Variation in ACS patient hospital resource utilization: Is it time for advanced NSTEMI risk stratification in the ED?

Abstract

Objectives: A majority of patients who experience acute coronary syndrome (ACS) initially receive care in the emergency department (ED). Guidelines for care of patients experiencing ACS, specifically ST-segment elevation myocardial infarction (STEMI) are well defined. We examine the utilization of hospital resources between patients with NSTEMI as compared to STEMI and unstable angina (UA). We then make the case that as NSTEMI patients are the majority of ACS cases, there is a great opportunity to risk stratify these patients in the emergency department.

Materials and methods: We examined hospital resource utilization measure between those with STEMI, NSTEMI, and UA. These included hospital length of stay (LOS), any intensive care unit (ICU) care time, and in-hospital mortality.

Results and conclusions: The sample included 284,945 adult ED patients, of whom 1195 experienced ACS. Among the latter, 978 (70%) were diagnosed with NSTEMI, 225 (16%) with STEMI, and 194 with UA (14%). We observed 79.1% of STEMI patients receiving ICU care. 14.4% among NSTEMI patients, and 9.3% among UA patients. NSTEMI patients' mean hospital LOS was 3.7 days. This was shorter than that of non-ACS patients 4.75 days and UA patients 2.99. In-hospital mortality for NSTEMI was 1.6%, compared to, 4.4% for those with STEMI patients and 0% for UA. There are recommendations for risk stratification among NSTEMI patients to evaluate risk for major adverse cardiac events (MACE) that can be used in the ED to guide admission decisions and use of ICU care, thus optimizing care for a majority of ACS patients.

Keywords: ACS; Emergency department; NSTEMI.