In 2010, the researchers report, more than 17 million patients with chest pain visiting an emergency department in the United States received cardiac biomarker testing.
Between August and October 2011 at Johns Hopkins Bayview Medical Center, the team introduced written institutional guideline and changes to the computerized provider order entry system designed to reduce redundant testing.
The new guidelines suggest ordering troponin alone, without creatine kinase or creatine kinase-MB, for patients suspected to have acute coronary syndrome. It specifies that troponin should be assessed no more than three times over 18 to 24 hours.
Internists and emergency department doctors attended informational sessions to learn the guidelines, and all received quick reference cards summarizing them.
In the computerized provider order entry system, orders for creatine kinase and creatine kinase-MB were removed from all standardized order sets. Troponin orders were removed from all order sets, except two that are used for evaluating new acute coronary syndrome symptoms. A pop-up warning alerted providers when a troponin test was ordered sooner than six hours after a previous one, or when a provider attempted to order creatine kinase or creatine kinase-MB at the same time.
Twelve months after the interventions, doctors' use of the new guidelines increased from 57.1 percent to 95.5 percent and led to a 66 percent decrease in the absolute number of tests ordered. Also, there was a small but statistically significant increase in the primary or secondary diagnosis of acute coronary syndrome after the intervention period.
Lead author Marc R. Larochelle, M.D., an internal medicine resident at Johns Hopkins Bayview Medical Center during the study and now a fellow in general medicine at Harvard Medical School, says that, "Through
|Contact: Karen Tong|
Johns Hopkins Medicine