It seems to me that your A&E consultant wants a 'rule out' strategy. Here we
use CK-MB activity because it is easily (and inexpensively) available on a
24 hour basis. The protocol asks that for those in whom doubt exists (on ECG
etc) are tested twice at a minimum 4 hour interval. We automatically use the
ratio to total CK and have a cut-off selected for high sensitivity. In cases
of doubt we have troponin I available (throughout the 24 hour period for
those willing to contact me to justify their request). Having said this our
test use figures do not suggest that the protocol is widely followed and
daily cardiac enzyme requests are common.
Our protocol is not exclusive for A&E and most of our suspected coronaries
go straight to CCU.
The problem is partly one of reliability of history. Many of our patients
arrive some time (often hours) after onset of pain. It is pre-arrival delays
that could be your A&E's best ally in keeping the department clear.
> -----Original Message-----
> From: Philip Hyde [SMTP:[log in to unmask]]
> Sent: 31 October 2000 17:00
> To: [log in to unmask]
> Subject: Discharge of chest pain patients from A/E
> I have had a query from our A/E Consultant regarding early assessment and
> potential discharge of patients with chest pain. We use a single sample
> taken at > 12 hours for troponin T as our sole cardiac marker strategy (we
> can't afford to do one on admission as well...yet) and his contention is
> that he cannot afford to wait for > 12 hrs to elapse as he has no beds. He
> wants strategy for all his A/E staff to follow to avoid admitting all such
> patients and clogging the system up. Notwithstanding members feelings
> impatience, medicolegal issues, I wondered what, if anything, other
> laboratories may have agreed with their A/E Depts (as opposed to MAU's -
> ours are ecstatic with trop T).
> Philip Hyde,
> Consultant Clinical Biochemist,
> Pilgrim Hospital,
> Boston (UK).
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