Chest pain units work; One hospital tests the theory
St. Joseph Mercy Hospital in Ann Arbor, MI finds that its chest pain center effectively rules out AMI and is still cost effective for the facility
Managed care has upped the stakes for emergency physicians in one of the most troubling areas of potential clinical malpractice: the incorrect diagnosis of patients with acute ischemic coronary syndrome (AICS) in the ED.
According to authorities, some 20-25% of malpractice awards in emergency medicine involve the incorrect diagnosis and stabilization of patients with AICS. However, of patients with AICS seen by emergency physicians nationally, only 2-3% represent the number that was incorrectly discharged home from a hospital despite evidence of acute myocardial infarction (AMI).1,2
These same patients originally presented in the ED with palpable chest pain, according to studies. But after examination during an initial observation period of 3-5 days, they were discharged home instead of being kept at the hospital and later suffered a heart attack within 72 hours.
And, due partly to the effects of managed care, the routine admission of patients with a low-to-intermediate risk of AICS is all but disappearing. In effect, health plans are refusing to pay claims for patients who are admitted for prolonged observation and released after physicians have concluded a low probability of impending heart attack.
"Pressure on primary-care physicians (PCPs) to avoid admitting patients, combined with retrospective denial of payments for patients not found to have AICS after hospitalization, has made routine admission for patients with possible AICS difficult for emergency physicians," wrote W. Brian Gibler, MD in the Annals of Emergency Medicine recently.1 Gibler is an emergency physician at the University of Cincinnati (OH) College of Medicine.
Chest pain cases pose Achilles' heel
"Those 2-3% represent the largest dollar liability for emergency physicians of all other areas of emergency physician malpractice," observes Michael G. Mikhail, MD, an emergency physician at St. Joseph Mercy Hospital in Ann Arbor, MI.
In 1992, physicians at St. Joseph's, including Mikhail, decided to act on concerns that chest pain patients were receiving inconsistent care. Even the patients admitted for observation from their ED wer e later falling into the 2% category who suffered heart attacks within 72 hours, they feared.
At the time, there was no formal set of protocols for chest pain evaluation in the ED, he notes. Stress testing wasn't available to every observation patient, even though they were kept for more than a day.
After numerous discussions with clinicians from various departments and hospital management, a team composed of physicians from emergency medicine, cardiology, and primary care finally designated a nine-bed dedicated unit across the hall from the ED as a formal outpatient chest pain observation center.
Chest unit threatens inpatient sector
However, any effective approach to establishing an accurate, dependable, hospital-based diagnostic system is not easy. In the first place, the program needs a workable, established set of clinical protocols and guidelines that would stand up to retrospective scrutiny.
The program also has to be operated in an outpatient setting and would need the confidence and support of a diverse, often conflicting group of clinical and political interests within the hospital.
After all, any dedicated chest pain screening unit inevitably threatens a hospital's inpatient census, empties several inpatient beds, and significantly decreases the number of cardiac admissions over time.
The financial impact of an outpatient chest pain screening center could be significant in that it would result in loss of considerable inpatient, DRG-based revenue that would not be offset by an outpatient diagnostic service, Mikhail theorized.
St. Joseph Mercy physicians decided to also test whether their dedicated chest pain center could work in response to managed care without hurting a hospital financially. It also would test whether established clinical guidelines and algorithms for identifying high-risk AICS patients in the ED could achieve results by keeping certain patients alive beyond the normal 72-hour time line following discharge.
"We started out to look at different factors in the current state of evaluating patients who presented with chest pain. But we also wanted to efficiently manage them at an efficient cost," Mikhail says.
Evolution was a lengthy process
But it wasn't easy. A year-and-a-half of meetings occurred from the time the idea was conceived in 1992 before actual progress was made, Mikhail says.
"The hardest part was to keep people focused," Mikhail recalls. "The challenge was to overcome a sense of inertia and resistance to new ideas," he stated.
Although the St. Joseph Mercy Chest Pain Center is now roundly supported by the hospital, the nine-bed unit operates unlike any other inpatient or outpatient department, says nurse manager Charlene Britton, RN.
