Development of a Clinical Care Pathway for Patients with Suspected Acute Coronary Syndromes in the Emergency Department

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dc.contributor.advisorMcRae, Andrew D.
dc.contributor.advisorRonksley, Paul Everett
dc.contributor.authorO'Rielly, Connor M.
dc.contributor.committeememberAndruchow, James E.
dc.contributor.committeememberSajobi, Tolulope T.
dc.date2020-06
dc.date.accessioned2020-05-14T18:23:17Z
dc.date.available2020-05-14T18:23:17Z
dc.date.issued2020-04-30
dc.description.abstractChest pain is a predominant reason for emergency department (ED) visits and hospitalizations in Canada. ED physicians use diagnostic tools (e.g., biomarkers) to identify patients with myocardial infarction (MI) requiring intervention, and prognostic tools (e.g., risk scores) to determine which patients without MI are eligible for discharge. While clinical guidelines recommend that these two portions of the assessment occur sequentially, the evidence for each has emerged in isolation. There is also a paucity of evidence on risk score use in the era of high-sensitivity cardiac troponin (hs-cTn) assays, adverse event risk factors for patients without MI, and appropriate timelines for follow-up. This project had three complimentary objectives: (1) Synthesize available evidence on prognostic prediction score performance when hs-cTn assays are incorporated; (2) Quantify the time course of major adverse cardiac events (MACE) in patients without index MI and identify characteristics with potential predictive value for MACE, and; (3) Develop a sequential clinical pathway for the assessment of chest pain in the ED and measure the impacts on diagnostic and prognostic accuracy as well as ED patient flow. A systematic review was conducted to synthesize evidence on the chest pain risk scores to be prioritized for integration into the clinical pathway. A time-to-event analysis was then conducted to measure timing of MACE in patients without index MI, as well as a stratified analysis to identify characteristics with predictive value for 30-day MACE to be used in the pathway for clinical stratification. Trial clinical pathways were developed and quantitatively compared. Pathways combined a validated 2-hour hs-cTn diagnostic algorithm with variable clinical pre-stratification, risk score types, and low-risk cut-offs. A sequential clinical pathway using a validated hs-cTn algorithm and the HEART score can identify nearly 40% of ED chest pain patients as eligible for discharge without the need for further testing with no missed MI or 30-day MACE. This thesis project contributed evidence necessary for the updating and advancing of the ED chest pain assessment and presents an evidence-based sequential clinical pathway that maximizes the efficiency of the ED chest pain assessment.en_US
dc.identifier.citationO'Rielly, C. M. (2020). Development of a Clinical Care Pathway for Patients with Suspected Acute Coronary Syndromes in the Emergency Department (Master's thesis, University of Calgary, Calgary, Canada). Retrieved from https://prism.ucalgary.ca.en_US
dc.identifier.doihttp://dx.doi.org/10.11575/PRISM/37832
dc.identifier.urihttp://hdl.handle.net/1880/112045
dc.language.isoengen_US
dc.publisher.facultyCumming School of Medicineen_US
dc.publisher.institutionUniversity of Calgaryen
dc.rightsUniversity of Calgary graduate students retain copyright ownership and moral rights for their thesis. You may use this material in any way that is permitted by the Copyright Act or through licensing that has been assigned to the document. For uses that are not allowable under copyright legislation or licensing, you are required to seek permission.en_US
dc.subjectEmergency Departmenten_US
dc.subjectChest Painen_US
dc.subjectClinical Pathwayen_US
dc.subjectHigh-Sensitivity Cardiac Troponin Assaysen_US
dc.subject.classificationEpidemiologyen_US
dc.subject.classificationHealth Care Managementen_US
dc.titleDevelopment of a Clinical Care Pathway for Patients with Suspected Acute Coronary Syndromes in the Emergency Departmenten_US
dc.typemaster thesisen_US
thesis.degree.disciplineMedicine – Community Health Sciencesen_US
thesis.degree.grantorUniversity of Calgaryen_US
thesis.degree.nameMaster of Science (MSc)en_US
ucalgary.item.requestcopytrueen_US
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