Care Redesign

Improving Emergency Department Care for Low-Risk Chest Pain

Case Study · April 18, 2018

A large health care organization aimed to improve its emergency department (ED) standard of practice for patients with possible acute coronary syndrome (ACS) by adopting an evidence-based clinical decision tool, the HEART score, and tracking patient outcomes and the use of hospitalization and noninvasive stress testing for low-risk patients across 14 sites. Results showed opportunities to reduce low-value care and costs.

Key Takeaways

  1. Adopting an evidence-based clinical decision aid like the HEART score to risk-stratify patients may improve the quality and efficiency of ED care for low-risk patients with possible acute coronary syndrome.

  2. Patients who have low-risk HEART scores are at extremely low risk for 30-day adverse events, and below previously reported acceptable “miss rates.”

  3. A large opportunity exists to avoid unwarranted hospital admissions and noninvasive cardiac testing, which have not been shown to improve outcomes for low-risk chest pain patients.

  4. Early engagement of thought leaders and frontline physicians through multiple modes of communication is vital to the success of a large-scale intervention like this.

The Challenge

Heart disease is the country’s leading cause of death and a key priority for health professionals and health systems. Chest pain and related symptoms are the number two reason patients visit U.S. emergency departments, accounting for nearly 7 million visits in 2014.

The current ED standard of practice for managing patients with possible acute coronary syndrome involves routine hospitalization/observation and noninvasive cardiac testing. However, this approach is inefficient, does not contribute to improved patient outcomes, and is costly; numerous reports question its benefits. Physicians frequently underestimate the risks of bringing patients into the hospital and of false positives associated with noninvasive cardiac tests. And with missed diagnosis of heart attacks a top cause of malpractice lawsuits against emergency physicians, erring on the side of testing and admissions for suspected ACS is common.

ED management of patients with possible ACS is driven by patient history, exam, and diagnostic tests available in the ED. Our integrated health system, Kaiser Permanente Southern California (KPSC), previously had no system-wide guidelines to standardize the risk-stratification of patients with possible ACS.

The Goal

To improve the quality and efficiency of ED care for low-risk patients at 14 KPSC hospitals by adopting and implementing system-wide recommendations informed by updated American Heart Association guidelines and recent trials indicating the potential benefits of treatment algorithms designed to expedite the discharge of low-risk chest pain patients.

The Execution

We drew on lessons learned from similar large-scale efforts to avoid unwarranted care, such as antibiotic or medical imaging programs,­ to improve care for patients with chest pain.

  • Tool selection: We chose the HEART score as a standard algorithm to assist ED providers in the evaluation and management of patients with possible ACS. HEART, developed in The Netherlands, stands for History, ECG, Age, Risk Factors, and Troponin.
  • Leadership buy-in: We secured clinical leadership support (e.g., chiefs of cardiology, ED, and hospitalist services), and KPSC adopted an Acute Chest Pain Reference in January 2016. For patients with a HEART score of zero to 3 and negative troponin, we recommend discharge with a primary care follow-up.
Acute Chest Pain HEART Score Reference (MI)

  Click To Enlarge.

  • Physician education (the initiative targeted MD behavior only):
    • At a regional hospitalist and emergency medicine summit, we discussed medical evidence behind the KPSC recommendations and our expectations for physicians.
    • We developed and distributed an online CME module for physicians similar to information presented at the summit. All emergency physicians last year received a small financial incentive for participating in the performance-improvement effort.
  • HEART documentation: To optimize physician decision support and to stratify patients based on ACS risk, physicians were asked to document the history and ECG findings discretely in the medical record, to be combined with age, risk factors, and troponin level to calculate a HEART score for appropriate patients. Physicians who ordered a troponin test but did not document in a way to calculate a HEART score were prompted to do so in the medical record.
  • Performance reporting: We created health system dashboard reports to measure facility performance related to HEART score reporting and admissions/observations or cardiac stress testing for low-risk patients. These reports showed the degree to which facilities were “discordant” with our recommendations.
Dashboard for Performance Reporting - HEART Score Risk

  Click To Enlarge.

  • Outcomes: We examined the outcomes (30-day death or myocardial infarction) of 12,128 adult ED encounters at any of the 14 community EDs affiliated with KPSC in which a troponin test was ordered and a HEART score documented in 2016.
Patient Outcomes Stratified by Low, Moderate, and High-Risk HEART Score

  Click To Enlarge.

The Team 

Research scientists, clinical leadership across disciplines, physicians across disciplines and sites, an electronic health record IT specialist, and a data analyst.

Metrics/Findings

  • The overall 30-day “miss rate” using the HEART score was 22 out of 12,128, or 0.18%. This is well below published estimated miss rates of 2.1% in the United States.
  • Among 6,876 low-risk patients, the rate of 30-day myocardial infarction or all-cause death was 0.09%. (The 30-day MI/death rate was 0.26% for moderate-risk patients and 0.68% for high-risk patients.)
  • Across 14 sites, 12% of patients with a documented low-risk HEART score were admitted/observed or received noninvasive cardiac testing.
  • There was significant variation in the management of low-risk patients with possible ACS among the 14 medical centers, ranging from 3% to 22% of patients receiving stress testing or hospital admission/observation.

Where to Start

Identify a standard approach to ED chest pain management using a proven risk-stratification tool like the HEART score. Evaluate and report patient outcomes and target opportunities to eliminate low-value hospitalization and cardiac testing in low-risk populations.

Challenges

As with any intervention within a large health system, getting everyone to agree on a standard practice is hard to do, and implementation is equally challenging. We also acknowledge that there are always limitations to decision rules, and physicians should maintain the autonomy to deviate from recommendations when it is in the best interest of their individual patients.

Next Steps

Kaiser Permanente has plans to adopt the HEART score or similar risk-stratifying tools in other regions.

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