Michael A. Ross

Impact on the Care of the Emergency Department Chest Pain Patient from the Chest Pain Evaluation Registry (CHEPER) Study

This study examines the question of whether chest pain observation units increase the proportion of chest pain patients with an extended evaluation for cardiac ischemia (rule out myocardial infarction [MI] evaluation), decrease the number of missed MIs, and decrease costs. This is a multiple site registry study of 8 established chest pain observation units (complying with the American College Emergency Physicians Observation Sections standards) compared with previous studies on chest pain evaluation without the use of observation (5 studies, 12,405 patients). A total of 23,407 of 444,189 emergency department patients (5.3%) had the chief complaint of chest pain during the study period. In the chest pain observation units, 153 of 2,229 patients (6.9%) with acute MI were identified. Most of the observation chest pain patients (76%) were discharged home without hospital admission. Compared to previous studies, a higher proportion of patients underwent a rule out MI evaluation (67%, 95% confidence interval [CI] 66%, 68% vs 57%, 95% CI 56%, 58%; p <0.001) equal to 2,250 additional patients completely evaluated (

Emergency department revisits

1,219,500 additional costs). A lower proportion of MIs were missed (0.4%, 95% CI 0.3%, 0.5% vs 4.5%, 95% CI 4.0% to 5.5%; p <0.001) as estimated by return visits within 72 hours. Compared to previous studies, final hospital admission rate was lower (47%, 95% CI 46%, 48% vs 57%, 95% CI 56%, 58%; p <0.001), equal to 2,314 hospital admissions avoided in the study population (

The feasibility of Rubidium-82 positron emission tomography stress testing in low-risk chest pain protocol patients.

4,093,466 saved costs). Calculated true costs overall were lower by

A Comprehensive Acute Coronary Syndrome Algorithm for Centers With Percutaneous Coronary Intervention Capability

2,873,966 at the study hospitals. Thus, chest pain observation units increased the proportion of chest pain patients thoroughly evaluated with improved quality of care and lower costs.

A Randomized Controlled Trial of Multi-Slice Coronary Computed Tomography for Evaluation of Acute Chest Pain

We reviewed the charts of patients returning within 72 hours to our emergency department to determine whether monitoring revisits is a useful quality assurance indicator. Patient visits for June and December 1987 were selected to eliminate a potential seasonal difference. Of the 13,261 visits during these two months, 455 (3.4%) were revisits within 72 hours. Charts were available on 444 patients, of whom 407 (91.7%) represented cases in which the return and the initial visits were clearly related. Charts were reviewed for deficiencies in medical management, appropriate prescribed follow-up, patient education, and patient compliance. Suspected medical management problems were discussed by the three senior authors, and a consensus decision was made. Return visits were considered avoidable if a deficiency was noted in at least one of the areas listed above. There were 297 unscheduled related return visits, 96 (32.3%) of which were avoidable. Of these avoidable visits, 38 (39.6%) had medical management deficiencies, 14 (14.6%) had inappropriate prescribed follow-up, 20 (20.8%) had not been given proper education, and 35 (36.5%) were due to patient noncompliance. Of the 110 scheduled return visits, there was one (0.9%) deficiency in medical management and none in the other categories. Of the unscheduled return visits, 146 (49.2%) returned within 24 hours; 89 (30.0%) between 24 and 48 hours; and 62 (20.8%) between 48 and 72 hours. Of the avoidable visits, 85% returned within 48 hours, as did 92% of those with medical management deficiencies.(ABSTRACT TRUNCATED AT 250 WORDS)

Atypical Chest Pain: Coronary, Aortic, and Pulmonary Vasculature Enhancement at Biphasic Single-Injection 64-Section CT Angiography

OBJECTIVEnTo evaluate the feasibility of dipyridamole-induced reversible ischemia on myocardial perfusion positron emission tomography (PET) imaging using Rubidium-82 (Rb-82 PET) to predict the presence of acute coronary syndrome (ACS) in emergency department (ED) chest pain patients at low risk who were admitted to an observation unit.nnnMETHODSnRetrospective cross-sectional study of electronic medical records after computerized record retrieval. We matched all ED chest pain visits to a database of all scans read by cardiology between January 1, 2004 and January 1, 2006. A PET scan was performed at the ED physicians discretion after a negative observation unit workup, including serial cardiac biomarkers and ECGs. Data were collected on a standardized abstraction instrument.nnnRESULTSnThere were 7,691 ED visits for chest pain. Among these patients, 1177 had an Rb-82 PET. Fifty four (4.6%) of these patients had an abnormal or probably abnormal scan. Of these, 28 had catheter-proven significant coronary disease, requiring either revascularization or intensive medical management; 22 patients had ACS by clinical assessment but did not undergo catheterization. Four had no coronary artery disease on catheterization.nnnCONCLUSIONnIn a low-risk chest pain population, cardiac PET imaging had true-positive cardiac catheterization rates which were comparable to prior studies of SPECT sestimibi imaging and coronary CTA imaging. With the rapid dissemination of PET technology, and superior performance compared to current imaging methods, myocardial perfusion PET is a feasible alternative to traditional provocative testing in an ED observation unit.

Mortality Benefit of Immediate Revascularization of Acute ST-Segment Elevation Myocardial Infarction in Patients with Contraindications to Thrombolytic Therapy: A Propensity Analysis

A comprehensive acute coronary syndrome (ACS) protocol was developed to improve the quality of care for patients admitted with definite or probable ACS. These protocols were constructed to streamline the practice for diverse clinicians who care for ACS patients across a variety of clinical settings. They are applicable in the emergency department, the cardiac catheterization laboratory, and the inpatient settings for hospitals with primary percutaneous coronary intervention capability. These protocols standardized the care by selecting the best therapy for each clinical scenario based on available established guidelines to insure the safest and highest value (quality/cost) medical care.