New technology: EKG computerized tool predicts outcomes
Although thrombolytic therapy can save the lives of patients having acute MIs, the benefits depend on treating appropriate patients as quickly as possible. A newly developed Thrombolytic Predictive Instrument (TPI) can help physicians to predict whether a patient will benefit from thrombolytics.
"The TPI automatically identifies patients with EKG abnormalities that make them candidates for thrombolytic therapy (or primary PTCA if there are contraindications to the use of thrombolytic therapy)," reports Harry Selker, MD, MSPH, the developer of this technology and chief of the division of clinical care research at New England Medical Center in Boston, MA.
Predictions are printed on the top of the EKG, improving the ED physician's decision making, Selker explains. "We felt that given the enormous potential of thrombolytic therapy and that it was being underused and used too late, this was an area where we could help," he says. As a result, medication can be given in a more timely fashion.
After basic features of the patient's clinical presentation are entered into a computerized EKG machine, the predictions of the TPI are printed on the EKG report. "The formula for the TPI's five component predictive instruments (30-day mortality, 1-year mortality, cardiac arrest, thrombolysis-related stroke, or major bleed) are programmed into the standard computerized electrocardiograph," Selker explains.
The predictions are automatically printed out on the EKG text header. "Thereby, the TPI provides for earlier treatment of patients who should receive such treatment, and increases the number of patients identified for treatment, thereby also saving lives,"says Selker.
Patients who are not likely to benefit from thrombolytics are also identified. "In patients with very small or low-risk infarctions, or after too much time has passed, thrombolytics offer little chance of benefit, yet still incur risk for complications and considerable costs," notes Selker. "In these cases, the TPI will quantify the tradeoffs for the emergency physician."
The TPI is FDA approved and is due on the market at any time from Hewlett-Packard, Selker reports. Other major electrocardiograph manufacturers are also planning on offering the TPI in their ED and EMS electrocardiographs, he adds.
The Medical College of Georgia Hospital and Clinics will eventually join the ranks of hospitals operating an observation or short-term evaluation unit. However, for now, a number of hurdles remain to be cleared before the concept gains full acceptance and support. Recently, the ambulatory hospital concept, a potentially useful compilation of well-recognized and previously described services, was developed during the process of program justification.
We thought it potentially valuable enough to present for review by the reader's ED Management.
Ambulatory refers to the outpatient practice of medicine and the word, hospital, represents the traditional inpatient setting. Used together, the name Ambulatory Hospital defines a location where healthcare activities traditionally accomplished in the inpatient are occurring in the outpatient arena.
The emphasis on outpatient care continues to grow, and hospital admissions are decreasing in many parts of the country. Managed care recognizes that the greatest healthcare costs occur when patients are admitted to an inpatient unit. Furthermore, the length of stay significantly impacts on the cost of healthcare. Managed care organizations are naturally attracted to programs that result in fewer hospital admissions and greater savings.
The broad application of clinical pathways (evidence-based medical practice) would also contribute to these savings and efficiencies. Consequently, the Ambulatory Hospital concept would appear to meet the concerns and expectations of managed care and simultaneously be a valuable marketing tool for hospitals.
The Component Parts: Express Admissions. At this location all stable admissions to the hospital would take place at a single location.
A "SWAT team" approach to the admission process could be developed.
The potential for increased efficiencies on the nursing units may exist, and hospital human resource needs may be better managed.
The express admissions component could potentially become a marketable and attractive service to community physicians.
Improved patient care would be an expected consequence, as patients would receive their initial medications and therapies in a more timely fashion.
A geographic location immediately adjacent to the emergency department (ED) would be an important triage and risk management benefit.
Admission Holding. Admission holding units are difficult to justify. However, ED throughput frequently benefit from a "wide spot in the road" to place patients waiting for an inpatient bed.
The admission holding unit component prevents ED room gridlock, allows continued room turnover, and prevents diversion of ambulances.
A centralized, single location, specifically dedicated to the admission process of all patients would be potentially more efficient for housestaff.
Short-term Observation. Patients for whom the need for an admission is not immediately clear often benefit from short-term observation or treatment.
Patients presenting with known terminal conditions who are dying or who require a brain death protocol could be evaluated or allowed to expire in this setting.
The home healthcare interface can be accomplished in this setting. Patients traditionally admitted will begin their therapy in the Ambulatory Hospital and receive follow-up by a home health nurse within 24 hours.
Patients who may not meet admission criteria but who require short-term observation for social or family resource reasons often remain overnight in this location-a kinder and gentler practice of medicine.
Chest Pain Unit. There is good evidence that the management of the atypical chest pain patient in a chest pain unit can be accomplished with fewer days of hospitalization and increased savings.
The management of chest pain patients typically operates under a well-defined clinical pathway.
It is becoming increasingly clear that chest pain patients being evaluated in a chest pain center receive more timely and better orchestrated clinical interventions.
Express Procedure. Many minor outpatient procedures may be accomplished in this setting. Foley catheter or G-tube replacements are common procedures presenting to EDs.
Other procedures, such as outpatient antibiotics, routine transfusions, and central line management, could be easily managed as an express procedure.
Conscious sedation for various procedures could be accomplished in this setting.
The close proximity of the ambulatory hospital to the ED would allow attending physician supervision by emergency physicians 24 hours per day. However, the compilation of these various elements might for the first time justify the use of hospitalist physicians in the outpatient setting.
In summary, there seems to be great potential benefit in developing a strategy that will adjust to the demand for increased outpatient care delivery. When funding approval for our program finally occurs, the Ambulatory Hospital concept as a compilation of these described programs will most likely be the model applied.
Editor's Note: This month, ED Management introduces The Cutting Edge column. This column will serve as a forum for readers to present progressive and visionary ideas about the future of emergency medicine. We invite readers to send in ideas or contribute guest columns for future issues. Please send any ideas or submissions to Staci Bonner, ED Management, P.O. Box 740056, Atlanta, GA 30374. Telephone: (516) 425-9760. E-mail: [email protected].
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