EBM Review Series: Point of Care Troponin in the Emergency Department: Faster Results, Same Throughput?
VACEP Evidence-Based Medicine for General Emergency Physicians Series
Authors: Authors: Gabriella Dean, MD | UVA Health & Winston Wu, MD | Virginia Tech Carilion
Reviewers: Sarah Emslie, MD PGY-3 & Ambika Anand, MD | VCU Health
The VACEP Evidence-Based Medicine Review Series allows Virginia emergency medicine residents and attendings to share and analyze a recent peer-reviewed clinical study. You can also read the full article, “Effectiveness of Point-of-Care High-Sensitivity Troponin Testing in the Emergency Department: A Randomized Controlled Trial” from the Annals of Emergency Medicine in their August 2025 issue.
THE CASE
It is a busy shift when a 61-year-old male presents to your ED with chest pain. He is roomed immediately, but your lobby is pushing capacity and there are 42 admitted patients boarding in your department.
He describes left-sided chest discomfort radiating to his left arm and jaw, beginning two hours earlier. He is hemodynamically stable and his medical history includes hypertension, hyperlipidemia, and type II diabetes. EMS administered 324 mg of aspirin with partial improvement. His ECG demonstrates nonspecific T-wave changes without acute ischemia.
You plan to obtain laboratory evaluation including a troponin level. Your ED director recently noted availability of a new point-of-care (POC) high-sensitivity troponin assay for use in the department. You consider whether utilizing POC testing versus standard central laboratory testing may improve efficiency for this patient and the department.
How do you maximize throughput while maintaining high-quality patient care?
STUDY SUMMARY
Chest pain is among the most common presentations to the emergency department, yet only 5–20% of patients ultimately receive a diagnosis of acute coronary syndrome (ACS). High-sensitivity troponin (hs-cTn) assays allow earlier detection of myocardial injury, and numerous accelerated diagnostic pathways incorporating serial hs-cTn measurements have been developed to identify those who can be safely ruled in or ruled out.
Meanwhile, ED overcrowding and boarding have become global concerns, contributing to increased costs, morbidity, mortality, and decreased patient satisfaction. Efforts to optimize ACS evaluation now include not only diagnostic accuracy but also operational efficiency.
This trial evaluated whether point-of-care hs-cTn testing would reduce ED length of stay (LOS) compared with standard central laboratory testing. Secondary outcomes assessed whether POC implementation altered rates of adverse events.
METHODS
The WESTCOR point-of-care study was a single-center, prospective, randomized controlled trial conducted at a University Hospital in Bergen, Norway. A total of 1,494 patients presenting with possible ACS were randomized to one of two groups:
Control: standard central laboratory hs-cTnT testing
Intervention: point-of-care hs-cTnI testing
Both groups utilized a 0-and-1-hour serial troponin protocol. The primary outcome was ED length of stay.
OUTCOMES
Median ED length of stay was 174 minutes in the POC group and 180 minutes in the central laboratory group resulting in a difference of 6 minutes, which was not clinically meaningful. There were no significant differences between groups in 30-day outcomes including acute myocardial infarction or death. These findings suggest that implementing a POC troponin protocol did not substantially reduce ED LOS or alter clinical safety outcomes compared to traditional laboratory testing.
ANALYSIS
The WESTCOR trial provides insight into whether adopting POC high-sensitivity troponin testing improves operational metrics in modern ACS evaluation. In this study, POC testing did not meaningfully reduce ED LOS or alter clinical outcomes. This suggests that other components of patient care such as workflow, reassessment timing, consultations, and disposition processes likely constitute more significant contributors to ED inefficiency than assay turnaround time alone.
About the EBM Review Series
This is a literature review series started by the University of Virginia’s Josh Easter, MD, MSc, a VACEP board member working to connect the academic community in Virginia. We invite each residency in Virginia (and D.C.) to create a faculty/resident team to submit and review articles. Sign up to submit one.
Goals
Provide a brief monthly synopsis of a high yield article germane to the practice of emergency medicine for distribution to all VACEP members
Provide an opportunity for a peer reviewed publication and invited presentation for faculty and trainees
Foster an academic community focused on evidenced based medicine for emergency medicine residency programs in the region
STRENGTHS, LIMITATIONS, & IMPLICATIONS
This was a large randomized controlled trial which provides high-quality evidence and minimizes selection bias. It also utilized a protocolized ACS diagnostic pathway incorporating 0- and 1-hour troponin measurements which are consistent with current clinical practice and increasing relevance to emergency medicine.
