Critical pathways in cardiology
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Of all stress tests done in low risk Emergency Department observation units (OU), a small, but significant number may be reported as positive or indeterminate. The objective of this study is to quantify the prevalence and costs associated with positive and indeterminate stress tests that result in negative cardiac catheterization. ⋯ The probability of going to the OU and having a positive or indeterminate stress test resulting in a subsequent negative catheterization was double the probability of having a stress test result in catheterization that detected significant coronary artery disease. These patients incurred 5 times the total cost when compared with those patients with negative stress testing. Further investigation is warranted to determine alternative risk stratification methods for these low risk chest pain patients with positive stress tests.
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Acute decompensated heart failure (ADHF) is a major public health problem and leading cause for hospitalization in people 65 years and older. Admission rates for ADHF, accounted for more than 1 million heart failure (HF) hospitalizations in 2004, and more than 6.5 million inpatient hospital days. Despite significant advances in HF management, including pharmacotherapy and devices; and extensive collaborative efforts of the American College of Cardiology, and American Heart Association to disseminate evidence-based practice guidelines for management of chronic HF in adults; 3 patients continue to present to the emergency departments in ADHF. The hospital treatment of HF frequently does not follow published guidelines, potentially contributing to the high morbidity, mortality, and economic cost of this disorder. This highlights an ongoing need for development of quality improvement programs that focus on delivering reliable, evidence-based care for patients with ADHF. Consequently, the development of clinical pathways has the potential to reduce the current variability in care, enhance guideline adherence, and improve outcomes for patients. ⋯ Successful strategies to improve care for HF patients need to assist health care providers with rapid recognition and early aggressive treatment, while creating a reliable process that ensures continuity of care. This critical pathway for management of acute HF at the VASDHCS provides computerized order sets that guide health care providers through accepted treatment regimens, providing documentation of treatment and assists with compliance data collection. The quality of the care is assessed by monitoring the nationally established performance measures for HF. Through the use of the HF computerized order sets, the VASDHCS currently achieves a performance level above most Joint Commission accredited organizations and in many areas achieves the best possible results compared with the top 10% of hospitals in the nation.
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Comparative Study
Emergency Department greeters reduce door-to-ECG time.
Screening for Acute Coronary Syndrome in chest pain patients can be initiated with a 12-lead electrocardiogram (ECG). Current American College of Cardiology/American Heart Association guidelines recommends getting an ECG performed and reviewed within 10 minutes of the time these patients present to the Emergency Department (ED). One innovative method to improve door-to-ECG time is by placing a trained greeter in the triage section of the ED. ⋯ ED triage greeter can be effectively used to obtain timely ECGs in suspected Acute Coronary Syndrome patients.
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Clinical Trial
Evaluation of proton pump inhibitor use in patients with acute coronary syndromes based on risk factors for gastrointestinal bleed.
Use of proton pump inhibitor (PPI) reduces the risk of gastrointestinal (GI) bleeding, and is generally recommended for high GI risk patients taking nonsteroidal anti-inflammatory agents. Aspirin and/or anticoagulants have been identified as increasing the risk of GI bleeding, whereby use of PPI could reduce this risk. The use of PPI in routine practice is not well defined, especially in patients with acute coronary syndromes (ACS) who require one or several antithrombotic drugs. ⋯ Use of PPI following ACS is modest, although it did increase with an increasing number of previously identified GI risk factors. Further, larger studies are warranted to validate prior, or identify new, risk factors as predictors of long-term bleeding, and improve awareness of GI bleeding risk such that use of PPI could be optimized.
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Risk of acute coronary events in patients with methamphetamine and cocaine intoxication has been described. Little is known about the need for additional evaluation in these patients who do not have evidence of myocardial infarction after the initial emergency department evaluation. We herein describe our experience with these patients in a chest pain unit (CPU) and the rate of cardiac-related chest pain in this group. ⋯ These findings suggest a relatively high rate of CAD in patients with methamphetamine and cocaine use evaluated in a CPU.