Abstract
Background
Most patients admitted for chest pain rule-out for acute coronary syndrome yet undergo low-value inpatient testing that prolongs stay and consumes scarce community-hospital resources.
Project Rationale
Baseline review showed utilization misaligned with HEART (History, Electrocardiogram, Age, Risk factors, Troponin)-derived risk and inconsistent, upwardly inflated score documentation, indicating the need for a standardized discharge pathway.
Project Summary
Among 156 emergency department chest-pain encounters (0% 6-week major adverse cardiac events), 89% received cardiology consultation and 45% echocardiography (88% normal); 44% of documented HEART scores were inflated. We adopted the HEART Score-Guided Accelerated Discharge Protocol: mandatory same-admission cardiology consult, indication-only echocardiography, no reflexive labs, target discharge under 24 hours, and guaranteed follow-up, with prespecified measures and an approximate cost avoidance of $120,000 (about $1,000 per patient) per rule-out cohort.
Take-Home Message
A simple, electronic medical record–free HEART-guided pathway can safely reduce low-value testing and redirect scarce resources to higher-acuity patients.
Key Words: blood tests, cardiac risk, chest pain
Visual Summary
Visual Summary.
HEART Score-Guided Accelerated Discharge (HGAD): Baseline Problem, the Protocol, Projected Impact, and Take-Home Messages
ECG = electrocardiogram; EMR = electronic medical record; HEART = History, Electrocardiogram, Age, Risk factors, Troponin; MACE = major cardiovascular event; NPO = nothing by mouth.
Acute chest pain is a leading reason for hospital admission, yet most admitted patients rule-out for acute coronary syndrome (ACS). Many still undergo inpatient testing and observation that rarely changes management, adding cost, exposing low-risk patients to iatrogenic harm, and, at small community hospitals with finite imaging and phlebotomy capacity, diverting resources from higher-acuity patients. The HEART score, which assigns 0 to 2 points across History, Electrocardiogram (ECG), Age, Risk factors, and Troponin for a total of 0 to 10, stratifying patients as low (0-3), intermediate (4-6), or high (7-10) risk reliably identifies low-risk patients with a very low short-term risk of major adverse cardiac events (MACEs),1,2 and the 2022 American College of Cardiology Expert Consensus Decision Pathway endorses their early discharge with structured follow-up.3 In practice, utilization often remains misaligned with measured risk, and HEART scores are inconsistently documented and prone to upward inflation. We conducted a baseline quality improvement (QI) analysis of admitted chest-pain encounters and translated the findings into the HEART Score-Guided Accelerated Discharge (HGAD) Protocol, now adopted as our institutional standard.
Take-Home Messages
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Documented HEART scores were systematically inflated, driving low-value inpatient echocardiography and prolonged stays in patients with a 0% short-term MACE risk.
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A simple, electronic medical record–free HEART-guided accelerated-discharge pathway safely eliminates low-yield testing and redirects scarce community-hospital resources to the patients who need them most.
Case Summary Prompting the Project Launch
A representative low-risk patient illustrates the gap the project targets: an older adult admitted from the emergency department (ED) for atypical chest pain, with 3 negative high-sensitivity troponins, a nonischemic ECG, and hemodynamic stability. Despite a low recalculated HEART score, the patient received an inpatient echocardiogram, which showed no wall-motion abnormality, and remained hospitalized overnight largely awaiting that study; cardiology consultation and next-morning laboratory draws were ordered reflexively rather than for a specific indication. The patient was discharged well, with no adverse event. Recognizing that this sequence, low-risk presentation, reflexive testing, and an avoidable extra day, recurred across the cohort prompted the project.
