Multicenter Implementation of a High-Sensitivity Troponin Rapid Rule-Out Pathway and Its Impact on Emergency Department Utilization and Outcomes

Chest pain is one of the most common chief complaints in the emergency department (ED), yet a substantial portion of patients may have non-cardiac etiologies. High-sensitivity cardiac troponin (hs-cTn) assays enable earlier detection of myocardial injury and may help reduce unnecessary hospital admissions for patients presenting with chest pain. The objective of this study was to evaluate the system-wide impact of implementing an hs-cTn–based rapid rule-out care pathway across a large healthcare system and we examined its effect on admissions, 72-hour return visits, and 30-day major adverse cardiac events (MACE).

This retrospective cohort study included adults presenting with chest pain to one of 21 emergency departments across Ohio and Florida from 2017–2024. Patients were categorized as pre-implementation or post-implementation of the high-sensitivity troponin care rapid rule-out pathway. Outcomes included hospital admission, 72-hour ED return visits, and 30-day MACE (PCI, CABG, acute myocardial infarction, all-cause death). Multivariable logistic regression controlled for age, sex, race, insurance, Emergency Severity Index (ESI), Charlson Comorbidity Index (CCI), and ED type.

A total of 106,768 encounters were included (mean age 54 years, balanced sex and race distribution). Due to the large sample size and expansion of participating sites during the study period, most demographic characteristics differed between groups. Post-implementation patients presented with greater comorbidity and acuity, longer ED and hospital length of stay, and were less likely to be admitted or require ICU-level care. Implementation of the hs-cTn pathway was associated with a 55% reduction in hospital admissions compared with pre-implementation (AOR 0.45; 95% CI 0.43–0.47). There was no significant difference in 72-hour ED return visits (AOR 1.08; 95% CI 0.95–1.22), indicating no increase in early missed diagnoses. However, patients returning within 72 hours more frequently required admission in the post-implementation period. Among discharged patients, 30-day MACE increased by 0.33 percentage points following hs-cTn implementation (0.63% vs. 0.96%), primarily driven by an increase in percutaneous coronary intervention. After adjustment, discharged patients in the post-implementation group had higher odds of MACE (AOR 1.84; 95% CI 1.32–2.55), though absolute rates remained low (<1%).

Implementation of the hs-cTn care pathway substantially reduced hospital admissions despite a higher acuity and more comorbid patient population in the post-implementation cohort. The pathway did not increase 72-hour ED return visits, suggesting no rise in early missed pathology, though those who returned were more often admitted. An increase in 30-day MACE, largely driven by revascularization, highlights the need for continued refinement of risk stratification when using hs-cTn to guide discharge decisions. Overall, hs-cTn pathways improve ED resource utilization while emphasizing the importance of balancing efficiency with patient safety.