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Implementation of a Clinical Pathway for Chest Pain in a Pediatric Emergency Department.

ABSTRACT: OBJECTIVE:To evaluate the impact of a pediatric emergency department (ED) chest pain clinical pathway on resource utilization. METHODS:Motivated by perceived overuse of cardiology consultation for non-cardiac chest pain in the ED, clinicians from the Divisions of Cardiology and Emergency Medicine collaboratively developed a chest pain clinical pathway, educated staff, and implemented the pathway on March 1, 2014. We reviewed records of children aged 3 to 18 years without prior diagnoses of heart disease who presented to the ED with chest pain between March 1, 2013, and April 22, 2015. We compared diagnostic testing rates, ED length of stay, and cardiology consults before and after implementation of the pathway. RESULTS:A total of 1687 patients were pathway eligible (675 patients preimplementation and 1012 postimplementation). Resource utilization was lower than expected before pathway implementation and remained low after implementation. There was a statistically significant reduction in rates of chest x-ray ordering after pathway implementation and ED length of stay but no change in other diagnostic testing or cardiology consultation. Follow-up in our health care system for pediatric chest pain increased from 15% to 29% with implementation, but none of these visits resulted in the diagnosis of a new cardiac condition. There were no instances identified where use of the pathway resulted in missed cardiac disease. CONCLUSIONS:Implementation of a clinical pathway for pediatric chest pain did lead to a reduction in chest x-ray ordering in the ED and was associated with a higher rate of outpatient follow up for non-pathologic chest pain. Preimplementation utilization was lower than the prepathway perceptions of overuse suggested.

SUBMITTER: Mohan S

PROVIDER: S-EPMC5359077 | biostudies-literature | 2018 Nov

REPOSITORIES: biostudies-literature

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Implementation of a Clinical Pathway for Chest Pain in a Pediatric Emergency Department.

Mohan Shaun S Nandi Deipanjan D Stephens Paul P MʼFarrej Mirna M Vogel R Lee RL Bonafide Christopher P CP

Pediatric emergency care 20181101 11

<h4>Objective</h4>To evaluate the impact of a pediatric emergency department (ED) chest pain clinical pathway on resource utilization.<h4>Methods</h4>Motivated by perceived overuse of cardiology consultation for non-cardiac chest pain in the ED, clinicians from the Divisions of Cardiology and Emergency Medicine collaboratively developed a chest pain clinical pathway, educated staff, and implemented the pathway on March 1, 2014. We reviewed records of children aged 3 to 18 years without prior dia ...[more]

PMID: 27649041

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Project description:ImportanceNoninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain.ObjectiveTo determine whether cardiovascular testing-noninvasive imaging or coronary angiography-is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia.Design, setting, and participantsThis retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia.ExposuresNoninvasive testing or coronary angiography within 2 days or 30 days of presentation.Main outcomes and measuresThe primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography.ResultsThe patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.Conclusions and relevanceCardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.

Project description:Introduction/backgroundAdults with chest pain presenting to an emergency department are high-risk and high-volume. A methodology which gathers practicing physicians together to review evidence and share practice experience to formulate a written algorithm with key decision points and measures is discussed with implementation, based on change management principles, and results.MethodsA methodology was followed to "establish the standard-of-care". Literature and data were reviewed, a written consensus algorithm was designed with ability to track adherence and deviations. We performed a before and after analysis of a performance improvement intervention in adult patients with undifferentiated chest pain in our nine-campus hospital system in Florida between January 1st, 2014 and December 31st, 2018.ResultsA total of 200,691 patients were identified as adults with chest pain and the algorithm was used. A dramatic change in the disposition decision rate was noted. When the 'Baseline-Year' was compared with the 'Performance-Year', chest pain patients discharged from the ED increased by 99%, those going to the 'Observation' status decreased by 20%, and inpatient admissions decreased by 63% (p?<?0.0001) All patients were tracked for 30-days for major adverse cardiac event (MACE) or return to the ED within the same system. If the s emergency physicians had not changed their practice/behavior and the Baseline-Year decision rate during the entire Performance-Year was unchanged, then 4563 more patients would have gone to Observation and 7986 patients to Inpatient. The opportunity costs avoided would be approximately $31million (US$.ConclusionsFor successful clinical transformation through change management, we learned: select strategic topics, get active physicians together, write a consensus algorithm with freedom to deviate, identify and remove barriers, communicate vision, pilot with feedback, implement, sustain by "hard wiring" into the electronic medical record and measure outputs.

Project description:BACKGROUND:The HEART Pathway (history, ECG, age, risk factors, and initial troponin) is an accelerated diagnostic protocol designed to identify low-risk emergency department patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30-day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30-day hospitalizations) in emergency department patients with possible acute coronary syndrome. METHODS:A prospective pre-post study was conducted at 3 US sites among 8474 adult emergency department patients with possible acute coronary syndrome. Patients included were ?21 years old, investigated for possible acute coronary syndrome, and had no evidence of ST-segment-elevation myocardial infarction on ECG. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013 to January 2016. The HEART Pathway accelerated diagnostic protocol was integrated into the electronic health record at each site as an interactive clinical decision support tool. After accelerated diagnostic protocol integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or non-low risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death, and myocardial infarction (MI) and hospitalization rates at 30 days were determined from health records, insurance claims, and death index data. RESULTS:Preimplementation and postimplementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the postimplementation versus preimplementation cohort (55.6% versus 61.6%; adjusted odds ratio, 0.79; 95% CI, 0.71-0.87). During the index visit, more MIs were detected in the postimplementation cohort (6.6% versus 5.7%; adjusted odds ratio, 1.36; 95% CI, 1.12-1.65). Rates of death or MI during follow-up were similar (1.1% versus 1.3%; adjusted odds ratio, 0.88; 95% CI, 0.58-1.33). CONCLUSIONS:HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients who can be safely discharged without stress testing or angiography. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov . Unique identifier: NCT02056964.

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Implementation of a Clinical Pathway for Chest Pain in a Pediatric Emergency Department.

Publications

Implementation of a Clinical Pathway for Chest Pain in a Pediatric Emergency Department.

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