Per the 2021 American Heart Association and American College of Cardiology guidelines, high-sensitivity cardiac troponin assays (hs-cTn) are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury in the evaluation and diagnosis of chest pain or anginal equivalents. Transitioning from conventional cardiac troponin to hs-cTn also allows for earlier rule out while reducing rates of missed myocardial infarction. However, troponin may also be elevated in conditions such as cancer, diabetes, and end-stage renal disease. In this setting, there are concerns that implementation of hs-cTn can include risks of diagnostic errors, inappropriate admissions, rise in cardiology consultations and unnecessary imaging, and delayed discharges from the emergency department (ED).
To provide accurate result interpretation and diagnosis, the Penn Medicine Enterprise High Sensitivity Troponin Implementation Team developed hs-cTn chest pain algorithms through multidisciplinary teams across five hospitals. This pathway was developed for various clinical settings, including the ED and outpatient and inpatient populations. The ED algorithm was particularly complex. Instead of relying on a single value and a reference range, proper use requires evaluation within the clinical context and interpretation of temporal changes (deltas) at set intervals such as baseline, at one and/or three hours relative to presentation. To further support this paradigm shift, both in workflow and interpretation, Penn Medicine developed innovative, patient-centered clinical decision support tools to display real-time status updates, including reminders for lab collection for nursing staff and automatic interpretation guidance for acute coronary syndrome in the electronic health record (EHR).
The team formed an enterprise, interdisciplinary governance group of 89 participants, designed research-based algorithms embedded in the EHR, and developed a clinical reference site. Additionally, they coordinated the launch with laboratory teams, educated more than 8,000 caregivers, and implemented an electronic dashboard for continuous monitoring. Since initiation, Penn Medicine has also scaled its tools outside of the enterprise’s five hospitals to an organization in Texas.
The initiative launched successfully in June 2022, achieving a smooth transition to high-sensitivity troponin without diagnostic errors, inappropriate admissions, or increased cardiology consultations. Diagnoses of non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) improved for chest pain patients, who also benefited from detailed test results via the patient portal and providers. Benefits realized include:
- Patients with chest pain or shortness of breath saw a 13% increase in ED discharge dispositions and a 17% decrease in observation dispositions
- Patients with chest pain had a 26% decrease in ED observation dispositions
- Reduced ED length of stay by 71 minutes for admitted cardiac patients and 24 minutes for discharged patients
The initiative generated more than $3.9 million in savings within 10 months by reducing length of stay, enhancing patient throughput, and increasing ED capacity. This project aligned with Penn Medicine’s institutional goals of quality, patient safety, continuity of care, high reliability, and innovation and achieved a smooth implementation and sustained successful outcomes— providing significant safety benefits for patients, inclusive of quicker, more accurate diagnosis, as well as ED utilization.
