Identifying AMI risk saves money
Tests can be quick, propitious
If you can identify a chest pain patient’s degree of risk upfront by knowing when to run appropriate tests, you can work to modify that risk before untoward and expensive events occur.
Late last year, the cardiac service line and emergency department (ED) at St. Francis Hospital & Health Centers in Beech Grove, IN, initiated an action team to better manage their patients presenting with chest pain. Jerri DeVaney, RN, BSN, care manager of the cardiac service line at St. Francis explains, "We wanted the answers to some questions such as, do we automatically send chest pain patients up to the CCU, or do we monitor them in the ED?’"
Upon entering the ED at St. Francis, patients are classified into categories:
• Possible acute myocardial infarction (AMI) and unstable angina.
Patients falling into these two categories receive rapid triage and monitoring by 12-lead EKGs. They are prepared for immediate reperfusion, either mechanical or thrombolytic.
• Chest pain noncardiac etiology.
Patients with pneumonia, rib fracture, zoster, or gastroesophageal reflux disease fall here. No cardiac testing is ordered.
• Chest pain unknown etiology.
This category includes the most problematic group. These patients have varying presentations, and a definite diagnosis cannot be established during the initial one-to-two hour evaluation. Nor can AMI or other forms of ischemic heart disease be excluded. Patients with unknown etiology cannot be discharged from the ED until more is known.
DeVaney says her team is working on a chest pain and AMI algorithm that will become a pathway once it’s approved. It has four branches based on EKG results. (See chest pain algorithm, p. 99.)
"Sometimes a pathway is left standing and unchanged," says DeVaney, "simply because that’s the way you’ve always done it, and you’re comfortable with it that way. Cardiac pathways need continual updating. When we started our service line project, we looked at our open-heart DRG pathways and tore them apart. We asked, Why are we doing this?’ and Why are we doing it that way instead of another way?’"
Guidelines for AMI evaluation and management have been available since the early 1990s from the American College of Emergency Physicians (ACEP) in Dallas. More recently, guidelines from the American College of Physicians (ACP) in Philadelphia, as well as joint guidelines from the American College of Cardiology in Bethesda, MD, and the American Heart Association in Dallas have been published.1,2
National guidelines serve as starting point
Such guidelines provide a basis to start from, but clinical judgment is required to implement them. "How patients present is key to their treatment," says DeVaney. "When patients have multiple comorbidities or no comorbidities, the paths become complex and have to be individualized."
According to DeVaney, it’s important to get the physicians’ support when redesigning protocols. Cardiologists at St. Francis participated in the AMI algorithm’s development by standardizing their orders. St. Francis’s cardiac service line medical director acts as the department’s champion for change. "If, for example," says DeVaney, "a patient comes in who should be on an ACE inhibitor and isn’t, and there’s no documentation as to why he or she isn’t, the director will go physician-to-physician and discuss the patient’s care."
Doctors at St. Francis, she says, cooperate by discussing costs and benefits of patient outcome guidelines. A group of interventional cardiologists meets monthly to review the latest technologies and the best recommendations for their patients. "They look at outcomes of patients in their group," says DeVaney. "They’re in tune with all the recent studies and guidelines that come down, but if they think their patients can benefit from a protocol, they’ll do it even if a guideline says it’s not cost-effective."
"You can initiate lifestyle modification for a patient who comes to the ED with chest pain even if it turns out they don’t need to be admitted," says DeVaney. In the short run, you may not see savings because they cannot be measured, but in the long run, money is conserved.
"Patients benefit on a personal level as well," continues DeVaney, "because they don’t have to spend any more time in a hospital environment than is absolutely necessary. People do better in their home environments."
References
1. Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation 1996; 94:2,341-2,350.
2. Peterson ED, Shaw LJ, Califf RM. Risk stratification after myocardial infarction. Ann Intern Med 1997; 126:561-582.
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