Critical pathways in cardiology
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Currently, the wide variety of antithrombotic agents as adjunctive pharmacological therapy for non-ST-segment elevation acute coronary syndromes (ACS) in the setting of contemporary percutaneous coronary intervention (PCI) available for clinical use has made choosing the optimal drug therapy a complex and difficult task. In the stent era, bivalirudin, a semisynthetic direct thrombin inhibitor, has recently been shown to provide similar efficacy with less bleeding compared with unfractionated heparin plus platelet glycoprotein IIb/IIIa inhibitors in ACS patients treated with PCI. ⋯ With current findings in contemporary PCI, there may be a steady increase in the utilization of bivalirudin. On the other hand, in the real world, there may be reinforcement in the sole use of unfractionated heparin confining glycoprotein IIb/IIIa inhibitors and other intravenous antithrombotics to bailout therapy for periprocedural PCI complications in ACS patients.
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Patients presenting to the emergency department with chest pain require prompt identification and referral, as early treatment of patients with an acute coronary syndrome (ACS) is crucial to decrease morbidity and mortality (Steurer et al, Emerg Med J. 2010;27:896-902). Although rule-in ACS is critical and time dependant, other difficulties arise during the rule-out ACS process (Steurer et al, Emerg Med J. 2010;27:896-902). Inappropriate discharge of patients with misdiagnosed acute myocardial infarction is associated with significant morbidity and mortality. ⋯ The development and implementation of chest pain pathways is not without difficulties. These may arise from differences in the management approaches of health practitioners, poor adherence to guidelines, and concerns for costs. New procedures such as new cardiac injury markers, stress testing, and specialized chest pain units have led to a reduction in admission rates and length of stay, reduced costs, and a reduction of inappropriate discharge of patients with ischemic heart disease.
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The management of patients after cardiac arrest is a prominent example of complexity on many levels of decisions. We designed a pathway for the management of survivors of cardiac arrest, guiding such decisions as cardiac catheterization, induction of therapeutic hypothermia, placement of defibrillator, and ethical decision making for life support. ⋯ We used the power of survivors' stories to inspire and educate clinicians in the utility of our multidisciplinary pathway approach. This approach may serve as a model for patient-centered care in medicine.
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: Hospitals measure patient satisfaction through Press Ganey (PG) surveys. The impact of an emergency department observation unit (EDOU) on patient satisfaction has not been reported to date. We hypothesize that an EDOU has a positive impact on patient satisfaction results as measured by PG surveys. ⋯ : The introduction of an observation unit appears to be associated with a statistical improvement in patient satisfaction scores as reported by PG, in the setting of same facility, physician staffing, and nursing staffing.
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Recent evidence suggests that stress testing prior to emergency department (ED) release in low-risk chest pain patients identifies those who can be safely discharged home. When immediate stress testing is not feasible, rapid outpatient stress testing has been recommended. The objective of this study was to determine compliance rate and incidence of adverse cardiac events in patients presenting to the ED with low-risk chest pain referred for outpatient stress testing. ⋯ No significant differences in adverse cardiac events were documented in patients who did and did not comply with outpatient stress testing. Compliance with outpatient stress testing is poor in low-risk chest pain patients following ED release. Despite poor compliance, the documented incidence of adverse cardiac events in this low-risk cohort was lower than that reported in patients with negative provocative testing prior to ED release.