Project Rationale
Baseline review revealed a persistent mismatch between HEART-derived risk and resource use: inconsistent score documentation, no standardized discharge pathway, and no formalized outpatient follow-up process. Routine inpatient echocardiography and reflexive next-morning laboratory draws are rarely actionable once a patient has ruled out for ACS with serial negative troponins, a nonischemic ECG, and stability, yet both add cost and can prolong the stay while results are awaited. In a small community hospital, the scarcer currency is capacity: an echocardiography slot or phlebotomy round consumed by a low-yield study is unavailable to a higher-acuity patient who needs it sooner. The missing element was a standardized, low-burden pathway rather than new evidence, as supporting guidelines already exist; the opportunity was to align everyday practice with the risk the HEART score already measures.
Project Description
This single-center QI initiative was conducted at a community teaching hospital and reported per SQUIRE 2.04 (Standards for QUality Improvement Reporting Excellence); institutional review board review was waived under institutional QI policy. A multidisciplinary team spanning emergency medicine, cardiology, hospital medicine, nursing, care coordination, and health information technology developed the HGAD Protocol for adults admitted from the ED for chest pain who rule out for ACS with 3 negative serial high-sensitivity troponins (0, 2, and 4 hours), a nonischemic ECG, and hemodynamic stability. The protocol has 5 components: mandatory same-admission cardiology consultation; inpatient echocardiography (resting transthoracic echocardiography; CPT 93306, not stress imaging) only for defined indications (new ST changes, positive troponin, hemodynamic instability, or documented cardiology concern); elimination of reflexive next-morning labs and default NPO (nothing per mouth) status, with explicit exceptions (chronic kidney disease, diuretic use, abnormal admission labs, or active anticoagulation); target discharge within 24 hours; and guaranteed outpatient cardiology follow-up before discharge. The ED retains full authority over admission, and cardiology oversight is restructured, not reduced, by pairing an inpatient consult with assured outpatient follow-up. The protocol requires no electronic medical record build, allowing immediate launch. We prespecified process, outcome, and balancing measures (Table 1). Adherence is reviewed monthly by the resident QI team using statistical process control charts and Plan-Do-Study-Act cycles; sustainability is supported through residency education, laminated HEART-score reference cards, standing leadership review, and a 30-day MACE safety review.
Table 1.
Prespecified Process, Outcome, and Balancing Measures
| Type | Measure | Target/Direction |
|---|---|---|
| Process | Same-admission cardiology consult completed | 100% of protocol patients |
| Process | Inpatient echo only for a defined indication | Indication-driven only |
| Process | Next-morning labs only for a defined exception | Exception-driven only |
| Process | Outpatient cardiology follow-up before discharge | 100% of protocol patients |
| Outcome | Median length of stay (rule-out cohort) | Decrease vs baseline |
| Outcome | Inpatient echocardiography rate | Decrease vs baseline 45% |
| Outcome | Estimated cost avoidance per patient | Increase |
| Balancing | Major adverse cardiovascular event within 30 d of discharge | No increase (baseline 0%) |
| Balancing | 30-d readmission/emergency department revisit | No increase |
| Balancing | Outpatient follow-up completion | Maintained/improved |
Project Deliverables
Deliverables included a baseline analysis of 156 consecutive ED chest-pain encounters with independent HEART-score recalculation; the written HGAD Protocol with explicit eligibility, indications, and exceptions; a prespecified measures framework (Table 1); laminated point-of-care HEART reference cards; a residency education module; an illustrative cost-avoidance model; and a monthly chart review and run-chart tracking system. Institutional acceptance was obtained from cardiology and hospital medicine, and the baseline analysis was accepted for ePoster presentation at the 2026 American College of Cardiology Quality Summit.
