ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome)

Abstract

Background: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. Methods: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation Results: There were 11 529 participants in the preimplementation phase (range, 284–3465) and 19 803 in the postimplementation phase (range, 395–5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%–37.7%) to 18.4% (6.8%–43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3–2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4–3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P =0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. Conclusions: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. Clinical Trial Registration: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.

Myocardial Infarction Can Be Safely Excluded by High‐sensitivity Troponin I Testing 3 Hours After Emergency Department Presentation

“…Many studies have been published using an accelerated diagnostic protocol strategy in the management of ED suspected ACS patients. [20][21][22][23] These generally use risks scores (e.g., EDACS, HEART), ECG, and serial troponin obtained at baseline and 1, 2, or 3 hours. What is clear is that, as the sensitivity of the clinically available assays have improved, so have safe ED discharge rates as evaluated by 30-day outcomes.…”

Relationship between the frequency of nursing activities and adverse outcomes in patients with acute coronary syndrome: A retrospective cohort study

“…Previous studies also reported that hypoalbuminemia (<3.5 g/dL) and a low baseline hemoglobin level were independent predictors of long‐term outcomes for patients with myocardial infarction after PCI (Akirov et al, ; Hosseini et al, ; Wada et al, ). Most patients with ACS after PCI were hospitalized for no more than 3 days, as the critical process for ACS management was applied to them in general (Than et al, ). Our findings showed that discharging patients with ACS within 1–3 days was related to a low incidence of MACE.…”

“…Our findings showed that discharging patients with ACS within 1–3 days was related to a low incidence of MACE. Although LOS must be carefully balanced with healthcare quality, it is a critical index of healthcare efficiency regarding inpatient guideline adherence for patients with ACS (Swaminathan et al, ; Than et al, ; Tickoo et al, ). Despite these findings, our results obtained through multi‐variate Cox regression analysis demonstrated that the frequency of nursing activities was the strongest factor affecting the incidence of MACE in patients with ACS.…”

“…If the frequency of nursing activities during hospitalization is a significant factor related to health outcomes, it is possible to use it to accurately identify patients who need intensive post‐discharge management education and to provide appropriate education for such patients through an analysis of nursing activities during their hospitalization. Although several studies have analyzed the relationship between the length of hospital stay or the severity of patients with ACS and the incidence of MACE (Swaminathan et al, ; Than et al, ; Tickoo et al, ), to our knowledge, no studies have examined the association between the frequency of nursing activities during hospitalization and the incidence of MACE.…”

Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review

“…OR-based studies addressing long LOS are evidenced in Chan et al [91], Derni et al [87], Liu et al [95], and Oueida et al [86,96]. Apart from the aforementioned single techniques, less popular methods like critical pathways [88,89,97], pivot nursing [92], and process redesign [94] were also used by some practitioners and researchers to diminish the total burden produced by long ED-LOS. Table 3 presents all the papers aiming at shortening the door-to-physician time in EDs.…”