeed having a heart attack or other cardiac event.

The Henry Ford HEART Study found that patients in the low-risk category could be discharged with instructions to follow up with their doctors had a 100 percent chance of safety. The average per-patient savings associated with this early discharge in low-risk cases was $6,500 per person and 20 hours.


The Takeaway


Using the HEART score to identify which ED chest pain patients is a reliable way to cut costs and hospital staff time while keeping patients safe. The metrics we get from the tests we perform in the ED are a good gauge of which patients need more immediate care.


Talking Points

  • Talk to your doctors in the ED about the HEART study. Ask if they would recommend using this particular protocol to evaluate patients presenting with chest pain.
  • Ask your doctors which factors they use to predict which chest pain patients will have positive or negative outcomes.
  • Tell the doctor about research which says that discharging low-risk patients according to the HEART score can save the hospital up to 20 percent. If your hospital does not use the HEART score, ask the doctor to explain what they use as an alternate approach.
  • Remember that discussing medical research is an additional learning opportunity during breaks or in your down time between patients. As a scribe, your role is to learn and assist, not to question the doctor or express your opinions about diagnoses, especially about the patients you see..


Hospital boards generally determine treatment protocols and individual doctors may not have much control over these decisions. However, doctors should be well-versed enough in the protocol of their facility to explain it, which can educate you about a variety of treatment procedures.


Remember to approach these discussions with a spirit of openness and curiosity. Talking with your doctor about studies should always be conversations seeking their professional opinion to help you learn. You don’t want to give the impression that they could be doing something wrong or that you’re trying to diagnose a patient. Keep the conversations private, away from patients’ ears.


Join the conversation by commenting below to tell us the protocol used at your hospital for dealing with chest pain patients? Do the results of this study surprise you or are they in line with what you’ve observed in the ED?



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Topics: medical scribes, Medical Student Documentation, Medical Students, HEART score, medical journal review, chest pain, case study


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