An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO)

J Am Coll Cardiol. 1996 Jul;28(1):25-33. doi: 10.1016/0735-1097(96)00093-9.


Objectives: We tested the hypothesis that an emergency department-based protocol for rapidly ruling out myocardial ischemia would reduce hospital time and expense but maintain diagnostic accuracy.

Background: Patients with a missed diagnosis of myocardial infarction have a high mortality rate; however, providing routine hospital care to low risk patients may not be time- or cost-effective.

Methods: One hundred low risk patients were entered into the study and randomized either to an emergency department-based rapid rule-out protocol (n = 50) or to routine hospital care (n = 50). Patients receiving routine care were managed by their attending physicians. The rapid protocol included serum enzyme testing at 0, 3, 6 and 9h, serial electrocardiograms with continuous ST segment monitoring and, if results were negative, a predischarge graded exercise test. Study patients were also compared with 160 historical control subjects.

Results: Myocardial infarction or unstable angina occurred in 6% of patients within 30 days; no diagnoses were missed. By intention to treat analysis (n = 50 in each group), the hospital stay was shorter and charges were lower with the rapid protocol than with routine care (p = 0.001). Among patients in whom ischemia was ruled out, those assigned to the rapid protocol had a shorter hospital stay (median 11.9 vs. 22.8 h, p = 0.0001) and lower initial ($893 vs $1,349, p = 0.0001) and 30-day ($898 vs. $1,522, p = 0.0001) hospital charges than did patients given routine care. In historical control subjects, the hospital stay was longer (median 34.5 h, p = 0.001 vs. either group) and charges greater (median $2,063, p = 0.001, vs rapid protocol, p = 0.02, vs. routine care group).

Conclusions: In low risk patients who present to the emergency department with chest pain, the rapid protocol ruled out myocardial infarction and unstable angina more quickly and cost-effectively than did routine hospital care.

Publication types

  • Clinical Trial
  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Clinical Enzyme Tests
  • Clinical Protocols
  • Cohort Studies
  • Cost-Benefit Analysis
  • Electrocardiography
  • Emergency Service, Hospital*
  • Exercise Test
  • Female
  • Hospital Charges / statistics & numerical data
  • Humans
  • Length of Stay / economics
  • Length of Stay / statistics & numerical data
  • Male
  • Middle Aged
  • Myocardial Ischemia / diagnosis*
  • Myocardial Ischemia / economics
  • Myocardial Ischemia / epidemiology
  • Outcome and Process Assessment, Health Care
  • Patient Admission / economics
  • Patient Admission / statistics & numerical data
  • Prospective Studies
  • Risk Factors