In fact, across the country, there are approximately six million ED visits for chest pain each year—the highest volume of ED visits across CV conditions. When chest pain patients present in the ED, they are often admitted given the potential for adverse events. Inpatient short stays may be unnecessary and even vulnerable to payment scrutiny. These short inpatient stays are typically for lower-risk patients who can be managed more appropriately in observation or discharged home with outpatient clinic follow-up.
Not surprisingly, numerous protocols exist for ruling out a STEMI (ST-elevation myocardial infarction) or ACS (acute coronary syndrome)—two of the most significant adverse events associated with chest pain. However, the existing protocols often fail to account for low-risk chest pain patients who may be candidates for direct discharge without a stress test.
Triaging low-risk chest pain patients
As part of the 2015-16 National Meeting series, the Cardiovascular Roundtable shared a new protocol— called the HEART Score—in the presentation, Perfecting CV Short-Stay Patient Management, including clinical literature and a case study of how a program effectively used this tool. The HEART Score helps ED physicians identify low-risk chest pain patients who may be appropriate for early discharge. The pathway works by assigning each patient a score based on five factors (e.g., History, ECG). If a patient is deemed to be low-risk based on the score, the patient does not receive a stress test. Instead, the patient is discharged after repeat negative serial troponins at zero and three hours.
In a randomized clinical trial published in Circulation in 2015, utilization of the HEART score in the ED led to significant improvements compared with usual care based on the ACC/AHA guidelines. The HEART score decreased length of stay by 12 hours, reduced cardiac testing by 12%, and increased early discharge by 21%. Notably, none of the patients who were discharged early experienced an adverse cardiac event within 30 days.
MemorialCare finds success with the HEART score
CV leaders from MemorialCare, a five-hospital nonprofit system in Southern California, learned of the HEART score while attending the Cardiovascular Roundtable National Meeting in January 2016. At the time, they were searching for a new strategy to facilitate more cost-effective and standardized ED management of chest pain patients. After the conference, MemorialCare's CV leaders reviewed the profile in further depth and reviewed the HEART score clinical literature referenced in the presentation. They then contacted colleagues across the country who were already using the HEART score, and adapted the pathway to the local patient population and medical community before successfully implementing the pathway in May 2016 at their Los Angeles County hospital, Long Beach Medical Center.
MemorialCare's CV leaders shared some advice to others who want to implement the HEART score or other similar care pathways:
- Use data-driven results to gain provider support. Given the risk of adverse events associated with chest pain, ED physicians often are not initially comfortable with discharging low-risk patients. MemorialCare CV and ED leaders presented results from HEART score trials performed in Europe and the United States to demonstrate the positive impacts of the HEART score and minimal risk for adverse events of patients with low-risk scores who were discharged home. Following implementation, the ED physicians appreciated having a feedback loop to receive the data and outcomes associated with using the HEART score at Long Beach Medical Center.
- Develop a unified strategy to disseminate information. Using a new CV protocol in the ED impacts both the Emergency Medicine and CV service lines. As such, CV and ED leaders were jointly involved in the decision and worked with all providers involved. They each used standing physician meetings to educate ED physicians and cardiologists on the new protocol and the impacts on patient care delivery.
- Leverage members of the broader care team to support implementation. Since ED physicians aren't only managing CV patients, it can be difficult to remember to follow new protocols for a particular patient population. MemorialCare supported widespread utilization of the HEART score by educating ED scribes on how and when to use the protocol, who would in turn help remind ED physicians of the opportunity to use the protocol for chest pain patients.
Protocol reduces care variation and unnecessary resource utilization
Within six months of implementation, MemorialCare was able to demonstrate impressive results by using the HEART score. They reduced the 30-day ED return rate by 70% and performed fewer stress tests and cardiac consults. The HEART score also improved collaboration between CV and ED leadership at Long Beach Medical Center. Due to the success of the protocol, hospitals across the MemorialCare network now implement the HEART score.
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Learn more: How MemorialCare improved the outcomes of their chest pain patients
Read our new case study to learn more about MemorialCare and the HEART score, and how they improved the outcomes of their chest pain patients in the ED.