Differential effects of a 0/1-hour high-sensitivity troponin algorithm across academic and community emergency departments.

Background

High-sensitivity cardiac troponin (hs-cTn) accelerated diagnostic protocols (ADP) improve chest pain evaluation, but their differential impact across academic and community emergency departments (EDs) is unknown.

Methods

We performed a retrospective multicenter pre-post study across five EDs (two academic, three community) within a southeastern U.S. regional health network. Adults undergoing electrocardiography and troponin testing were evaluated during the 12 months before and after implementation of an hs-cTnI-based 0/1-hour ADP. The primary outcome was hospitalization. Secondary outcomes included ED length of stay (LOS), coronary computed tomography angiography (CCTA) utilization, and missed 30-day major adverse cardiac events (MACE). Multivariable generalized linear mixed models adjusted for patient characteristics and hospital-level clustering.

Results

A total of 9297 encounters were included (4201 pre-implementation; 5096 post-implementation). After adjustment, implementation was not associated with hospitalization at academic hospitals (adjusted odds ratio [aOR] 1.20, 95% CI 0.97-1.50), but remained associated with lower odds of hospitalization at community hospitals (aOR 0.35, 95% CI 0.31-0.40). Implementation was associated with increased ED LOS at academic hospitals (+44 min, 95% CI 33-55) and decreased ED LOS at community hospitals (-16 min, 95% CI -27 to -5). CCTA utilization decreased at academic hospitals (aOR 0.57, 95% CI 0.46-0.70). Thirty-day MACE remained rare.

Conclusion

An hs-cTnI-based 0/1-h ADP was associated with lower hospitalization rates and shorter ED LOS at community hospitals, whereas academic hospitals demonstrated reduced CCTA utilization without reduced hospitalization. These findings suggest that the impact of hs-cTn ADPs may depend on practice environment and local operational factors.