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Reduction in Radiation Exposure through a Stress Test Algorithm in an Emergency Department Observation Unit

Volume 17, Issue 2, March 2016.
Margarita E. Pena, MD, et al.

Introduction: Clinicians are urged to decrease radiation exposure from unnecessary medical
procedures. Many emergency department (ED) patients placed in an observation unit (EDOU) do not
require chest pain evaluation with a nuclear stress test (NucST). We sought to implement a simple
ST algorithm that favors non-nuclear stress test (Non-NucST) options to evaluate the effect of the
algorithm on the proportion of patients exposed to radiation by comparing use of NucST versus NonNucST
pre- and post-algorithm.
Methods: An ST algorithm was introduced favoring Non-NucST and limiting NucST to a subset of
EDOU patients in October 2008. We analyzed aggregate data before (Jan-Sept 2008, period 1) and
after (Jan-Sept 2009 and Jan-Sept 2010, periods 2 and 3 respectively) algorithm introduction. A
random sample of 240 EDOU patients from each period was used to compare 30-day major adverse
cardiac events (MACE). We calculated confidence intervals for proportions or the difference between
two proportions.
Results: A total of 5,047 STs were performed from Jan-Sept 2008-2010. NucST in the EDOU
decreased after algorithm introduction from period 1 to 2 (40.7%, 95% CI [38.3-43.1] vs. 22.1%, 95%
CI [20.1-24.1]), and remained at 22.1%, 95% CI [20.3-24.0] in period 3. There was no difference in
30-day MACE rates before and after algorithm use (0.1% for period 1 and 3, 0% for period 2).
Conclusion: Use of a simple ST algorithm that favors non-NucST options decreases the proportion
of EDOU chest pain patients exposed to radiation exposure from ST almost 50% by limiting NucST
to a subset of patients, without a change in 30-day MACE.

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Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.