Improving Care Processes for Patients with Possible Acute Coronary Syndrome (ICARE-ACS)

Patients with potential ACS Non-ACS 80% 2 4 6 ED 8 Ward Because the treatmentof STEMI is time critical most countries run public awareness campaigns encouraging patients with symptoms suggestive of a heart attack (such as chest pain) to immediately attend hospital. As a result of this in most studies the proportion of patients presenting to hospital with symptoms such as chest pain that have an acute coronary syndrome is usually less than 20% and sometimes less than 10%. Historically patients had serial testing for cardiac troponin over a period of 6 to 12 hours or more and because of this patients generally were admitted to some form of water observation. The light bulbs in this slide represent decisions to admit or discharge. 10 12+ Time MT 22.09.14

Patients with potential ACS Non-ACS 80% 2 Low Risk 35% 4 6 ED Intermediate Risk 25% 8 Ward Since most patients do not have an acute coronary syndrome it will be useful if it were possible to identify as many as possible of those patients so that they can be investigated through a more expedited process thus avoiding hospital admission and shortening length of stay. Processes to do this should also provide greater consistency in risk assessment leading to a reduction or elimination of cases of patients that do have an acute coronary syndrome that are discharged early. 10 Highest Risk 20% 12+ Time MT 22.09.14

ADP = Accelerated decision-making pathways ADAPT (modified TIMI score) EDACS (Emergency Department Assessment of Chest-pain Score) HEART Modified HEART (HAR) European society of cardiology Vancouver Manchester score tMACS ALL BRING FORWARD TIMEPOINT OF 2ND TROPONIN SAMPLE FOR LOW-RISK PATIENTS TO 1,2,OR 3 HRS A number of accelerated decision-making pathways have been developed in order to expedite decision-making for lower risk patients

And Christchurch New Zealand, since 2007 we have undertaken a series of studies moving from observational to 2 randomised controlled trials to demonstrate the effectiveness of clinical pathways for patients with suspected heart attack and which incorporate some form of accelerated diagnostic protocol Phases of ICARE-ACS related to specific studies that formed the evidence base for the project

NZ chest pain pathway implementation: A clear clinical pathway documentation process a structured and reproducible process of ACS risk stratification (e.g. clinical score) guidance for consistency of sampling time-points for performing cTn and ECG testing (e.g. on arrival and after a further specified timepoint(s). guidance about how to combine clinical risk stratification, and ECG and troponin testing with a structure on how to guide patient management (admission, discharge and further investigations) guidance and timeframes for performing follow-up testing; e.g. stress testing guidance for selection of patients for telemetry and removal from telemetry clear discharge planning, which includes patient education and lifestyle modification advice (where appropriate). A robust quality assurance program Following the success of the RCT is in Christchurch and implementation of their findings the New Zealand Ministry of health created with the assistance of clinician stakeholders and clinical guidance framework for the assessment of patients with possible heart attack and mandated implementation nationwide

CSANZ - 2016 2.4.1 Use of clinical assessment pathways Recommendation: A patient presenting with acute chest pain or other symptoms suggestive of an ACS should receive care guided by an evidence-based Suspected ACS Assessment Protocol that includes formal risk stratification. (NHMRC Level of Evidence (LOE): IA; GRADE strength of recommendation: Strong). The use of such pathways is in keeping with the latest version of the cardiac Society of Australia and New Zealand guidelines 2016

Knowledge translation of the best research evidence into practice is a difficult process and their is a lot of research evidence demonstrating gradual loss of effectiveness of interventions a bit like losing water pressure from a leaking pipe

HYPOTHESIS That the introduction of clinical pathways for possible heart attack incorporating an Accelerated Diagnostic Pathway (ADP) will…. increase the proportion of patients safely discharged home within 6 hours of presentation to ED.

INCLUSION Adults (≥18 years of age) Serial troponin testing for possible ACS as indicated by a cardiac troponin test performed during initial assessment in the ED with a 2nd test performed within 24 hours of attendance. Data extraction scripts prospectively written into local laboratory information systems

SETTING 7 NZ HOSPITALS Deliberately, different sizes, demographics, troponin assays

Stepped wedge study design: A 6-month control period for each site followed by an intervention phase comprising a 4-month implementation phase and ADP continuance phase. Study End is at the completion of the final implementation phase and follow-up data is collected on the final patients for 30-days

Plan Do Study Act (PDSA) Cycle as followed We deliberately used the well-established PDSA cycle developed by the Institute of health improvement to study and learn from the implementation process between hospitals Plan Do Study Act (PDSA) Cycle as followed

A key feature of the implementation process was the use of Kotters "eight steps for change", change management process. Extensive effort was made to ensure that all possible key stakeholders were actively engaged in the process. Details of ICARE-ACS pilot and national implementation stakeholder involvement

% Maori in catchment population Troponin assay Site (Hospital) DHB ED presentations p.a. % Maori in catchment population Troponin assay Wellington Capital and Coast 53,000 13% hsTnT (Roche) Middlemore Counties Manukau 101,293 15% hsTnI (Abbott) Rotorua Hutt 44,470 14% Waikato 65,223 22% Wairarapa 15,000 North Shore Waitemata 66,194 8% TnI (Siemens) Waitakare 44,198 17% Here are the demographics of the participating sites Study sites

Risk process stratification   Risk scores Hospital TroponinAssay Timing for low risk Thresholds (ng/L) ECG to exit pathway Clinical Decision Aid score Low Intermediate High Wairarapa Hs-cTnT 0h & 2h ≥14 Ischemic changes not known to be old EDACS <16 ≥16 North Shore TnI 0 & 2h§ ≥40 Ischemic change on ECG mTIMI* 1-3 ≥4 Waitakere Middlemore Hs-cTnI 0 & 3h ≥26 Dynamic ST changes Only Low risk go down the pathway Waikato ≥16 & mTIMI<4 ≥16 & mTIMI≥4 Wellington Hutt Risk process stratification

RESULTS Data collected on 31,332 patients 11,529 patients pre-implementation 19,803 patients post-implementation

Pre Post n 11,529 19,807 Female (%) 46.5 45.6 Maori (%) 10.4 10.5 MACE in 30d (%) 13.6 12.9 One key concern was that the introduction of a pathway would result in increasing numbers of ever lower risk patients being entered into the pathway. If that happened there would be a noticeable decrease in prevalence of major adverse cardiac event in the post implementation group. Fortunately this did not happen

Time difference between the first two troponin measures. The time gap between sampling for troponin tests decreased Time difference between the first two troponin measures.

Forest Plot of the Odds Ratio for each hospital. Overall odds ratio = 2.3 (2.2-2.6); p<0.0001 The primary outcome was the change in odds of discharge within six hours. There was a significant change collectively and across all but one site. Forest Plot of the Odds Ratio for each hospital. An OR>1 indicates increased odds of being discharged within 6 hours.

Length of hospital stay for non-ACS patients This and the following graft demonstrate the reduction in length of stay Length of hospital stay for non-ACS patients

Non-ACS patients Median reduction length of stay = 2.9 h (2.4-3.4)

SAFETY Sensitivity Negative predictive value PRE POST 99.7 (99.3-99.9) 99.4 (99.0-99.7) Negative predictive value 99.5 (98.8-99.8) 99.6 (99.3-99.7) P=0.28 There was no change in diagnostic safety.

NO PATIENT MANAGED ACCORDING TO PATHWAY HAD MACE For example, in several cases mace events all occurred in patients who were discharged despite having initial troponin results above the 99th percentile

CONCLUSION ACS assessment pathways are EFFECTIVE and SAFE in real life practice Careful attention to and tenacity with change management is crucial