As a single-center study, external generalizability may be limited, particularly for emergency departments with different patient volumes, staffing models, or laboratory workflows. Additionally, ED length of stay (LOS) was derived from hospital software timestamps marking when a patient physically entered the department and when they physically departed or were transferred. This definition captures the entire ED visit and may therefore include time spent waiting for room placement as well as boarding after disposition decisions. As a result, LOS may reflect broader operational factors beyond the diagnostic evaluation itself. The study also provides limited description of department workflow, including whether physician evaluation occurred in triage or only after bed placement. Notably, adherence to the accelerated diagnostic protocol was high in both groups, with approximately 87% of patients obtaining the second troponin sample within the intended 60 ± 10-minute window, suggesting that repeat sampling timing was unlikely to explain the minimal difference in LOS. In settings with prolonged waiting room times or boarding, other contributors to ED throughput such as clinician reassessment, consultations, imaging or procedural interventions, and bed availability may play a larger role in determining overall length of stay than laboratory turnaround time alone.
This randomized trial challenges the assumption that faster diagnostic assays translate to shorter ED length of stay. Although POC testing reliably produced earlier troponin values, it did not meaningfully reduce ED LOS, suggesting that troponin turnaround time is not the primary operational bottleneck in contemporary ACS pathways. Instead, downstream processes such as clinician reassessment, bed placement, consultations, and discharge logistics likely drive disposition timelines. Importantly, safety outcomes were similar at 30 days, indicating that POC testing does not pose a safety concern. The utility of POC troponin may therefore be context-dependent, with potentially greater benefit in environments where laboratory turnaround genuinely constitutes the rate-limiting step or where triage-level testing may accelerate care. Broader adoption requires consideration of workflow integration, resource utilization, and cost-effectiveness. For emergency physicians, the practical takeaway is that faster troponin results alone are insufficient to meaningfully improve ED throughput and therefore system-level redesign is needed to realize operational benefit.
PEER REVIEWER COMMENTS
Firstly, we would like to thank Dr. Dean and Dr. Wu for choice and review of such a germane article to emergency medicine. There was a great review of the clinical scenario, summary of the study, and survey of the methods. We do think it’s worth adding a mention of how the study authors defined length of stay (LOS) as they collected that data from hospital software which registered when the patient physically entered the department, when they physically left, or when they were physically transferred. This distinction would capture long wait times before being roomed as well as long boarding times before a floor bed is available indiscriminately, which we think is important to note in a study framed around the boarding crisis, especially if we are trying to generalize to a US emergency department (ED), however information regarding this was not noted in the study.
This could have been elaborated on a little more in the reviewer’s limitations. It’s unclear in the study if there were significant wait times or boarding times, or what their average wait and boarding times are. There could be a hidden outcome of decreasing time to disposition decision within the study that would be masked by the defined LOS. One other specific limitation noted in terms of generalizability was their time to an ED physician assessing the patient at 34 minutes for the point-of-care (POC) arm and 36 minutes for the control arm. The footnote for this result indicates that this does not include initial triage, but they do not define their ED workflow regarding possible presence of a physician in triage or if patients were only having physician evaluation after bed placement. If it's the latter, we know department wait times can reach several hours in the waiting room depending on overall volume, acuity, and if admission holds are present. Given their LOS started when the patient arrived, this could significantly skew data since so much of that time may be relative dead space where clinicians cannot move disposition ahead unless waiting room medicine is being practiced.
Overall, we think the reviewers did an excellent job of outlining the takeaways and implications of this paper, and hitting home that in the right context utilizing POC testing could help reduce LOS, but in general, it’s likely not the rate limiting factor in an acute coronary syndrome work up. It can be tempting to grasp at any new technologies to shave time off of our ED evaluations and help with through-put, but if it doesn’t hit on the right multi-factorial bottlenecks that cause increased ED LOS and boarding, it may just place more cost and burden on patients and our staff, and the reviewers communicated that important nuance.
AUTHOR RESPONSE
Thank you for this thoughtful and constructive feedback. The trial defined ED length of stay using electronic medical record timestamps of when the patient entered the department and when they were discharged or transferred. As noted by the reviewers, this definition of length of stay likely incorporates both waiting room time and potential boarding time in the department. They identified the median time to physician assessment was 34 minutes in the POC group and 36 minutes in the control group, however did not describe how long patients waited prior to this evaluation or how long after this evaluation they were placed in a room. They do note that this value does not include “initial triage” time, however this is not explained further. In Emergency Departments where provider in triage models exist, this would significantly alter timestamp date such as initial point of contact with a provider. Additionally, in departments where there are long wait times and significant boarding before being transferred to an inpatient service this would likely mask any impact a faster troponin turnaround time has on ED LOS. It is worth noting that adherence to their 0/1 hour pathway was high in both the POC and control groups, with about 87% of patients in each group having their second troponin sample drawn within the intended 60 +/- 10 minute window. This does suggest that ability to obtain samples did not impact LOS significantly at this particular hospital system and other operational factors such as bed availability and boarding play a larger role in overall throughput.
