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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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

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

12. 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

13. 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

14. 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

15. % 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

16. 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

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

18. 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

19. 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.

20. Forest Plot of the Odds Ratio for each hospital.
Overall odds ratio = 2.3 ( ); 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.

21. 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

22. Non-ACS patients
Median reduction length of stay =
2.9 h ( )

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

24. 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

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