Design: Pragmatic stepped-wedge cluster-randomised trial, six emergency departments
Population: 59,980 presentations with possible acute coronary syndrome
Primary outcome: Emergency department length of stay
Effect: 13% shorter (95% CI 9–16%), about 47 minutes; 30-day MI or cardiac death 0.39% vs 0.39%

ICare-FASTER was a pragmatic stepped-wedge cluster-randomised trial in six emergency departments. Each site moved from a single-sample rule-out pathway using a central laboratory high-sensitivity troponin to the same pathway using a whole-blood point-of-care high-sensitivity troponin I assay. It covered 59,980 presentations in 44,747 people between 2023 and 2025.

The point-of-care arm reduced length of stay by 13% (95% CI 9–16%), about 47 minutes from a control mean of 376 minutes. The 30-day rate of myocardial infarction or cardiac death was 0.39% in both arms.

The pathway did not change; only where the assay ran did. For crowded departments the gain is time and beds, provided the point-of-care assay is a validated high-sensitivity one and the rule-out thresholds are specific to it. Contemporary point-of-care devices that are not high-sensitivity should not be swapped into a high-sensitivity pathway.

Use only a validated high-sensitivity point-of-care troponin assay inside a single-sample rule-out pathway.
Apply the assay-specific rule-out thresholds; laboratory cut-offs do not transfer between assays.
Keep the time from symptom onset in the decision, as early presenters still need serial testing.
Audit 30-day events locally after a switch, as the trial did.

Why it matters

The bottleneck in chest pain rule-out is often the laboratory turnaround, not the pathway itself.

The statistics, in plain English

A 13% reduction with an interval of 9–16% is precise and clearly real. The safety outcome was identical, but with events this rare the trial could only exclude a large increase, not a small one.