I'm an ED scribe and I've recently become curious about the way other hospitals without cath labs handle admitting versus transferring patients with chest pain.
Policies at my local hospital have changed drastically over the last few years, as I'm sure they do everywhere in every field. I work in a hospital that until very recently had cardiology on call but no cath lab. The path to disposition 3 years ago was a single troponin which if elevated (>0.056) in the setting of chest pain which could reasonably be tied to ACS, you would transfer. That policy made sense to me because it left room to admit patients with CHF exacerbation and demand-related troponin elevations.
About 2 years ago the policy changed to require two normal 2-hour troponins (<0.056) before you could admit. From what I understand, medicine was having to transfer patients who would get to the floor with a single normal trop, only for the next to be significantly elevated and no interventions available in house. This change made sense to me too.
Maybe around a year and a half ago the ED started getting a lot of push-back on admitting patients with these 2-hour detectable-but-not-elevated troponins. First trop would be 0.020, second would be 0.028, stuff like that. If a troponin was normal but detectable, medicine wanted it to be down-trending before they would admit. It put us in this weird position where we're getting three or four serial trops from the ED and being told to transfer by the hospitalist, but the cardiologist thinks the patient can stay put, and the downtown hospital doesn't want to accept the transfer.
Very recently we lost one of our two local cardiology groups and we now only have cardiology coverage every other day. Since then, it's been getting harder and harder to admit anything except serial undetectable troponins (<0.017), regardless of history or what other tests suggest. Our accepting hospital has been really understanding because so many of those docs rotate between the two sites and are familiar with the uphill battle with these patients.
But I was wondering, am I biased? Is this reasonable practice and I'm just looking at it too much from the ER perspective?
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