High-Sensitivity Troponin Pathway and Emergency Department Length of Stay

Importance High-sensitivity cardiac troponin (hs-cTn) assays are the diagnostic standard for acute coronary syndrome but present significant implementation and workflow complexity. Objective To evaluate whether implementation of a structured, electronic health record (EHR)–integrated hs-cTn pathway was associated with changes in emergency department (ED) length of stay (LOS) and serial troponin testing times. Design, Setting, and Participants This retrospective quality improvement study compared preimplementation conventional cTn assay (June 1, 2021, to March 31, 2022) with a postimplementation integrated hs-cTn pathway (June 1, 2022, to March 31, 2023) in 4 urban EDs within a single health system. Participants were adults (aged ≥18 years) presenting with chest pain and at least 1 troponin assay result. Data analysis was performed from April to September 2024. Exposures Implementation of an hs-cTn assay within an EHR-integrated clinical pathway. Main Outcomes and Measures The primary outcome was ED LOS, defined as time from patient registration to ED departure. Secondary outcomes included time from first clinician evaluation to disposition (discharge or admission) and interval from the first troponin assay order to the second troponin assay result in patients with serial assays. Results Of the 16 094 patient encounters analyzed (9151 [56.9%] female; mean [SD] age, 49.5 [17.4] years), 8486 (52.7%) were in the hs-cTn and 7608 (47.3%) were in the conventional cTn cohort. Overall, hs-cTn implementation with workflow integration was associated with decreased mean ED LOS, from 6.18 (95% CI, 6.10-6.26) hours to 5.64 (95% CI, 5.57-5.71) hours. Compared with conventional cTn, implementation of the hs-cTn pathway was associated with shorter mean ED LOS in admitted patients (9.60 [95% CI, 9.35-9.87] hours vs 10.50 [95% CI, 10.22-10.78] hours; P = .003) and discharged patients (5.02 [95% CI, 4.96-5.08] hours vs 5.33 [95% CI, 5.26-5.40] hours; P = .006). Pathway implementation was also associated with shorter time from evaluation to disposition in patients receiving 2 or more troponin measurements (5.06 [95% CI, 4.97-5.15] hours vs 6.68 [95% CI, 6.52-6.85] hours; P < .001) and time from first troponin order to second troponin result in both admitted patients (3.18 [95% CI, 3.11-3.25] hours vs 5.16 [95% CI, 5.01-5.31] hours; P < .001) and discharged patients (2.78 [95% CI, 2.75-2.82] hours vs 4.54 [95% CI, 4.46-4.62] hours; P < .001). Conclusions and Relevance In this quality improvement study, an EHR-integrated hs-cTn pathway was associated with significantly reduced ED LOS and, in patients with serial troponin measurements, reduced time from evaluation to disposition and reduced time to serial assay results. The findings suggest this structured EHR approach may mitigate operational challenges of hs-cTn adoption and could serve as a scalable model to improve ED efficiency for patients with chest pain.