Identifying patient risk: The basis for rational discharge planning after acute myocardial infarction

Abstract

Variations in the management of patients with chest pain and acute myocardial infarction (MI) can significantly affect hospital length of stay and cost. Risk stratification of such patients, combined with data about effective therapies, provides the basis for developing rational guidelines for patient care that can improve efficiency while maintaining quality of care. Such standardized management approaches are often referred to as pathways or CareMaps. To be most effective in guiding hospital course and early discharge planning, risk stratification strategies must be applied early in a patient's course with continuous updating. The process of identifying risk in a patient with acute chest pain occurs in two segments: assessing the risk of acute MI at presentation, and subsequently assessing the morbidity and mortality risk of patients diagnosed with acute MI. Identification of patient risk at presentation has been the subject of intense investigation. The history, physical exam, initial electrocardiogram, and cardiac enzymes are the mainstays of the process, but because of inherent weaknesses in this approach (~25% of acute MIs missed at the initial screening), several risk stratification models have been developed. To date these models have not been widely employed, however. Very sensitive early cardiac markers, such as troponin T, and the use of diagnostic echocardiography or cardiolite perfusion imaging during pain are also being investigated. Chest pain observation units are an alternate strategy and have obviated the need to admit many low-to moderate-risk chest pain patients. In these protocol-driven units, continuous physiologic monitoring and serial cardiac enzymes and electrocardiography over a 9-12 hour period refine the risk assessment. For the majority who "rule out," the risk of subsequent MI or death is very low. Cost savings due to reduced length of stay and more efficient resource utilization are 63-76% compared with conventional ward or cardiac care unit management. For patients with acute MI, baseline characteristics, complications, and laboratory and diagnostic testing help define the risk of morbidity and mortality and guide management through the immediate post-MI phase and long term. Many models incorporating these features have been proposed for risk stratification after acute MI, and they have implications for both timing of discharge and necessary diagnostic testing. Savings by employing risk stratification to guide hospital course and discharge planning could be 30-44% in some patient groups. In conclusion, risk stratification models can facilitate early discharge planning, potentially reducing hospital stay, improving resource utilization, and reducing costs.Key Words. risk stratification, discharge planning, care pathway, chest pain unit Changes in the health care industry are prompting re-evaluation of the management of patients with coronary artery disease and clear or potential acute coronary syndromes. As the effort to control costs becomes increasingly important, reduction in hos...

Early Clinical Outcomes and Routine Management of Patients With Non–ST-Segment Elevation Myocardial Infarction

“…Early recognition of symptoms, prompt transport to a medical facility, and rapid diagnosis and treatment are the goals set forth by the National Heart Attack Alert Program, [14][15][16][17][18][19][20] the American Heart Association, and the American College of Cardiology. 21 Information derived from randomized clinical trials, national registries, and multicenter databases has been formulated to develop clinical scales that reliably identify patients at high 22,23 and low [24][25][26] risk for adverse outcomes. Risk scales and clinical event severity scores serve as the basis for management pathways, with the ultimate goal of providing optimal patient care.…”

“…The prospective data collection design does, however, permit a detailed overview of current hospital-based clinical practice. Although the criteria chosen to divide patients into major, intermediate, and minor severity clinical event categories represented investigator consensus, previously published risk assessment tools, severity scores, and guidelines 11,21,23,26,27 were used to develop the classification scheme.…”

A new simplified immediate prognostic risk score for patients with acute myocardial infarction

“…[1][2][3][4] Several simplified methods have been developed for risk stratification in this population, [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] and these have been perceived as valuable. [22][23][24][25] These methods generally use algorithms of varying degrees of complexity to summarise a patient's level of risk for mortality into a single numerical value based on multiple characteristics ostensibly obtainable at hospital presentation.…”