Reducing Unnecessary Noninvasive Testing for Inpatients With Unstable Angina: The RUNIT Protocol

Routine inpatient transthoracic echocardiography (TTE) for patients with unstable angina is common, but it anecdotally adds little value to clinical care. A practice audit at our academic hospital demonstrated that 61.5% of patients with troponin-negative chest pain (TNCP) had normal left ventriculography (LVG) during coronary angiography and normal TTE on the same admission (duplicate testing). We developed the Reducing Non-Invasive Testing (RUNIT) protocol, a clinical algorithm applied by clinical nurses to patient with TNCP. We performed a prospective assessment of rate of duplicate testing before and after intervention. If patients met certain simple clinical criteria, their TTE was cancelled (RUNIT positive). Patients then proceeded to have either coronary angiography with LVG or noninvasive risk stratification. We aimed to reduce duplicate testing by 25% over a 1-year period. Balancing measures included pathology on ordered TTEs, 30-day readmission, length of stay, and number of LVG. Among 254 patients admitted with TNCP over 12 months, we reduced duplicate testing from 61.5% (before intervention) to 34% (P = 0.001). There was no clinical difference in 30-day readmission (0.9% vs 0.7%), and length of stay was significantly shorter in RUNIT positive (3.48 vs 4.16 days, P = 0.02). The majority of duplicate TTEs did not reveal any management-informing pathology. RUNIT-positive patients underwent more LVG than RUNIT-negative patients (78.3% vs 62.8%, P = 0.008). We achieved a sustained reduction in reflexive TTE ordering in patients with TNCP, and we discuss the potential of nursing-led interventions to address other areas of low value care in cardiology. La réalisation systématique d’une échocardiographie transthoracique (ETT) chez les patients hospitalisés pour angine instable est une pratique courante, qui n’apporte toutefois qu’une valeur anecdotique aux soins cliniques. Un audit des pratiques en vigueur dans l’hôpital universitaire auquel nous sommes rattachés a révélé que 61,5 % des patients ayant une douleur thoracique sans élévation de la troponine (DTST) présentaient une ventriculographie gauche (VGG) normale à la coronarographie et une ETT normale lors de la même admission (tests effectués en double). Nous avons mis au point le protocole RUNIT (ReducingNon-InvasiveTesting, réduction des tests non invasifs), un algorithme clinique appliqué par le personnel infirmier clinicien aux patients présentant une DTST. Nous avons ensuite mené une évaluati