Dr Winchana Srivilaithon
First, we have to assess if the 0h/1h algorithm really works. After careful evaluation of the available data on the 0h/1h algorithm, we found that by using the 0h/1h algorithm, we would be able to rule out patients suspected of ACS. Many studies showed very high NPV of 90% or more. The rapid algorithm would also be able to rule out about 60% of low-risk patients, which would help us to make faster disposition decisions to discharge a patient who has waited a long time in the ER – send them back home, or admit them to hospital quicker.
The first step is to define the protocol. The second step is the phase of protocol creation. Our first practical protocol was different to the present protocol, because we keep improving and re-shaping it. The protocol amendments were not as easy as amending it, and then it would be ready for use. They need to be introduced to both emergency physicians and fellows, and proper guidance needs to be issued on their use, along with demonstrations of practical cases and decision-making. We have collected the feedback and made continuous improvements.
Currently, we are in the middle of the third step, which is implementation of the protocol. The protocol is in use and being observed for its outcomes and impacts. This is to ensure the safety of the algorithm for the patients that have been ruled out and received treatments. The next step is when we might consider the cost.
Dr Pisit Hutayanon
Adopting the use of the 0h/1h algorithm requires a great deal of collaboration. Doctors have to acknowledge the alternatives available to the current algorithm in use, and find out more about the algorithm, to see whether it can be taken on board or not. Are there any precise, acceptable cut-off points? They also need to acknowledge the information on the novel algorithm that can diagnose patients faster, which is different from the practice that required the patient to wait three hours to get the results. Implementing the 0h/1h algorithm requires a discussion on the entire system of patient care, including laboratory personnel, as the algorithm will provide faster results, which will subsequently lead to a higher number of patients we can service. This will take many parties, gathered together in discussion, to modify the operations, including the patient care.
Dr Masayuki Shiozaki
When the algorithm had just been implemented, detecting a troponin level slightly higher than the reference range, and measuring a high level for infectious diseases, led to a consultation request to a cardiologist. Elevation in high sensitivity troponin could be due to sepsis, tachycardia, AF (atrial fibrillation), as was pointed out in the previous publications, or myocardial ischemia associated with a reduced oxygen supply to the myocardial tissue. Making careful assessments and responding to each specific case deepened the level of understanding in physicians, and this eventually made troponin a popular test item among ER physicians. Currently it is being used without any major problems.
