ICare-FASTER (Improving Care by Faster Risk Stratification Through Use of High-Sensitivity Point-of-Care Troponin in Patients Presenting With Possible Acute Coronary Syndrome in the Emergency Department): A Stepped-Wedge Cluster-Randomized Trial

Summary

ICare-FASTER was a pragmatic stepped-wedge cluster-randomized trial across 6 New Zealand EDs with 59,980 presentations from 44,747 individuals. Using the same accelerated diagnostic pathway, whole-blood point-of-care hs-cTnI reduced adjusted ED length of stay by 13% (95% CI 9%-16%), an absolute 47 minutes (95% CI 33-61) from a control mean of 376 minutes, compared with central-laboratory hs-cTn. Thirty-day myocardial infarction or cardiac death was 0.39% in both groups (P=0.54).

Why it matters

For EDs already using an accelerated troponin pathway, a validated point-of-care hs-cTn assay can materially improve throughput by eliminating laboratory turnaround delay. The result supports an operational change rather than a new diagnostic threshold.

Main findings

• Adjusted ED length of stay was reduced by 13% (95% CI 9%-16%; P<0.001).
• The absolute reduction was 47 minutes (95% CI 33-61) from a control mean of 376 minutes.
• Thirty-day myocardial infarction or cardiac death occurred in 0.39% of presentations in both groups (P=0.54).
• The study included 59,980 ED presentations from 44,747 individuals; 31,392 presentations occurred during the intervention phase.

Limitations

This was a stepped-wedge implementation trial at six New Zealand sites, so the effect depends on the specific assay, pathway, staffing, and laboratory workflow. The identical observed 30-day event rates are reassuring but should not be interpreted as a formal proof of safety equivalence.