Critical Path Network-Chest pain rule-out MI clinical pathway saves $183,000
By Linn Kight, BSN, RN
Clinical Path Coordinator
Valley View Hospital
Glenwood Springs, CO
Valley View Hospital is a private, nonprofit organization located in the Rocky Mountains between Aspen and Vail, CO. The hospital is licensed for 80 beds and has 73 active and consulting physicians, including 24 specialties. The hospital offers a wide range of services, excluding transplants, cardiac surgery, and neurosurgery.
Valley View began its clinical pathway program in the fall of 1994, and successful implementation of a pneumonia path occurred the following year. Sixteen paths have been developed and implemented, using continuous quality improvement and/or rapid cycle plan-do-study-act methodologies. The original clinical pathway teams have evolved into three collaborative care teams: surgical, medical, and perinatal/pediatrics. The teams have a variety of clinical responsibilities, as well as responsibilities for pathway development and implementation, staff education, data review, and pathway revision.
The acute myocardial infarction (AMI) path was implemented in June 1997. A chart review on the diagnosis of chest pain was completed that fall and revealed the chest pain population to be high volume, high length of stay (LOS), high charges, and high risk. The review also showed that a large portion of that patient population is from out of town, coming from low elevation to high elevation and presenting in the emergency department (ED) with chest pain. The medical collaborative care team decided it was important to develop a chest pain pathway and a bridge order set so patients could be easily bridged from the chest pain path to the AMI clinical path. This medical collaborative care team is multidisciplinary and includes representatives from all clinical departments, as well as three physicians representing the ED, internal medi cine, and the laboratory department.
Physician involvement is extremely important to the pathway process, and especially for the chest pain path, because most patients present in the ED and are admitted to the hospital for observation. The physicians involved in the medical collaborative care team were pivotal in evaluating and trialing new blood tests that could aid in making a definitive diagnosis within eight to 12 hours.
The team did an extensive literature search, looked at examples of other chest pain pathways, and studied the ACC/AHA Practice Guidelines for "Management of Patients With Acute Myocardial Infarction" prior to pathway development, which began in 1997. The chart audit established current practice patterns at Valley View. Bridge orders from the chest pain rule-out MI pathway were also developed to move a patient from the chest pain path to the AMI path efficiently and without duplication.
Other considerations include:
• Chest pain sticker. The sticker is used on the ED record to aid in rapid cardiac assessment and identification of risk factors. (See sticker, above.) Duplication of critical information has decreased completely, and treatment occurs sooner. Use of the chest pain sticker is at 97%.
• Time of arrival in the ED to the time the patient receives aspirin therapy. Aspirin administration time pre-pathway was 72 minutes, and today it has decreased to 15.4 minutes. More patients are receiving aspirin prior to presenting to the ED. Patients are taking aspirin at home, in the physician's office, or in the ambulance. In addition, there has been a nationwide campaign to educate people about early administration of aspirin and its role in preventing or decreasing the damaging effects of a heart attack.
• Treadmills and patient education. Documentation of the treadmill process and patients receiving stress tests prior to discharge has shown improvement. More consistent patient education, which includes viewing a video on chest pain prior to the treadmill, allows physicians to address any patient questions.
• Standardization of the cardiac panel. Since adding troponin I to the panel, physicians are ordering it 100% of the time. Troponin I has enabled physicians to rule out MI within eight to 12 hours, thereby helping decrease charges and LOS.
• Additional procedures. The incidence of other diagnostic procedures being performed for patients who've been determined not to have had a heart attack has decreased mark edly. For example, esophagogastroduodenoscopy is being done on an outpatient basis rather than during the inpatient stay.
Implementation of the chest pain pathway has resulted in many positive outcomes. Through monitoring clinical outcomes, we have been able to demonstrate an improvement in care, as well as a decrease in LOS and charges. The pathway program is expanding into other areas of health care such as acute rehabilitation, home health/ hospice, and physician offices.
For more information, contact:
Linn Kight, BSN, RN, clinical path coordinator, Valley View Hospital, Glenwood Springs, CO. Telephone: (970) 945-3312.
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