Objective: Emergency department (ED) triage for acute cardiac ischemia in the primary teaching hospital in Geneva, Switzerland, is
very accurate, but at the cost of very long ED stays. Thus, the authors sought: 1) to determine the impact of the acute cardiac
ischemia time-insensitive predictive instrument (ACI-TIPI), incorporated into a computerized electrocardiograph, on length
of stay and speed of triage decision making for ED patients presenting with symptoms suggesting acute cardiac ischemia, and
2) to study the ACI-TIPI’s impact on physicians of different training levels.
Design: A seven-month prospective clinical trial with alternating-month experimental and control periods.
Setting: An urban major teaching hospital in Geneva, Switzerland.
Participants: Patients over the age of 18 years presenting to the ED with chest pain or other symptoms suggesting acute cardiac ischemia
(acute myocardial infarction or unstable angina pectoris). Emergency department physicians, classified as novice (those in
their first ED rotations) and experienced (those in their second or later ED rotations). Patients staying overnight in the
ED (n=111) were excluded from the analysis.
Intervention: During the experimental months, the computerized electrocardiograph printed the ACI-TIPI probability of acute cardiac ischemia
at the top of each subject’s electrocardiogram. During control months, the probability was not provided.
Measurements and main results: Among the 418 study subjects, for patients with acute ischemia seen by novice clinicians, the use of the ACI-TIPI decreased
ED time from presentation to triage decision and ED release by 0.7 hour (19%) (p=0.007). Subgroup analyses for patients with
acute myocardial infarction, patients with unstable angina pectoris, and patients given thrombolytic therapy also showed analogous
decreases in ED time consistent with this finding. Other key determinants of ED length of stay included: age, whether the
coronary care unit was full, whether patients received thrombolytic therapy, and whether admission was during the night shift.
The experimental and control groups did not differ in triage disposition appropriateness or mortality.
Conclusions: For ED patients with acute cardiac ischemia evaluated by novice clinicians, the ACI-TIPI substantially speeded ED decision
making and triage. The suggestion of an impact on different cardiac ischemia subgroups and mortality deserves further larger
clinical trials.
Key words acute cardiac ischemia - computerized electrocardiograph - emergency department - medical decision making - physician training - time-insensitive predictive instrument
Received from the Division of Internal Medicine, Hopital Cantonal Universitaire, Geneva, Switzerland, and the Center for Cardiovascular
Health Services Research, Divisions of General Medicine and Clinical Decision Making, New England Medical Center, Tufts University
School of Medicine, Boston, Massachusetts.