Patients are admitted for testing directly from the ED, where triage involves an initial electrocardiogram monitoring. Once in the chest pain unit, the patient can be discharged at any time once the attending physician believes it is safe to do so, Britton says.
"Inpatient departments operate on an eight-hour block of time," Mikhail notes. "But in the chest pain unit, a patient can be discharged at 2 a.m. as long as the final evaluation report is completed," he adds.
The criteria for transfer to the unit are formal and based on clinical guidelines that were adopted from the departments of cardiology and primary-care and enhanced by emergency physicians.
Patients are not admitted to the unit if initial testing shows the following:
· the prevalence of an AMI;
· a finding of creatine kinase (CK)-MB with increased total CK;
· continued chest pain suggesting ischemia;
· an unstable atrial or ventricular rhythm; and
· treatment with IV nitroglycerine or heparin.
Once accepted, the patient undergoes a series of formalized tests that conform to a set of approved clinical algorithms. (For an illustration of the algorithms, see the chart on page 43.) These tests include a standardized cardiac marker test involving four-hour myoglobin assay or six- or eight-hour CK-MB determination to rule out myocardial injury.
Unit's performance has been noteworthy
They also include continuous stress test (ST)-segment monitoring provided with an ELI-100 STM 12-lead monitor, except for patients with paced or left bundle-branch rhythms. They are monitored by means of portable telemetry. Following these tests, the algorithms address the management and disposition of patients with variable degrees of heart disease.
Since its inception, the unit's performance has been noteworthy. The ability of physicians to screen out patients with possible pending heart attacks has increased sharply, Britton says. Some 22% of patients admitted to the unit usually are safely discharged home within 23 hours.
Of the patients who are admitted to the hospital, as many as 80% are ultimately diagnosed with serious cardiac disease. Ironically, prior to the chest pain center's opening, the same proportion of inpatients were found to not have a potentially dangerous cardiac disorder.
These results were borne out in a published study last year of the center's performance.2 Here are some of the findings:
· Of 502 patients transferred to the chest pain center, 86%, or 400, were discharged home. Those discharged after diagnostic evaluation yielded negative findings had a 100% survival rate and a zero diagnosis of AMI after a five-month follow-up.
· The mortality rate and incidence of AMI for patients tested at the center during a long-term follow-up was 0.4% and 0.2%, respectively, according to the study.
· Thirteen percent were admitted to the chest pain unit, and 66% of those had a final diagnosis of ischemic heart disease (IHD).
· The cost of mandatory stress testing to identify one patient with IHD after AMI was ruled out was $3,125. The amount represented a cost savings of 62% for each patient transferred to the unit compared with a similar hospital admission.
Plans won't pay observation fees
Furthermore, the unit ended its first year with a $250,000 surplus after financial forecasts projected a first-year loss of more than $2 million. The surplus was achieved partly by a 25% increase in chest pain patients entering the ED, Mikhail says.
Yet despite these results, Mikhail has had trouble impressing health plans. Most local health maintenance organizations (HMOs), including Detroit-based Blue Cross Blue Shield of Michigan refuse to pay for the professional component of the patient's observation stay, Mikhail says.
The reason stems partly from a false assumption by insurers that there is little physician decision-making involved in the observation stay. It's mostly technical, he adds. And until this year, the Medicare program did not accept a physician's CPT code for observation stays. Although Mikhail can't understand the reason behind payers' decisions, he has at least found one responsive payer.
Currently, Care Choices, an 269,000-enrollee HMO operated by Mercy Health Services in Farmington Hills, MI, contracts with the hospital and its chest pain center. Mercy Health also owns St. Joseph Mercy.
But these factors don't get in the way of the unit's operation, says Britton. "We take all comers, and we don't worry about their ability to pay.
References
1. Gibler WB. Chest pain units: do they make sense now? Ann Emerg Med 1997;29:168-171.
2. Mikhail MG, Smith FA, Gray M, et al. Cost-effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med 1997;29:88-97.
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