Quality Improvement Program: Chest Pain Outpatient Testing Initial Concept and Strong Support from Daniel Himelic, MD Facility Medical Director St. Elizabeth’s Hospital

Chest Pain Workup Background Outpatient Chest Pain Program Documentation Patient Education

Chest Pain Historical Data Most chest pain is not cardiac in nature ( 75-85%) No good screening rule (e.g. PERC) for non-testing High risk, high litigation cohort

Nidus of Reflexive Admission Pope study in 2002 11,000 ED chest pain pt’s 48h follow up 8% MI and 9% unstable angina overall. 2% of MIs missed which was 0.18% of population Study Problems CKMB, not Troponin Listed as failure to diagnose leading to aggressive admission and observation

FHS Internal Data on CP Avg 168 (5.6pt) admits per day with stress tests Avg LOS 1.78 d Possible 9.97 beds per day in system No current system to coordinate outpatient stress test/follow up July 2014-March 2015

HEART Score Clinically based risk stratification rule Designed for ED patient population unlike TIMI Prospectively validated in multiple studies Recognized by TeamHealth Patient Safety Organization as a useful screening tool

Prospective Validation: Backus (2013) 2440 patients with chest pain Ten EDs in the Netherlands Evaluated for MACE within 6 weeks MACE included AMI, PCI, CABG, death HEART score used as compared to GRACE and TIMI with 6 week follow up

Prospective Validation: Results Low HEART Scores (0-3) 36.4% of patients 1.7% MACE Moderate HEART Scores (4-6) 16.6% MACE High HEART Scores (>7) 50.1% MACE

Prospective Validation: Risk Factors Reviewed Percentage of patients in each element of the HEART Score by whether they had MACE or not Points 1 2 MACE No Yes History 45.5 8.6 31.1 27.0 23.3 64.4 EKG 66.8 36.1 19.2 21.1 14.0 42.8 Age 19.0 3.7 43.5 42.0 37.5 54.3 RF 11.2 4.9 36.8 28.5 52.0 66.6 Troponin 92.1 53.6 4.5 13.5 3.4 32.9

US Retrospective Validation: Mahler 2011 Tertiary Residency Training Program (Wake Forest) CDU Patient population 1070 patients Results Low HEART scores (0-3) had 0.6% MACE High HEART Scres (>3) had 4.2% MACE OR of 7.92 Limitations = Pre-selected population of CDU patients, not all ED

Outpatient Chest Pain Program (One Sample Option)

Risk Stratification Program HEART score to identify low risk <3 gets outpatient evaluation >3 traditional admission or treatment Critical Elements Labs – Drawn in ED prior to discharge Outpatient Stress and Appointment Arranged via SJMC HUC log book

ED Labs Drawn and send DO NOT Hemaglobin A1C LAB102 Direct and LDL Cholesterol LAB90 DO NOT Worry about fasting Wait for results

Select Stress Test Need Stress test and MUST BE WITHIN 72 HOURS Medical Follow up for risk stratification

Documentation

Dot Phrase See attached documents for samples to create your own dot phrases / system algorithms for: Heart Score Inclusion Chest Pain Follow up Documentation Includes the guidelines and shared decision making conversation

Quality Follow Up CQIP will review all admissions and discharges with a diagnosis of chest pain looking at: Heart Score Disposition Results of studies Provide feedback on aggregate data on utilization and results Sentinel events or issues should be sent to Nathan Schlicher at Nathan_Schlicher@teamhealth.com for dissemination to the larger group

Education

Patient Education Sample forms for the following are included Patient Instruction sheet for stress test Patient Instruction sheet on where to go Patient Handout Physician Instructions on arranging program Additional examples can be provided upon request

References 1.Meyer MC, Mooney RP, Sekera AK. A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing.Ann Emerg Med. 2006;47(5):435.e1-3. 2. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac i schemia in the emergency department. N. Engl. J. Med. 2000;342(16):1163-1170. 3. Scheuermeyer FX, Innes G, Grafstein E, et al. Safety and Efficiency of a Chest Pain Diagnostic Algorithm With Selective Outpatient Stress Testing for Emergency Department Patients With Potential Ischemic Chest Pain. Annals of Emergency Medicine. 2012. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22221842. 4. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC. Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines. JAMA: The Journal of the American Medical Association. 2009;301(8):831 -841. 5. Hess, et al. The Chest Pain Chose Decision Aid: A Randomized Trial. Circ Cardiovasc Qual Outcomes. 2012:5: 251-259 6. Backus, et. al., A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology 168 (2013) 2153-2158