Coagulation Studies are Frequently Ordered in Emergency Department Chest Pain Patients and do not Change Emergency Department Management

Background

Despite research findings, implementation into clinical practice is often delayed. Coagulation panels are still ordered as part of an emergency department (ED) chest pain evaluation, despite multiple studies showing that it is unnecessary and does not change management.

Objective

Our primary outcome is to determine if the practice of ordering coagulation studies (prothrombin time [PT]/international normalized ratio [INR]) is still occurring in ED chest pain patients. Our secondary outcome is to determine if abnormal results change management.

Methods

We performed an institutional review board (IRB) approved retrospective chart review of patients with chest pain presenting to three rural-community EDs over 49 months. Medical students, blinded to the study intent, performed data abstraction using the approach of Gilbert and Lowenstein to determine if coagulation testing (PT/INR) was “indicated” based on a preexisting condition (i.e., liver disease) or medication use (warfarin). Next, the data abstractors determined if the abnormal coagulation results prompted a therapeutic intervention or change in the management in the ED.

Results

We randomly identified 1,200 patients with chest pain before covid-19 and, after exclusions, analyzed 830 patient charts. 440 patients (53.0%) had coagulation panels completed, but they were only indicated in 55 of the 440 patients (12.5%). Of the 385 patients without indications, 378 (98.2%) had an INR level in the normal range and 7 patients (1.8%) had an elevated INR. None of these 7 patients had a change in ED management.

Conclusions

In this multicenter study, 53% of ED patients with chest pain had coagulation studies ordered. Only 12.5% were indicated. None of the abnormal results in patients without indications resulted in a change in ED management.