Chest pain: Admit, send home, or something else?
[Editor’s note: The following articles are the last in a series of articles on re-engineering your emergency department (ED). Chest pain is a frequent complaint in all EDs, yet it presents some challenges to both your clinicians and your administrators. Cardiac care is expensive, yet a missed diagnosis also is potentially expensive in today’s litigious society. In this issue of Patient-Focused Care, we present an overview of a successful program at an Ohio hospital that turned the spotlight on chest pain patients and found a way to give the proper care while avoiding wasted use of hospital resources.]
Few things in today’s health care world can cut costs, reduce malpractice risk, and make patients happier at the same time. But taking a close look at your hospital’s ED and how it handles chest pain patients could provide you with that win, win, win situation. While not all hospitals can benefit from using a rule-out acute myocardial infarction (AMI) unit, many can save thousands of dollars a year, while providing superior patient care through the use of such units.
AMI is a frequently missed diagnosis, and a wrong guess either way is expensive. Send a patient home who later has a cardiac arrest, and you have a serious liability issue. On the other hand, admit a patient who really has heartburn, and you can spend thousands of dollars providing unnecessary care.
The University of Cincinnati Medical Center has saved thousands of dollars while providing excellent care to its chest pain patients through a dedicated program that involves little in the way of extra resources. A typical admission to the intensive care unit (ICU) to rule out AMI or ischemia in the patient with chest pain can cost between $3,500 and $4,000. A stay in a model short-term cardiac observation unit next to the ED costs $1,000 to $1,500.
If your ED doesn’t already have a rule-out AMI observation adjunct in place, consider implementing one. It could alleviate some pesky headaches and save money and patients’ lives at the same time.
The patient who presents in your ED with a chief complaint of chest pain can be one of the 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. (See algorithm, above.)
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 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 obser-vation 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 Catherine Hamilton, RN, MPH, clinical coordinator for Heart ER. "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."
"Our purpose in starting Heart ER," says Hamilton, "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."
The chest pain evaluation unit is self-contained and reduces the once three-day process to nine to 11 hours. The adjunct has two beds for patients who would otherwise be admitted to the CCU or released. Kent Hall, MD, is the current director.
"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
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.
But short-term observation units may not be 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 in order to rule out AMI. The patients were assessed to see if they were eligible for an alternative 12-hour chest pain observation unit there. 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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