Background: Guidelines are not available for which patients with acute chest pain should be admitted to the coronary care unit and which patients can be reasonably triaged to monitored beds in lower levels of care.
Methods And Results: Clinical and resource utilization data from 12 139 emergency department patients with acute chest pain were used in a decision-analytic model to identify cost-effective guidelines for the admission to a coronary care unit versus an intermediate care unit for initially uncomplicated patients without other indications for intensive care. The probability of clinical complications and death were derived from data on age-specific subsets of the population. Resource utilization estimates were based on cost data from a subset of 901 patients and length of stay data for the entire cohort. The survival benefit associated with initial triage to the coronary care unit instead of an intermediate care unit was assumed to be 15%. In the baseline analysis for 55- to 64-year-old patients, the probability of acute myocardial infarction (AMI) at which the coronary care unit had an incremental cost-effectiveness below $50 000 per year-of-life-saved was 29%. Triage to the coronary care unit was somewhat more cost-effective in elderly patients because their higher early complication rate more than offset their shorter life expectancy.
Conclusions: This analysis indicates that the coronary care unit usually should be reserved for patients with a moderate (21% or more, depending on the patient's age) probability of AMI unless patients need intensive care for other reasons. Clinical data suggest that only patients with ECG changes of ischemia or infarction not known to be old have a probability of AMI this high. Intermediate care units are appropriate for patients whose risks are not high enough for a coronary care unit to be cost-effective but too high for other alternatives to be recommended for safety and effectiveness.
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