September 11, 2015Emergency Medicine JournalOpen Access

Beyond triage: the diagnostic accuracy of emergency department nursing staff risk assessment in patients with suspected acute coronary syndromes

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Suspected acute coronary syndromes (n=960). Intervention: Nursing staff risk-assessment (m-Goldman score) vs. Physician risk-assessment. Primary outcome: AUC of the m-Goldman score for predicting 30-day MACE (p=0.09).

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Key result

Emergency department nursing staff risk assessment using the modified Goldman score demonstrated similar diagnostic accuracy to physician assessment for predicting 30-day MACE (AUC 0.572 vs 0.647, P=0.09).

Why the study?

Does emergency department nursing staff risk assessment using the modified Goldman score and an accelerated diagnostic protocol accurately predict 30-day MACE compared to physician assessment in patients with suspected acute coronary syndromes?

Population

960 consecutive patients, aged ≥18 years, presenting to a UK District Emergency Department with suspected…

Comparison

Risk assessment by emergency department nursing… vs Risk assessment by emergency department…

Design

Cohort, Treating physicians were blinded to the initial hs-cTnT result…

Follow-up

30 days

Authors

ECEdward CarltonSouthmead Hospital AKAhmed KhattabAin Shams University KGKim GreavesSunshine Coast University Hospital

Discussion

Member takes

Implication

Nurse assessment may match physician accuracy for 30-day MACE prediction in suspected ACS; leaves open prospective validation before practice change.

Study Design

Type

Observational (n=960)

Blinding

Single-blind

Multicenter

Structured PICO

Population

960 adult patients under 80 years old with suspected acute coronary syndrome and non-ischaemic ECG, evaluated in a UK emergency department and followed for 30 days.

Exposure

Risk assessment by emergency department nursing staff using the modified Goldman (m-Goldman) score alone and incorporated with presentation high-sensitivity troponin T (hs-cTnT) testing as part of the TRUST accelerated diagnostic protocol (ADP).

Comparator

Risk assessment by emergency department physicians using the same modified Goldman score and TRUST accelerated diagnostic protocol (ADP).

Outcome

30-day major adverse cardiac events (MACE), defined as a composite of death due to ischaemic heart disease, cardiac arrest, symptom-induced revascularisation, cardiogenic shock, ventricular arrhythmia, high-degree atrioventricular block needing intervention, and acute myocardial infarction.composite

Main Result

Absolute Event Rate: 0.572% vs 0.647%

p-value: p=0.09

Emergency department nursing staff can safely risk-stratify patients with suspected acute coronary syndromes using an accelerated diagnostic protocol incorporating high-sensitivity troponin, achieving a low 30-day MACE miss rate of 1.1%.

Limitations

Single-centre observational design
Nursing staff had no formal training in the use of the m-Goldman score
Not all patients had risk scores recorded by both nursing staff and physicians
Only included patients with suspected ACS as decided by the treating physician, limiting conclusions on the ability of nursing staff to identify suspected ACS from undifferentiated chest pain.
Difference in the proportion of patients who underwent assessment by physicians (95.0%) compared to nursing staff (77.6%), which may cause unseen bias in clinical characteristics or a Type II statistical error.

Cite This Study

Carlton et al. (2015) conducted an observational in Suspected acute coronary syndromes (n=960). Nursing staff risk-assessment (m-Goldman score) vs. Physician risk-assessment was evaluated on AUC of the m-Goldman score for predicting 30-day MACE (p=0.09). Emergency department nursing staff risk assessment using the modified Goldman score demonstrated similar diagnostic accuracy to physician assessment for predicting 30-day MACE (AUC 0.572 vs 0.647, P=0.09).

synapsesocial.com/papers/6a20836bcd682a52c6f89d85 https://doi.org/10.1136/emermed-2015-204780

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Implication

Nurse assessment may match physician accuracy for 30-day MACE prediction in suspected ACS; leaves open prospective validation before practice change.

Beyond triage: the diagnostic accuracy of emergency department nursing staff risk assessment in patients with suspected acute coronary syndromes

Discussion

Member takes

Implication

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

Beyond triage: the diagnostic accuracy of emergency department nursing staff risk assessment in patients with suspected acute coronary syndromes

Discussion

Member takes

Implication

Study Design

Structured PICO

Main Result

Limitations

Cite This Study

Also Consider

Also Consider