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Critical pathway for an aggressive diagnostic strategy for patients who present with chest pain but a nondiagnostic electrocardiogram to the emergency department.

BACKGROUND
The prolonged length of stay for patients who seek treatment in the emergency department with chest pain and normal or nondiagnostic electrocardiogram has led to a backlog of patients in the emergency department and the telemetry unit. Correct early management requires risk stratification processes that can effectively separate the majority of these patients into low-risk, low/intermediate-risk, intermediate-risk, and high-risk subsets.


METHODS AND RESULTS
Patients who seek treatment in the emergency department with chest pain are risk-stratified into low-risk, low/intermediate-risk, and high-risk categories using a Risk Score to determine who would benefit from immediate exercise stress testing. Nurse-directed exercise stress testing using the Duke Treadmill Score is used to risk-stratify intermediate-risk patients further "on-the-fly". Intermediate-risk Duke Treadmill Score patients are injected during exercise with a Tc-myocardial perfusion agent and undergo a gated single-photon emission computed tomography study. Normal exercise and single-photon emission computed tomography perfusion patients are discharged home. The overall length of stay and 30-day outcomes of these facilitated patients were compared with those of patients treated with a conservative approach using sequential electrocardiograms and cardiac enzymes. Patients who were evaluated using the facilitated approach had a shorter mean length of stay than those using a conservative method, with similar outcomes at 30 days.


CONCLUSIONS
A facilitated approach incorporating on-demand nurse-directed early exercise stress testing with the injection of a Tc-myocardial perfusion agent on the fly in intermediate-risk patients is safe and has decreased the backlog of patients in the emergency department and telemetry unit and expedited appropriate treatment of patients with acute chest pain and nondiagnostic electrocardiograms.