Appropriate pathology ordering? Troponin testing within an Australian Emergency Department

Abstract

Background: Cardiac Troponin I and Troponin T are both very sensitive and specific, with the troponin pathology test recommended for the diagnosis of myocardial infarction. The diagnosis of myocardial infarction, in conjunction with electrocardiogram myocardial infarction, is based on a rise or fall of troponin with at least one value above the 99th percentile for the population. Troponin levels are regularly ordered within hospitals, especially in emergency medicine. It has been suggested that much of this testing is ordered despite the absence of clinical suspicion for acute coronary syndrome.

Aim: This study examined the appropriateness of troponin testing within one Australian teaching hospital.

Methods: A retrospective chart review was conducted of 111 randomly selected patients who received a troponin assay within the hospital's Emergency Department. To determine appropriateness, the troponin test needed to reflect Australian clinical guidelines, and inform the ongoing management of the patient.

Results: Results demonstrate that the majority (76.6 %) of troponin testing was appropriate, with the remainder (23.4 %) deemed inappropriate due to not altering the ongoing patient management (n = 26), and not being informed by clinical guidelines (n = 26).

Conclusion: Troponin testing is important in the diagnosis of myocardial infarction, although should not be ordered routinely, or unnecessary. This study has determined that using clinical guidelines can promote rational ordering, and that testing should ultimately benefit patient management. Reducing inappropriate pathology test ordering is important to maximize productive clinical time, reduce false positives, maximize patient care, and to reduce financial waste.

Keywords: Acute coronary syndrome; Chest pain; Emergency Department; Emergency medicine; Troponin.