Critical pathways in cardiology
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Successful collaborative model for STEMI care between a STEMI-referral and a STEMI receiving center.
Patients with ST-segment elevation myocardial infarction (STEMI) greatly benefit from a rapid door-to-balloon (D2B) time. For hospitals without a catheterization laboratory, it is imperative to establish partnerships with a STEMI receiving center (SRC). STEMI systems of care have been established to facilitate these relationships to improve rapid reperfusion. We describe the experience and benefits of such a relationship. ⋯ Streamlining STEMI patient care to reduce D2B is a major priority. We have demonstrated that establishing a transfer program between a STEMI-Referral Hospital (SRH) and SRC can markedly improve time to reperfusion. This approach has resulted in D12B that match or exceeds the D2B for nontransfer patients at most STEMI-receiving hospitals.
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Observation Services (OS) was founded by emergency physicians in an attempt to manage "boarding" issues faced by emergency departments throughout the United States. As a result, OS have proven to be an effective strategy in reducing costs and decreasing lengths of stay while improving patient outcomes. When OS are appropriately leveraged for maximum efficiency, patients presenting to emergency departments with common disease processes can be effectively treated in a timely manner. ⋯ This white paper provides the reader with the foundational guidance for observational services. It defines how to set up an observational service program, which diagnoses are most appropriate for admission, and what the future holds. The goal is to help care providers from any hospital deliver the most appropriate level of treatment, to the most appropriate patient, in the most appropriate location while controlling costs.
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Randomized Controlled Trial
Utility of Framingham risk score in urban emergency department patients with asymptomatic hypertension.
Hypertension (HTN) is the primary population-attributable risk for the development of heart failure (HF); a disease with devastating consequences particularly in urban centers where morbidity and mortality are more pronounced. The Framingham Risk Profile (FRP) is widely used to quantify risk for cardiovascular disease (CVD), but its applicability in an urban population who utilize the emergency department (ED) for primary care is unknown. The objective of this study is to evaluate FRP scores in ED patients with asymptomatic HTN and subclinical hypertensive heart disease (SHHD). ⋯ The HF-specific risk score for patients with SHHD was 2.4, which equates to a 2.5% risk of HF development in 10 years. The FRP correctly identified those with SHHD as high-risk for general CVD but appeared to underestimate the likelihood of HF. Recalibration of the HF adjustment factor and inclusion of additional data elements such as echocardiography is needed to enhance applicability of the FRP in this setting.
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The objective of our study was to evaluate the effect of the STOP STEMI© medical application on door-to-balloon (D2B) time in patients arriving to our emergency department with an acute ST Elevation Myocardial Infarction (STEMI). STOP STEMI© is a novel medical application developed by physicians to improve the coordination and communication tasks essential to rapid assessment and care of the patients suffering from a STEMI. ⋯ In this cohort of patients, the utilization of STOP STEMI© decreased the average door-to-balloon times by 22% in the patients with acute STEMI arriving at our emergency department. This effect was maintained when looking at the subset of all STEMI cases reportable to CMS. We also observed modest improvements in meeting the less than 60-minute, less than 90-minute benchmarks, and improvements in the resource utilization.
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Emergency physician threshold to test for acute coronary syndrome (ACS) is directly related to ACS diagnosis rate and inversely related to ACS missed diagnosis rate. Feedback to emergency physicians of information on their prior patients whose ACS diagnosis was not identified may improve physician diagnostic performance. ⋯ Emergency physicians with lower threshold for ACS evaluation more frequently diagnose patients with ACS and less frequently miss the diagnosis of ACS. Feedback to emergency physicians of information on their patient's return visits and their own diagnostic performance may improve outcome for patients with ACS.