An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: Results of a randomized study (ROMIO)

From the Journal of the American College of Cardiology:

Objectives. We tested the hypothesis that an emergency department-based protocol for rapidly ruling out myocardial ischemia would reduce hospital time and expense but maintain diagnostic accuracy.

Background. Patients with a missed diagnosis of myocardial infarction have a high mortality rate; however, providing routine hospital care to low risk patients may not be time- or cost-effective.

Methods. One hundred low risk patients were entered into the study and randomized either to an emergency department-based rapid rule-out protocol (n = 50) or to routine hospital care (n = 50). Patients receiving routine care were managed by their attending physicians. The rapid protocol included serum enzyme testing at 0, 3, 6 and 9 h, serial electrocardiograms with continuous ST segment monitoring and, if results were negative, a predischarge graded exercise test. Study patients were also compared with 160 historical control subjects.

Results. Myocardial infarction or unstable angina occurred in 6% of patients within 30 days; no diagnoses were missed. By intention to treat analysis (n = 50 in each group), the hospital stay was shorter and charges were lower with the rapid protocol than with routine care (p = 0.0001). Among patients in whom ischemia was ruled out, those assigned to the rapid protocol had a shorter hospital stay (median 11.9 vs. 22.8 h, p = 0.0001) and lower initial ($893 vs. $1,349, p = 0.0001) and 30-day ($898 vs. $1,522, p = 0.0001) hospital charges than did patients given routine care. In historical control subjects, the hospital stay was longer (median 34.5 h, p = 0.0001 vs. either group) and charges greater (median $2,063, p = 0.0001, vs. rapid protocol, p = 0.02, vs. routine care group).

Conclusions. In low risk patients who present to the emergency department with chest pain, the rapid protocol ruled out myocardial infarction and unstable angina more quickly and cost-effectively than did routine hospital care.