Chest Pain Clinical Pathway in Pediatric ED Can Influence Resource Use

Because most young children are not able to accurately describe or localize their pain, ruling out cardiac disease in children can be challenging, leading to increased health care utilization for chest pain evaluation. In a new study, published in Pediatric Emergency Care, researchers at Children’s Hospital of Philadelphia (CHOP) evaluated the impact of a pediatric emergency department (ED) chest pain clinical pathway on resource utilization. The findings showed that implementation led to reduction in chest x-ray ordering in the ED and was associated with a higher rate of outpatient follow-up for nonpathologic chest pain.
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Sharon Mohan, MD, MPH, Texas Children’s Hospital (Houston, TX), and colleagues developed a chest pain clinical pathway that was implemented on March 1, 2014. Using a quasi-experimental design, the researchers reviewed medical records of children aged 3 to 18 years without prior diagnoses of heart disease who presented with chest pain to the ED between March 1, 2013, and August 22, 2015. Diagnostic testing rates, ED length of stay, and cardiology consults before and after implementation of the pathway were compared. The researchers identified 1690 patients who met inclusion for the clinical pathway; after review of all ED encounters and documentation, 1687 patients were pathway eligible (pre-implementation, n=675; post-implementation, n=1012). The majority of patients were discharged from the ED, with 111 patients admitted to the hospital during the study period.

After pathway implementation, there was a statistically significant reduction in chest x-rays ordered, from 46.1% of pathway-eligible patients to 35.6% (P < .01). The use of other tests decreased as well, but this was not found to be clinically significant. Although there was an increase in electrocardiogram ordering (45% vs 47.7%), the researchers acknowledged that the increase was not surprising because it is the first recommended diagnostic test in the pathway when trying to screen for cardiac pathology. The researchers also observed a statistically significant reduction in length of stay in the ED for the entire study period, from 3.3 hours pre-implementation to 3.08 hours post-implementation. Patient follow-up after the ED visit increased from 15% to 30% after pathway implementation. Follow-up was considered to have taken place if the patient saw their primary care doctor or a pediatric cardiologist within the CHOP health care system. The researchers found that none of these visits resulted in the diagnosis of a new cardiac condition with follow-up range of 4 weeks to 2 years, and no instances of missed cardiac etiologies of chest pain were identified.

“As is the case for most pediatric conditions, efforts at improving quality of care will require modifications to our existing practice,” explained the researchers. “Further directions of the study include modifications of the clinical pathway to reduce the unnecessary cardiology consultation and outpatient follow up.”—Eileen Koutnik-Fotopoulos


Mohan S, Nandi D, Stephens P, M’Farrej M, Vogel RL, Bonafide CP. Implementation of a clinical pathway for chest pain in a pediatric emergency department [published online ahead of print September 20, 2016]. Pediatr Emer Care. doi:10.1097/PEC.0000000000000861.