1. CRITICAL/CLINICAL PATHWAYS ACUTE CORONARY SYNDROMES
National Heart Attack
Alert Program (NHAAP)
CRITICAL/CLINICAL PATHWAYS
FOR THE TREATMENT OF
PATIENTS WITH
ACUTE CORONARY SYNDROMES
I am very pleased to present an overview of the National Heart Attack Alert Program (NHAAP) and to highlight some of its history, educational recommendations, achievements, and future directions. (The speaker may wish to add a personal comment concerning his or her involvement with the program.)

2. Critical Pathways Standardized protocols for care Strict definition
Full list of all tasks, tracks variances
Broader definition
Includes clinical protocols (NHAAP 4D’s)
Diagnostic pathways - Chest Pain Centers
Treatment pathways - Thrombolysis

3. TABLE 1: Goals of Critical Pathways
Increase use of recommended medical therapies (e.g., aspirin)
Decrease use of unnecessary tests.
Decrease hospital length of stay
Increase participation in clinical research
Improve patient care and decrease costs.

4. Need ad Rationale for Critical Pathways
Underutilization of recommended medications (e.g. Aspirin)
Overutilization of procedures
Length of stay, # ICU days
Quality of care measures (door-to-drug, door-to-balloon times)

5. TABLE 2: Steps In The Development And Implementation Of Critical Pathways
Identify problems ( practice variation)
Identify working committee/task force to develop path
Distribute draft Critical Pathway to all personnel and departments involved. Revise based on approach.
Implement pathway
Collect and monitor data on pathway performance.
Modify the pathway as needed to further improve performance.

6. Methods of Implementation of Pathways
Specific case manager for each Pt
High compliance, high cost
Standardized order sheets, Pocket guides
“Championing” - Grand rounds
Recent study -> similar improvements in care with either formal or simpler pathways (Holmboe, ES et al. Am J Med 1999;107: )

7. Goal: < 30 Minutes
NHAAP
Ann Emerg Med
1994;23:

8. W. Rogers, personal communication

9. Door-to-Needle Time vs. Mortality
NRMI-2: Thrombolysis
Door-to-Needle Time vs. Mortality
P=0.0001
P=0.01
P=NS
1.23
1.11
1.03
N=28, , , ,316
Cannon CP ACC 2000

10. BWH ED Checklist Orders for ACS
ST  MI-Angioplasty ST  MI- Thrombolysis
1 2
Clinical Acute MI Acute MI
EKG ST elevation/New LBBB ST elevation/New LBBB
Goals Call Cath lab <20 min Door to Needle <30 min
Leave ED <30 min (Actual_ _ _)
Door to Balloon <90 min
(Actual_ _ _)
Tests CBC, CMP, PT/PTT CBC, CMP, PT/PTT
CK-MB CPK/MB
Lipid profile Lipid profile
Medications
ASA 325mg chew ASA 325mg chew
Heparin IV r-PA 10U & 10U in 30 min
IV dose: 60U/kg bolus, 12U/kg/hr infusion
Metoprolol IV Heparin IV
Clopidogrel 300 mg PO Metoprolol IV/PO
NTG PRN NTG PRN

11. Univ. Cincinnati “Heart ER”
Symptoms suspicious for ACS
ECG changes of AMI or UA
Nondiagnostic ECG
Treat and Admit
Consider rest nuclear imaging in patients able to be injected during pain
Positive
Negative
6-hour CPC evaluation
Serial cardiac markers 0, 3, 6 hours
ST-segment trend monitoring
Discharge with followup
Negative
ECG exercise stress test
Discharge

12. NHAAP Web site - Critical Pathways
NHAAP review paper
Annotated literature review with figures
Example critical pathways
Downloadable slides
Possible links to other sites

13. Conclusions
Critical pathways hold great promise to improve the quality of care, clinical outcomes and the cost-effectiveness
Several levels of complexity
Primary focus should be on improving the quality of care
Further research is needed to better define the true worth of these tools.
NHAAP web page examples of specific pathways, to facilitate the use

14. What To Do If You Think You Are Having a Heart Attack:
Patient Advisory Form
What To Do If You Think You Are Having a Heart Attack:
Recognize how you may feel
– List of symptoms
Take medication as instructed
– Aspirin, nitroglycerin
Act if symptoms continue for more than 15 minutes
Call EMS phone number wherever you are
Go to the location of the nearest full-service ED
Patients must be clear about the actions they should take if AMI symptoms occur, including taking nitroglycerin (if prescribed), taking aspirin, and calling EMS.
The working group has developed a Patient Advisory Form for health care providers to give their high-risk patients and their families or significant others. Patients should be encouraged to put it in a prominent place, especially near the telephone.
The form reviews the most common symptoms of AMI, medication instructions regarding aspirin and nitroglycerin, and what to do if symptoms persist, and it has places to write in critical phone numbers.
As part of the instructions given to all high-risk patients, it is important to emphasize that patients should call EMS, via or a seven-digit emergency telephone number, rather than their own physician if symptoms suggestive of AMI persist beyond 15 minutes.
Arrival at the emergency department in a private vehicle can delay the process of triage and assessment of trauma patients and can ultimately increase the delay between symptom onset and initiation of treatment. In contrast, when patients can have ECGs done in transit and give histories to EMS personnel, time to treatment is decreased.
Dracup K,et al. Ann Intern Med 1997;126:

15. National Heart Attack Alert Program (NHAAP) Recommendations: Summary
Use standardized MI and ACS protocols
Door-to-Drug time < 30 mins, door-to-balloon mins
ED/Chest Pain Centers appear effective
Evaluate and Integrate new technologies in pathways
Use CQI: Analyze processes of care to eliminate delays and refine protocols
Community Planning to establish “Chain of Survival” for cardiac arrest/AMI; Expand use of 9-1-1
Educate “high-risk” patients on timely presentation
NHAAP: Phone:

16. NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality
P=NS
P=NS
P=0.01
P=0.0007
P=0.0003
1.62
1.61
1.41
1.14
1.15
N=2, , , , , ,412
Cannon CP, et al Circulation 1999;100:I-360.