Chest pain procedure: Admit, send home, or something in between?
Rule-out AMI units bring definition to a gray area
Nurses at the University of Cincinnati Medical Center provide excellent care to chest pain patients in their emergency department (ED). At the same time, the facility saves thousands of dollars with a dedicated program, Heart ER, that involves few extra resources. A stay in its model short-term cardiac observation unit costs $1,000 to $1,500, compared with $3,500 to $4,000 typically spent on chest pain patients in intensive care units to rule out acute myocardial infarction (AMI) or ischemia.
If your ED doesn't already have a rule-out AMI observation adjunct in place, suggest implementing one. It could alleviate some pesky nursing headaches and save money and patients’ lives at the same time.
"Our purpose in starting Heart ER," says Catherine Hamilton, RN, MPH, clinical coordinator for Heart ER, "was to save the hospital money by avoiding admissions. We also wanted to learn at what point patients, once admitted to the ED, can be safely discharged to home."
Creating an adjunct like the medical center’s Heart ER project doesn't have to cost a lot of money; it depends on how the administrator chooses to set it up. Some facilities make hard construction changes where a separate unit is placed next to the ED, says Kent Hall, MD, an emergency physician and director of the center’s Heart ER. If you buy all new equipment for a separate adjunct and change staffing patterns as well, the unit is going to be costly. Set-up minus personnel would cost in the range of $20,000 to $30,000. If you add in salaries and benefits of an extra two nurses, the cost is brought up to approximately $110,000. But all that doesn’t have to be done.
Heart ER integrated into ED
"Our Heart ER is an integral part of our ED," says Hamilton. "It’s not in a special separate room, and with the exception of our cardiology fellows, not much additional staff were required when we set up the program." Two beds are set up for Heart ER patients, but they are interchangeable with others, so if Heart ER patients are not using them, they can be used for other ED patients. The hospital added a couple of full-time ED nurses in addition to the EDs usual 50 to 60. It did need some extra equipment, such as ST segment monitors and graded exercise testing equipment, but the manufacturer of the ST segment monitors contributed those items. It revised the wiring and added computer space and televisions for the Heart ER patients.
The ED nurses received special training on the Heart ER equipment and the observation format. The traditional focus of an ED nurse is not to observe patients for extended periods of time; it’s to move them along as quickly as possible to their ultimate destination, says Hamilton. The nine-hour protocol is a different perspective. A two-hour inservice training session on the equipment and Heart ER philosophy is required for every nurse on the staff. The session is repeated when new nurses are hired.
Hall elaborates, "We need to keep certain aspects of the ED mentality rapid evaluation, and management and combine that with a floor nurse mentality where emergency care is done over a more extended period than what the ED nurse is used to."
Clinical and legal considerations
The patient who presents in your ED with a chief complaint of chest pain can be one of your most problematic, both from a clinical standpoint and a legal one. Do you admit the patient, or can you safely send him or her home? Many chest pain patients have no history of heart disease and cannot readily be definitively diagnosed. In fact, diagnoses can range from AMI or ischemia to pleurisy or heartburn. Approximately 5% of chest pain patients in the United States are discharged in error, only to have serious events while at home.
Five years ago, W. Brian Gibler, MD, FACEP, chairman of the department of emergency medicine at the University of Cincinnati Medical Center founded the Heart ER program there. His ED team was looking for a safer, faster, more cost-effective way to diagnose ischemia and infarction in low- to moderate-risk chest pain patients.
Patients admitted to Heart ER undergo observation for nine hours with continuous 12-lead EKGs/ serial ST-segment trend monitoring and frequent rapid creatine kinase (CK-MB) testing.1 After AMI and ischemia at rest are ruled out, ischemia is provoked by graded treadmill exercise. On the basis of the results of that provocation, patients are either admitted for further testing or discharged home and referred to their family physicians.
"Echocardiology used to be a part of the provocation procedure, but we found we weren’t getting any valuable clinical information from it," explains Hamilton. "We were looking for wall motion abnormalities that would indicate ischemia of a heart muscle, but the echo didn't show us that after the nine-hour observation period."
The chest pain evaluation unit is self-contained and reduces the once three-day process to nine to 11 hours. The adjunct beds are for patients who would otherwise be admitted to the critical care unit or released.
"We are currently talking about evaluating our Heart ER nine-hour protocol," says Hamilton, "so we can shorten the observation period to six hours. Instead of having four sets of enzymes, we’d eliminate the ninth hour and have three." (See Heart ER's protocol, inserted in this issue.)
How do patients like the observation units as opposed to standard inpatient hospitalization? Patients interviewed upon discharge give them high scores for satisfaction.2
Are rule-out units feasible for your facility?
The University of Cincinnati Medical Center is a 550-bed urban tertiary care center that logs more than 72,000 ED visits a year. Chest pain accounts for 2% to 3% of those.
Short-term observation units may not be wise for every facility. A recent study evaluated the feasibility of the short-stay protocol.3 Researchers looked at 500 patients who presented with chest pain to Cook County Hospital’s ED in Chicago and were on their way to being admitted to rule out AMI.
Nurses assessed the patients to see if they were eligible for an alternative 12-hour chest pain observation unit. Of the patients screened, half were found to have low probability for AMI, but only a minority were eligible for the protocol that requires patients to be free of known coronary artery disease and able to perform an exercise tolerance test.
The investigators advise evaluating an observation unit’s potential impact before adding to existing hospital services.
References
1. Gibler WB, Runyon JP, Levy RC, et al. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med 1995; 25:1-8.
2. Rydman RJ, Zalenski RJ, Roberts RR, et al. Patient satisfaction with an emergency department chest pain observation unit. Ann Emerg Med 1997; 29:109-115.
3. Zalenski RJ, Rydman RJ, McCarren M, et al. Feasibility of a rapid diagnostic protocol for an emergency department chest pain unit. Ann Emerg Med 1997; 29:99-108.
Suggested reading
Mikhail MG, Smith FA, Gray M, et al. Cost-effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med 1997; 29:88-98.
Selker HP, Zalenski RJ, Antman EM, et al. An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: Report from a national heart attack alert program working group. Ann Emerg Med 1997; 29:13-87.
Tatum JL, Jesse RL, Kontos MC, et al. Comprehensive strategy for the evaluation and triage of the chest pain patient. Ann Emerg Med 1997; 29:116-125.
Lambrew CT. Chest pain evaluation, editorial. Ann Emerg Med 1997; 29:163-164.
Hoekstra J. Randomized trials and common sense, editorial. Ann Emerg Med 1997; 29:164-166.
Ryan TJ. Refining the classification of chest pain: A logical next step in the evaluation of patients for acute cardiac ischemia in the emergency department, editorial. Ann Emerg Med 1997; 29:166-168.
Gibler WB. Chest pain units: Do they make sense now? editorial. Ann Emerg Med 1997; 29:168-171.
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