Project Outcome, Impact, and Future Directions/Next Steps
The baseline cohort (mean age 65 years; 53% women) demonstrated overutilization disproportionate to risk (Table 2, Figure 1). Cardiology consultation occurred in 89% and inpatient echocardiography in 45%; median was 1 day, with 27% staying longer, and no MACE occurred at 6 weeks (0%). Among 70 encounters with paired scores, HEART scores documented in the admitting physician's note exceeded scores independently recalculated by structured chart review (median 5 vs 4; Wilcoxon P = 0.0003), with 44% reclassified to a lower tier and 10% to a higher tier on independent review (Figure 2); this discrepancy itself suggests the HEART score, as applied at the bedside under real-world documentation conditions, is not a fully reliable instrument on its own. Of 69 echocardiograms performed, all were resting transthoracic studies rather than stress imaging, and 88% showed no wall-motion abnormality (Figure 3), consistent with the absence of a guideline-based indication for ischemic evaluation in a population already ruled out by serial troponins and a nonischemic ECG. In the low-risk subgroup (recalculated HEART 0-3 with 3 negative troponins, n = 37), 46% still underwent echocardiography and 92% received consultation, with no MACE. Using rechecked, approximate published unit costs (echocardiography about $250 on a conservative Medicare-reimbursement basis5; an inpatient bed-day about $3,0006; a laboratory panel about $50), eliminating routine echocardiography and next-morning labs and recovering half of the excess bed-days in the rule-out cohort (n = 116) yields an approximate avoidance of $120,000, or roughly $1,000 per patient (Table 3, Figure 4); commercial and hospital-facility cost bases would be higher. The directly eliminated testing alone, the highest-confidence component, accounts for approximately $19,000. Beyond dollars, the pathway addresses concrete operational bottlenecks at a small community hospital. Echocardiographer availability is limited; when the sonographer is performing a study on a rule-out patient that returns no actionable finding, a patient with new heart failure or hemodynamic instability may wait hours for their study, and we observed that some rule-out patients remained hospitalized specifically while awaiting an echocardiogram. Phlebotomists serve the entire hospital on each morning round; every unnecessary draw on a stable rule-out patient is time the phlebotomist is unavailable for higher-acuity patients who genuinely need monitoring, delaying their care. Eliminating reflexive draws also removes a direct patient-level harm: each venipuncture carries a small but real risk of phlebitis, local infection, and hematoma, and serial unnecessary draws contribute to iatrogenic anemia, which is particularly consequential in older patients (cohort mean age 65). Reducing unnecessary hospital days further lowers exposure to hospital-acquired infection and delirium. Following adoption, prespecified measures are tracked monthly; postimplementation outcomes are accruing and not yet mature. The planned follow-up analysis will report change in length of stay, echocardiography and laboratory rates, follow-up completion, realized cost avoidance, and 30-day MACE and readmission, using this baseline cohort as the historical comparator, and a future institutional review board–approved interventional study may use the current blinded cohort as a control.
Table 2.
Baseline Characteristics of the Chest-Pain Cohort (N = 156)
| Age, y, mean ± SD | 65.0 ± 13.4 |
| Female sex, n (%) | 82 (53) |
| Hypertension/Hyperlipidemia, % | 70/68 |
| Known coronary artery disease/Diabetes, % | 49/30 |
| Three negative troponin sets, n (%) | 116 (74) |
| MACE at 6 wk, % | 0 |
Percentages are calculated among encounters with the field recorded.
MACE = major adverse cardiovascular event.
Figure 1.
Baseline Resource Utilization in the Full Cohort and Low-Risk Subgroup
LOS = length of stay; MACE = major cardiovascular event.
Figure 2.
Documented vs Recalculated HEART Scores (n = 70): Documented Scores Were Biased Upward
HEART = History, Electrocardiogram, Age, Risk factors, Troponin.
Figure 3.
Yield of Inpatient Echocardiography (n = 69 performed)
Table 3.
Approximate Cost-Avoidance Estimate for the Rule-Out Cohort (n = 116), Conservative Basis
| Component | Volume | Approx. Avoidance |
|---|---|---|
| Routine echocardiography eliminated (∼$250 each) | 54 | ∼$13,500 |
| Next-morning laboratory panels (∼$50 each) | 116 | ∼$5,800 |
| Excess inpatient bed-days, 50% capture (∼$3,000/d) | 33.5 | ∼$100,500 |
| Total (cohort) | — | ∼$120,000 |
| Per rule-out patient | — | ∼$1,000 |
Approximate, rounded estimates from published unit costs (Medicare echo reimbursement ∼$210–$235; Kaiser Family Foundation/American Heart Association bed-day ∼$3,130), not internal accounting. Commercial/charge and hospital-facility bases would be higher. Testing-only avoidance (echo + labs) ≈ $19,000.
