Discharge Error Rate for Chest Pain: 1%–2% Seen as OK

NEW ORLEANS — What constitutes an acceptable rate of erroneous discharge of patients who present to the emergency department with chest pain?

Somewhere between 1% and 5%, according to a survey of experienced emergency physicians at two prestigious Boston academic medical centers. A narrow majority of responding physicians drew the boundary of acceptability more tightly at 1%–2%, Dr. John Nagurney reported at the annual meeting of the Society for Academic Emergency Medicine.

Whether to admit or discharge a patient who presents to the ED complaining of chest pain is a common dilemma. It has been estimated that up to 80% of patients with chest pain who are admitted to rule out acute coronary syndrome turn out not to have ACS. On the flip side, 2%–4% of ED patients with ACS are misidentified and erroneously discharged.

A figure of 1% has begun appearing in the literature as an “acceptable” erroneous discharge rate, but without any supporting evidence to show that physicians on the front lines actually agree it's a reasonable number, Dr. Nagurney said. To clarify the situation, he and his coinvestigators interviewed 31 emergency medicine faculty or fellows at two Harvard University-affiliated hospitals. Many were reinterviewed a few weeks later; if their answers were discordant, the results were averaged.

Sixteen physicians (52%) said that a 1%–2% erroneous discharge rate is acceptable. Another 8 (26%) indicated they considered an acceptable error rate to be 1%–5%, according to Dr. Nagurney, an internist at Massachusetts General Hospital, Boston.