Some common issues that contribute to unnecessarily long stays, inappropriate resource consumption, or unnecessary hospital stays have been identified in patients presenting for evaluation of chest pain.

1. Patients being admitted to hospital (observation or admission) who could have been sent home directly from ER.
2. Workups being conducted for other medical issues that do not need to be performed in the hospital.
3. Echocardiograms without documented indication consistent with existing criteria for echocardiography.
4. Nuclear stress tests or stress echo without appropriate criteria when traditional exercise stress test (faster and quicker as well as much lower in cost) is only test indicated.
5. Hospital-based stress testing when outpatient stress testing can be done. By definition of low-risk chest pain there is no medical indication for such patients to remain in hospital for testing and delay their discharge. Such testing ties up critical resources and personnel who are stretched thin and limiting their availability for more acute inpatient needs, in addition to raising the cost of care substantially.
6. “Routine” cardiology consultation when no Cardiology consult appears indicated.
7. Consultation requests for other specialty or subspecialty services that are not critical/urgent and can be done on an outpatient basis

Suggestions to improve Length of Stay and avoid unnecessary hospital stays:

1. 1. Low risk chest pain patients seen in the ER who are candidates for discharge directly to home from ER.
   1. Attending (IM/FP) to attending (ER) discussion to seek mutual agreement in collaborative and collegial fashion to discharge patient directly from ER.
   2. Most if not all of the time there should be a direct examination of the patent in the ER as a key part of such discussion.
   3. Criteria exist for classifying patients with chest pain to recognize those who are” low risk” and thus are not candidates for high resource utilization in acute care settings. Both ER physicians and hospital physicians need to be familiar with and utilize such classification schemes.
      d. If followup (office visit or any cardiac testing) are indicated, appropriate providers (PCP and/or cardiologist) should be contacted and agree to arrange any recommended followup and/or contact of patient. In such cases there should be direct discussion or secure text messaging with PCP and/or cardiologist, rather than just leaving a message or sending a report and presuming it will be sufficient.
      e. Billing, insurance and contact information can be transmitted to such providers who do not already have a relationship with the patient via photo of document sent to provider via secure texting program (Tiger Text). This makes it easier to set up the patient’s followup or testing that is being ordered for the patient with the testing or referring physician having the information needed to contact the patient and create a chart with billing information available.

2. Low risk chest pain patients who are admitted (Obs or Admission – with Obs almost always the designation) when patient not being sent home by ER following evaluation for chest pain.
a. Where appropriate, patient can be examined and evaluated in ER and discharged at same time as Observation admission when ER discharge is indicated but ER physician is not planning to discharge the patient from ER.
b. Direct discussion with PCP to identify salient history that may be relevant to presentation as well as identify previous testing, consultations, diagnoses and medications that are relevant to the hospital stay. Such discussions are important to avoid duplicative consultation or testing.
c. Direct discussion with PCP and/or cardiologist so that followup – including stress test when indicated – can be done on outpatient basis with speedier discharge.
d. Avoid workup of associated issues during hospital stay unless they are of such a severity that they would independently justify a hospital stay. Discuss followup of such issues with PCP so any prior evaluations of such problems can be reviewed and subsequent outpatient followup, if needed, is planned.
e. Echocardiogram, telemetry monitoring, CT scans, MRI’s and other complex diagnostic studies would not typically be indicated for low-risk chest pain patients. Evaluations should be focused on issues that require hospitalization and should be indicated for the patient’s diagnosis and condition.
f. Cardiology consultations are certainly needed in some cases of chest pain and clearly not in others. Best process is to work with your (preferred) cardiologist to develop the most efficient workflow to improve efficiency. Many prefer the “Curbside Consult” – now being upgraded to secure text messaging – to give fast recommendations culminating in a prompt followup in the cardiologist’s office and avoiding unnecessarily long hospital delays.
g. Consultations other than cardiology would typically not be indicated in hospital as such evaluations would be suitable and appropriate for the outpatient setting in a chest pain