Figure 4.
Approximate Cost Avoidance by Component (Conservative Basis)
Discussion
This baseline analysis quantified a measurable, modifiable gap between guideline-concordant risk stratification and practice. The persistence of high utilization despite a 0% event rate indicates that the barrier was the absence of a standardized pathway rather than absent evidence. Upward inflation of documented HEART scores is a particularly actionable driver: because the score determines disposition, even a 1-point bias can move a low-risk patient into an intermediate tier and trigger admission, consultation, and imaging. The discrepancy between admitting-physician-documented scores and scores independently recalculated by structured chart review further indicates that the HEART score, as applied at the bedside, cannot be relied on as a fully reproducible instrument on its own; this argues for a protocol-level safeguard rather than for gating testing and consultation on score documentation alone. The HGAD Protocol addresses this at the source while restructuring, not reducing, cardiology oversight. Notably, the consultation rate in this cohort, 89% overall and 92% in the independently confirmed low-risk subgroup, substantially exceeds typical ED practice, in which cardiology is not routinely consulted for low-risk chest pain. This pattern, paired with reflexive resting echocardiography ordered without an ischemic or structural indication, suggests baseline practice at our institution had drifted from guideline-concordant, risk-stratified care rather than merely lagging behind it. None of the inpatient echocardiograms in this cohort were stress studies; as resting studies performed in patients who had already ruled out for ACS by serial troponins and a nonischemic ECG, they could not contribute incremental ischemic risk stratification, a role reserved for stress testing, with or without imaging, under existing chest-pain guidelines.3 That nearly half the cohort, and nearly half of the confirmed low-risk subgroup, nonetheless underwent this nonindicated study is why correcting this specific pattern, rather than incrementally trimming an already-reasonable baseline, is the central aim of the HGAD Protocol. Our findings extend the evidence behind accelerated diagnostic protocols,7,8 such as the HEART Pathway randomized trial, into the everyday operations of a resource-limited community hospital, where the practical constraint is often capacity rather than knowledge. Routine echocardiography and morning labs are not actionable in a ruled-out patient unless cardiology identifies an indication, so performing them reflexively adds cost without value. In a small community hospital where a single echocardiographer may serve the entire facility, occupying that resource with a low-yield study directly delays imaging for sicker patients. Similarly, each reflexive morning draw adds to the phlebotomist's workload and delays their rounds to patients who require serial monitoring. Eliminating these unnecessary draws also reduces the cumulative venipuncture burden, lowering the risk of phlebitis, bloodstream infection, and iatrogenic anemia from serial blood loss. Because the protocol is manual and electronic medical record–independent, it is readily transferable to other community hospitals with similar chest-pain volumes and limited imaging staffing. Limitations include the single-center retrospective baseline design, incomplete documentation of some variables, illustrative rather than internal-accounting cost estimates that depend on an assumed bed-day capture rate, and the absence of mature postimplementation data; these are the focus of the planned prospective evaluation.
Conclusions
In admitted chest-pain patients who rule out for ACS, baseline care featured low-value echocardiography and prolonged stays despite negligible risk, compounded by inflated HEART scores. The HGAD Protocol, now standard institutional practice, restricts low-yield testing to defined indications, mandates same-admission cardiology consultation, targets discharge within 24 hours, and guarantees follow-up, offering a scalable, electronic medical record–free framework for high-value chest-pain care at community hospitals.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Acknowledgments
The authors would like to acknowledge the nursing staff, pharmacists, case managers, fellow physicians, and quality improvement personnel at Landmark Medical Center for their support in implementing the interventions and facilitating data collection for this project. Their collaboration, dedication to patient care, and commitment to quality improvement were instrumental in the successful execution of this initiative.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
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