Chest pain is a scary symptom that sends more than 7 million Americans to the emergency department each year, about half of whom are admitted to the hospital for further observation, testing or treatment.

Now, emergency medicine physicians at The Ohio State University Wexner Medical Center and Mount Carmel Health System believe that number can be significantly reduced. Their study, published in JAMA Internal Medicine, finds a very low short-term risk for life-threatening cardiac events among patients with chest pain who have normal cardiac blood tests, vital signs and electrocardiograms.

“We wanted to determine the risk to help assess whether this population of patients could safely go home and do further outpatient testing within a day or two,” said Michael Weinstock, M.D., a professor of emergency medicine at The Ohio State University College of Medicine and chairman of the Emergency Department at Mt. Carmel St. Ann’s Hospital.

The researchers looked at data from 45,416 ED visits for chest pain at three Columbus-area hospitals between July 2008 and June 2013. Of those, 11,230 met the criteria for the study. Weinstock and colleagues looked for a primary outcome of life-threatening arrhythmia, inpatient heart attack, cardiac or respiratory arrest, or death. One of these bad outcomes occurred in four of the patients. Using a random sample of the medical records, that translates to a life-threatening event in 0.06 percent of these patients, or one in every 1,817.

“This data shows routine hospital admission is not the best strategy for this group. We tend to admit a lot of people with chest pain out of concern for missing a heart attack or some other life-ending irregularity,” Weinstock said. “To me, this says we can think more about what’s best for the patient long term. I’ve been having these conversations with my patients, and only one wanted to stay in the hospital. Most people want to go home and get tests done the next day.”

Additionally, Weinstock and his team believe current national guidelines to routinely admit, observe and test patients after a clean ED evaluation for chest pain should be reconsidered. “We’d like to see more emergency medicine physicians having that bedside conversation to ensure the chest pain patient knows the risks and benefits of hospitalization compared to outpatient evaluation. We think continuing evaluation in an outpatient setting is not only safer for the patient, it’s a less costly approach for the health care system,” Weinstock said.

Other team members included Colin Kaide, M.D., from The Ohio State University Wexner Medical Center; Frank Orth, M.D., Douglas VanFossen, M.D., and Judy Anderson from Mt. Carmel St. Ann’s; Scott Weingart, M.D., from Stony Brook Medicine; and David Newman, M.D., from Icahn School of Medicine.

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Stakeholders Join White House Effort to Combat Antibiotic Resistance

As part of the continued effort to combat antibiotic resistance, the Obama Administration in May convened a “White House Forum on Antibiotic Stewardship” to bring together key human and animal health constituencies involved in antibiotic stewardship — the development, promotion and implementation of activities to ensure the responsible use of antibiotics. As part of the event, more than 150 food companies, retailers, and human and animal health stakeholders highlighted commitments to implement changes over the next five years to slow the emergence of resistant bacteria and prevent the spread of resistant infections.

In addition, the president signed a memorandum directing federal departments and agencies to create a preference for meat and poultry produced according to responsible antibiotic-use. The Presidential Food Service also committed to serving meats and poultry that have not been treated with hormones or antibiotics.  Separately, the Food and Drug Administration announced that it has finalized changes to the Veterinary Feed Directive regulation, an important piece of FDA’s overall strategy to promote the judicious use of medically important antibiotics in food-producing animals as it facilitates bringing the feed-use of such antibiotics under the oversight of licensed veterinarians.

The administration said May’s event builds on a number of steps the president has taken to combat antibiotic resistance. In September 2014, Obama signed an executive order prioritizing federal efforts to combat the rise in antibiotic-resistant bacteria. The administration also issued the National Strategy on Combating Antibiotic-Resistant Bacteria, and the President’s Council of Advisors on Science and Technology released a report with recommendations to address the crisis of the proliferation of antibiotic-resistant bacterial infections. In March 2015, the administration released the National Action Plan for Combating Antibiotic-Resistant Bacteria, a comprehensive plan that identifies critical actions for key federal departments and agencies to enhance diagnosis and treatment and limit the spread of antibiotic-resistant bacteria.

The Centers for Disease Control and Prevention estimates that drug-resistant bacteria cause 2 million illnesses and about 23,000 deaths each year in the United States alone.

A number of health care organizations made commitments to fight antibiotic resistance, include:

Ascension Health will, establish facility-based antimicrobial stewardship programs in all its hospitals and adopt the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs, submit antibiotic use and resistance data to CDC, plus regularly evaluate facility antibiograms (the result of a laboratory test for the sensitivity of an isolated bacterial strain to different antibiotics).

Hospital Corporation of America will develop and implement new clinical decision support and real-time antibiogram tracking to rapidly respond to lab results, catch bug-drug mismatches, implement strategy to prevent health care-associated infections in adult intensive care unit patients, and strengthen national efforts to identify and report cases of antibiotic resistance.

Intermountain Healthcare will reduce inappropriate outpatient antibiotic use for upper respiratory conditions by 50 percent by 2020, ensure all of its acute care hospitals have antimicrobial stewardship programs by the end of 2017, plus support telemedicine efforts to extend infectious disease expertise to rural healthcare settings.

Kaiser Permanente will support antibiotic stewardship programs and guide prescribing practices for antimicrobials at every Kaiser Medical Center with electronic alerts, order sets, etc.

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