7,17,18,20,23,63 Trained research investigators do not work under the same time constraints and in the same distracted environment as a working ED provider. Most studies validating the utility of the TIMI risk score among ED populations used trained research investigators or a combination of trained researchers and ED providers to generate TIMI risk scores. Inaccurate TIMI risk scores may result in inaccurate risk stratification, as well as ineffectual or inappropriate management of patients with nonspecific chest pain. 73 suggest that patients presenting to the ED during times of increased ED crowding are at greater risk for adverse cardiovascular outcomes. Several studies have demonstrated how interruptions, distractions, and workload affect an ED provider’s ability to maintain thought flow and increase the likelihood of errors occurring. 64 Importanceįor many reasons, complete and accurate TIMI risk scores can be difficult to obtain when patients present with chest pain to a busy ED. 7,17 –21,63 –68 As a result of these studies, the TIMI risk score tool has made its way into the protocols of EDs and hospitals around the world, often determining whether a patient is admitted to a hospital, observation unit or discharged home. Though not originally designed for ED use, several additional studies have attempted to demonstrate the TIMI risk score’s ability to stratify risk among real-world ED populations. 15 Following the development of the TIMI risk score tool, several studies were performed validating the tool’s ability to stratify risk among patients with cardiac disease. 15 In this patient population the TIMI risk score was associated with 4.7% to 40.9% (or greater) risk of adverse cardiac outcome. The TIMI risk score was originally derived from a retrospective analysis of a relatively high-risk population of patients with known unstable angina/non-ST elevation myocardial infarction. 3,7,58,59Ī patient’s TIMI risk score is determined by assigning a value of one point for each of seven equally weighted prognostic variables with the total score determining a patient’s risk of adverse cardiac outcome (death, MI, severe recurrent ischemia requiring revascularization) within 14 days of presentation. 15 – 57 Of all the risk stratification systems developed, the thrombolysis in myocardial infarction (TIMI) risk score is the most studied, supported and used. In an effort to improve outcomes in patients with acute coronary syndromes, researchers have developed numerous risk stratification tools. Despite the use of electrocardiography (ECG) results, biomarker assays, patient history and clinical acumen, 0.4–5% of patients with acute myocardial infarction are inadvertently discharged from the ED. 2 – 6 A missed diagnosis of ACS may result in wrongful discharge, myocardial infarction and sudden death. Patients diagnosed early with acute coronary diseases (ACS) may benefit from early interventions.
1 Early determination of whether a patient’s chest pain origin is cardiac versus noncardiac is imperative. INTRODUCTIONĬhest pain is the second most common complaint of patients presenting to emergency departments (ED) in the United States, accounting for approximately seven million visits annually. TIMI risk scores determined by ED providers in the setting of a busy ED frequently differ from scores generated by trained research investigators who complete them while not under the same pressure of an ED provider. In our low-risk population the majority of TIMI risk score differences were small however, 12% of TIMI risk scores differed by two or more points. Of the 501 adult patients enrolled in the study, 29.3% of TIMI risk scores determined by ED providers and trained research investigators were generated using identical TIMI risk score variables. We examined provider type, patient gender, and TIMI elements for their effects on TIMI risk score discrepancy. This was an ED-based prospective observational cohort study comparing TIMI scores obtained by 49 ED providers admitting patients to an ED chest pain unit (CPU) to scores generated by a team of trained research investigators. We assessed whether TIMI risk scores obtained by ED providers in the setting of a busy ED differed from those obtained by trained research investigators. Most of the studies we reviewed relied on trained research investigators to determine TIMI risk scores rather than ED providers functioning in their normal work capacity.
Several studies have attempted to demonstrate that the Thrombolysis in Myocardial Infarction (TIMI) risk score has the ability to risk stratify emergency department (ED) patients with potential acute coronary syndromes (ACS).
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