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The HAS-Choice study: Utilizing the HEART score, an ADP, and shared decision-making to decrease admissions in chest pain patients

Published:February 07, 2018DOI:https://doi.org/10.1016/j.ajem.2018.02.005

      Abstract

      Objective

      The HAS-Choice pathway utilizes the HEART Score, an accelerated diagnostic protocol (ADP), and shared decision-making using a visual aid in the evaluation of chest pain patients. We seek to determine if our intervention can improve resource utilization in a community emergency department (ED) setting while maintaining safe patient care.

      Methods

      This was a single-center prospective cohort study with historical that included ED patients ≥21 years old presenting with a primary complaint of chest pain in two time periods. The primary outcome was patient disposition. Secondary outcomes focused on 30-day ED bounce back and major adverse cardiac events (MACE). We used multivariate logistic regression to estimate the odds ratio (OR) and its 95% confidence interval (CI).

      Results

      In the pre-implementation period, the unadjusted disposition to inpatient, observation and discharge was 6.5%, 49.1% and 44.4%, respectively, whereas in the post period, the disposition was 4.8%, 41.5% and 53.7%, respectively (chi-square p < 0.001). The adjusted odds of a patient being discharged was 40% higher (OR = 1.40; 95% CI, 1.30, 1.51; p < 0.001) in the post-implementation period. The adjusted odds of patient admission was 30% lower (OR = 0.70; 95% CI, 0.60, 0.82; p < 0.001) in the post-implementation period. The odds of 30-day ED bounce back did not statistically differ between the two periods. MACE rates were <1% in both periods, with a significant decrease in mortality in the post-implementation period.

      Conclusion

      Our study suggests that implementation of a shared decision-making tool that integrates an ADP and the HEART score can safely decrease hospital admissions without an increase in MACE.

      Keywords

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      References

        • Amsterdam E.A.
        • Kirk J.D.
        • Bluemke D.A.
        • et al.
        Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association.
        Circulation. 2010; 122: 1756-1776
        • Penumetsa S.C.
        • Mallidi J.
        • Friderici J.L.
        • Hiser W.
        • Rothberg M.B.
        Outcomes of patients admitted for observation of chest pain.
        Arch Intern Med. 2012; 172
        • Pope J.H.
        • Aufderheide T.P.
        • Ruthazer R.
        • et al.
        Missed diagnoses of acute cardiac ischemia in the emergency department.
        N Engl J Med. 2000; 342: 1163-1170
        • Pines J.M.
        • Isserman J.A.
        • Szyld D.
        • Dean A.J.
        • McCusker C.M.
        • Hollander J.E.
        The effect of physician risk tolerance and the presence of an observation unit on decision making for ED patients with chest pain.
        Am J Emerg Med. 2010; 28: 771-779
        • Roger V.L.
        • Go A.S.
        • Lloyd-Jones D.M.
        • et al.
        Heart disease and stroke statistics-2012 update: a report from the American heart Association.
        Circulation. 2012; 125
        • Field J.M.
        • Hazinski M.F.
        • Sayre M.R.
        • et al.
        Part 1: executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2010; 122
        • Mahler S.A.
        • Riley R.F.
        • Hiestand B.C.
        • et al.
        The HEART pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge.
        Circ Cardiovasc Qual Outcomes. 2015; 8: 195-203
        • Long B.
        • Oliver J.
        • Streitz M.
        • Koyfman A.
        An end-user's guide to the HEART score and pathway.
        Am J Emerg Med. 2017; 35: 1350-1355
        • Leite L.
        • Baptista R.
        • Leitão J.
        • et al.
        Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score.
        BMC Cardiovasc Disord. 2015; 15: 48
        • Cullen L.A.
        • Mills N.L.
        • Mahler S.
        • Body R.
        Early rule-out and rule-in strategies for myocardial infarction.
        Clin Chem. 2017; 63: 129-139
        • Callaway C.W.
        • Donnino M.W.
        • Fink E.L.
        • et al.
        Part 8: post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care.
        Circulation. 2015; 132: S465-82
        • Six a J.
        • Backus B.E.
        • Kelder J.C.
        Chest pain in the emergency room: value of the HEART score.
        Neth Hear J. 2008; 16: 191-196
        • Backus B.E.
        • Six A.J.
        • Kelder J.C.
        • et al.
        A prospective validation of the HEART score for chest pain patients at the emergency department.
        Int J Cardiol. 2013; 168: 2153-2158
        • Six A.J.
        • Cullen L.
        • Backus B.E.
        • et al.
        The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study.
        Crit Pathw Cardiol. 2013; 12: 121-126
        • Fanaroff A.C.
        • Rymer J.A.
        • Goldstein S.A.
        • Simel D.L.
        • Newby L.K.
        Does this patient with chest pain have acute coronary syndrome?: the rational clinical examination systematic review.
        JAMA. 2015; 314: 1955-1965
        • Stopyra J.P.
        • Miller C.D.
        • Hiestand B.C.
        • et al.
        Chest pain risk stratification: a comparison of the 2-hour accelerated diagnostic protocol (ADAPT) and the HEART pathway.
        Crit Pathw Cardiol. 2016; 15: 46-49
        • Backus B.E.
        • Six A.J.
        • Kelder J.H.
        • Gibler W.B.
        • Moll F.L.
        • Doevendans P.A.
        Risk scores for patients with chest pain: evaluation in the emergency department.
        Curr Cardiol Rev. 2011; 7: 2-8
        • Mahler S.A.
        • Miller C.D.
        • Hollander J.E.
        • et al.
        Identifying patients for early discharge: performance of decision rules among patients with acute chest pain.
        Int J Cardiol. 2013; 168: 795-802
        • Hess E.P.
        • Hollander J.E.
        • Schaffer J.T.
        • et al.
        Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.
        BMJ. 2016; : i6165
        • Hess E.P.
        • Knoedler M.A.
        • Shah N.D.
        • et al.
        The chest pain choice decision aid: a randomized trial.
        Circ Cardiovasc Qual Outcomes. 2012; 5: 251-259
        • Cuckler G.A.
        • Sisko A.M.
        • Keehan S.P.
        • et al.
        National health expenditure projections, 2012–22: slow growth until coverage expands and economy improves.
        Health Aff. 2013; 32: 1820-1831
        • Martin A.B.
        • Hartman M.
        • Washington B.
        • Catlin A.
        National health spending: faster growth in 2015 as coverage expands and utilization increases.
        Health Aff. 2017; 36: 166-176
        • Flynn D.
        • Knoedler M.A.
        • Hess E.P.
        • et al.
        Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review.
        Acad Emerg Med. 2012; 19: 959-967
        • Melki D.
        • Jernberg T.
        HEART Score.
        Crit Pathw Cardiol. 2013; 12: 127-131
        • Riley R.F.
        • Miller C.D.
        • Russell G.B.
        • et al.
        Cost analysis of the history, ECG, age, risk factors, and initial troponin (HEART) pathway randomized control trial.
        Am J Emerg Med. 2017; 35: 77-81
        • Mahler S.A.
        • Riley R.F.
        • Russell G.B.
        • et al.
        Adherence to an accelerated diagnostic protocol for chest pain: Secondary analysis of the HEART pathway randomized trial.
        in: Academic emergency medicine. 2016: 70-77
        • Than M.
        • Aldous S.
        • Lord S.J.
        • et al.
        A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department.
        JAMA Intern Med. 2014; 174: 51