Critical pathways in cardiology
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Comparative Study
Low-risk acute heart failure patients: external validation of the Society of Chest Pain Center's recommendations.
Risk-stratification in acute heart failure syndromes (AHFS) is problematic. A recent set of recommendations describes emergency department (ED) patients with AHFS who do not fulfill high-risk criteria and may be good candidates for observation unit (OU) management. The goal of this analysis was to report on the outcomes experienced by ED patients with AHFS who do not have any of these high-risk criteria. ⋯ AHFS patients at low-risk for subsequent morbidity and mortality based on recent consensus guidelines may be good candidates for early discharge after a brief period of observation in the OU or ED. Additional prospective research is needed to determine the impact of implementation of these criteria in ED patients with AHFS.
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Comparative Study
Utility of the emergency department observation unit in ensuring stress testing in low-risk chest pain patients.
Recent research has noted low rates of compliance among ED chest pain patients referred for outpatient stress testing. The practice at our institution, a 39,000 visits per year emergency department (ED), is to place chest pain patients considered low risk for acute coronary syndrome in an observation unit for serial biomarker testing and provocative cardiac testing. Our objective was to determine the rates of positive stress tests among this group and to extrapolate from this the potential missed positive stress tests if these patients were referred instead for outpatient stress testing. ⋯ Among chest pain patients admitted to an ED observation unit, the rate of positive stress tests was 11%. Approximately 3.3% of patients with positive stress tests may have been missed if these patients were instead referred for outpatient testing.
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For patients presenting to emergency departments (ED) with a suspected acute coronary syndrome, time of arrival until an electrocardiogram is performed is an important quality metric. In our ED routine quality monitoring found that mean door-to-electrocardiogram (D2ECG) time did not meet our goal and national benchmark of 10 minutes. We describe the use of quality improvement tools to assess and decrease our D2ECG time. ⋯ Mean time to ECG before intervention was 21.28 +/- 5.49 minutes. After the intervention period, the mean D2ECG for STEMI decreased to 9.47 +/- 2.48 minutes representing a 55% improvement. A D2ECG time of less than 10 minutes time can be achieved by the implementation of patient prioritization triage process changes, assigning specific personnel to obtain the ECG, continuous feedback by reviewing cases that fall outside the 10-minute goal and by ED staff education regarding STEMI symptoms other than chest pain.
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To reduce atherothrombosis-related morbidity and mortality, implementation of guideline-recommended therapies for primary and secondary prevention is necessary. Few data are available for outpatients in actual clinical practice, especially those without known heart disease treated by physicians trained in different specialties across the geographic regions of the United States. ⋯ Adherence to guideline-recommended preventive therapies in the outpatient setting was affected by patient characteristics, geographical region, and treating physician specialty. Novel approaches may be needed to improve the use of evidence-based, guideline-recommended therapies in these outpatient settings.