Effect of the Emergency Department Assessment of Chest Pain Score on the Triage Performance in Patients With Chest Pain

Abstract

The sensitivity of triage systems in identifying acute cardiovascular events in patients presented to the emergency department with chest pain is not optimal. Recently, a clinical score, the Emergency Department Assessment of Chest Pain Score (EDACS), has been proposed for a rapid assessment without additional instruments. To evaluate whether the integration of EDACS into triage evaluation of patients with chest pain can improve the triage's predictive validity for an acute cardiovascular event, a single-center prospective observational study was conducted. This study involved all patients who needed a triage admission for chest pain between January 1, 2020, and December 31, 2020. All enrolled patients first underwent a standard triage assessment and then the EDACS was calculated. The primary outcome of the study was the presence of an acute cardiovascular event. The discriminatory ability of EDACS in triage compared with standard triage assessment was evaluated by comparing the areas under the receiver operating characteristic curve, decision curve analysis, and net reclassification improvement. The study involved 1,596 patients, of that 7.3% presented the study outcome. The discriminatory ability of triage presented an area under the receiver operating characteristic curve of 0.688 that increased to 0.818 after the application of EDACS in the triage assessment. EDACS improved the baseline assessment of priority assigned in triage, with a net reclassification improvement of 33.6% (p <0.001), and the decision curve analyses demonstrated that EDACS in triage resulted in a clear net clinical benefit. In conclusion, the results of the study suggest that EDACS has a good discriminatory capacity for acute cardiovascular events and that its implementation in routine triage may improve triage performance in patients with chest pain.

Figure 1

Flow chart of patients enrolled in the study.

Figure 2

Representation of the 3 different priority classifications compared using receiver operating characteristic (ROC) curves. The black line represents triage performance, the gray line represents EDACS performance and the black dashed line represents the performance of EDACS and triage combined.

Figure 3

Decision curve analysis for the determination of the net clinical benefit from triage (black dashed line) and the implementation of EDACS in triage (gray dashed and dotted line) evaluation in patients with chest pain. The x axis indicates the threshold probability for adverse cardiac events and the y axis indicates the net benefit. The black line assumes that all the patients would have the composite outcome, whereas the gray line reflects the assumption that no patients would have the composite outcome. The dashed black line represents the net clinical benefit provided by the triage evaluation and the gray dashed and dotted line represents the net clinical benefit provided by the introduction of EDACS in the triage evaluation. As demonstrated in the graph, EDACS in triage achieved greater clinical utility in the threshold probability, indicating that EDACS may be a valuable tool in defining the priority of patients.