Brief ReportsALARMED: Adverse events in Low-risk patients with chest pain Receiving continuous electrocardiographic Monitoring in the Emergency Department. A pilot study
Introduction
Currently in the United States and Canada, most patients who present to an ED with chest pain are placed on a continuous electrocardiographic (ECG) monitor (ie, a telemetry monitor). Because of an increased risk of a fatal arrhythmia in patients experiencing an acute myocardial infarction [1], [2] and the effectiveness of early defibrillation for dysrhythmia termination [3], both the American Heart Association and the Canadian Association of Emergency Physicians stipulate that patients with chest pain that could be due to ischemia be placed on continuous ECG monitoring (CEM) [4], [5]. These guidelines are based on expert opinion, as there are no published clinical trials on monitoring for “rule-out myocardial infarction” patients in the ED [4], [5]. Several studies have questioned the use of CEM in admitted patients with chest pain [6], citing negligible rates of adverse events (AEs) in “very low-risk” patients in particular [7], [8], [9]. ED patients with chest pain are significantly different from their admitted counterparts because (1) if they are suffering an acute coronary syndrome (ACS), they are at a significantly higher risk of having an AE early in the course of their disease when they are in the ED [10], and (2) because the majority (more than 80%) of these patients are not actually experiencing an ACS [11], this dilutes the number of AEs in the ED chest pain patient population. Approximately 70% of ED patients with chest pain have no ACS nor an AE [12]. Although studies of continuous ST-segment monitoring have been conducted in ED patients [13], currently, most EDs do not use this technology [4], and no study has evaluated the use of standard CEM in ED patients with chest pain.
ED crowding is worsening [14], [15], and because patients with chest pain are subject to these forces [16], the availability of monitored beds for these patients has decreased. If all patients with cardiac-related chest pain, including low-risk patients, use CEM, sicker patients who will yield a greater benefit may be denied the technology because of a limited number of monitors [7], [16]. In addition, ED crowding is exacerbated by time spent in the ED awaiting a monitored ward bed [17], and monitoring carries a financial burden through increased nursing time and equipment costs [14]. These monitors could be allocated more efficiently if emergency physicians (EPs) could reliably identify a subgroup of patients with chest pain with a very low risk of having a monitor-signaled AE. We suspect that in the current practice environment, EPs are frequently faced with fully occupied ED monitors and are using their clinical judgment to decide which patients to remove from monitoring when a higher acuity patient arrives. In this situation in particular, evidence-based criteria for monitor removal would be very useful.
We conducted this pilot study to test the feasibility of a large, prospective, observational study on the utility of CEM in ED patients with chest pain. In this descriptive study, we determined the rate of AEs detected by CEM, the rate of change in management that occurred secondary to alarms, and the rate of false alarms that occurred during CEM.
Section snippets
Study design
We conducted a prospective, observational cohort study of patients with chest pain who were placed on CEM in the ED from June to August 2003. Care was directed by the managing physician and was not influenced by the study. Subjects were enrolled consecutively from 11:00 until 23:00, Monday to Friday. The protocols were reviewed and approved by the hospital research ethics board.
Setting
The study took place at Mount Sinai Hospital in Toronto, Ontario, a tertiary care teaching hospital ED with an annual
Results
We identified 86 patients who were eligible for study enrolment. Thirteen patients refused consent or were unable to consent because of a language barrier. Another patient left against medical advice before consent. Thus, we enrolled 72 patients; patient characteristics are presented in Table 2. One enrolled patient had insufficient data collected to characterize his risk with the stratification tools. Using triage logs, we identified 1 eligible patient who was missed for enrolment.
On initial
Discussion
The utility of CEM among patients admitted to hospital for known or potential ischemic heart disease has been questioned because of the low rate of AEs identified by the technology [5], [6], [7], [15]. Our study reached a similar conclusion among ED patients with chest pain. This small, prospective study found that only 0.62% of CEM alarms were sounded because of an AE, none of which were hemodynamically significant, and only 0.2% resulted in a change in management. This is despite a
Conclusions
The use of CEM in patients with chest pain in the ED may be of limited value, both because of a low rate of monitor-signaled AEs and in the high number of false alarms. This resource appears to be very inefficient in its current role: given that 99.4% of alarms were false, current CEM technology needs to be improved. A large prospective study is warranted to further evaluate the utility of this resource in ED low-risk patients with chest pain.
Acknowledgment
The authors thank Michelle Loftus, research coordinator, for her valuable research assistance.
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