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Chest pain units help EDs streamline care, boost throughput for low- to moderate-risk patients
Keys to success: High chest pain volume, partnerships with cardiology and radiology
The ED at Shands Critical Care Center at the University of Florida in Gainesville, FL, sees about 9,000 patients every year who present with chest pain, and until recently, a high percentage of the low- to moderate-risk patients were being admitted to the hospital for further observation. However, this was creating a bed crunch that Shands Cancer Hospital, where the ED is housed, could ill afford.
"We are a heavy-volume academic center; 75,000 patients a year come to the ED," says Preeti Jois, MD, an assistant professor of emergency medicine at Shands Critical Care Center Emergency Department. "So we looked for ways to alleviate the logjam with beds, and we decided one way to do it would be to create a unit where we could better evaluate the low- to moderate-risk chest pain patients that we were otherwise admitting."
The approach offered several advantages: The patients could be evaluated more efficiently, significantly shortening their length-of-stay (LOS) while also boosting throughput in the ED. Further, even without the routine 2- to 3-day hospital stay typically required to evaluate these patients, they could leave the hospital with a definitive diagnosis as opposed to receiving referrals for follow-up testing. This would also mean if these patients returned to the ED with chest pain, providers would have their cardiac evaluations in hand and could immediately rule out a heart problem. (Also, see Chest pain units guided by 'a clear plan of action,' below.)
Hospital administrators bought into the approach, and the "chest pain ER" at Shands opened in August of 2011. Jois is the medical director of the eight-bed, 1,500-square-foot unit that is housed within the main ED, and she indicates that some of the benefits of the unit were apparent in just the first three weeks. "We had 51 patients go through the new unit, and we admitted five of them," she says. "So if you think about it, we have diminished our low-to-moderate risk admissions by about two-thirds to one out of about every 10 patients."
Such units do require an investment in personnel, says Jois. Shands agreed to fund five dedicated mid-level providers, a nurse, and a tech to manage the chest pain unit, and there is also significant involvement and support from cardiology, she says. However, the approach can make sense for busy EDs that see high volumes of chest pain patients. "It benefits both the provider and the patient and, ultimately, the hospital as well because now you have a place where you can actually do decision-making at evaluation without necessarily admitting a patient for three days," adds Jois. "If you have freed up a bed for someone who really needs it, you have benefitted the whole system, and your throughput in the ED is positively impacted as well."
Keep an eye on outcomes, performance
While the chest pain unit at Shands is brand new, other hospitals have operated chest pain units for many years. Providence, RI-based Rhode Island Hospital, for example, has been operating a seven-bed chest pain center within the confines of its ED since 2007, explains Anthony Napoli, MD, the director of the unit. "Patients were coming into the ED more frequently with chest pain," he says, noting that many of the patients who went on to be admitted to the hospital were in need of observation. The chest pain unit offered a more direct and simplified way to care for this patient group under an observation protocol that was designed for their specific needs; it streamlined the process, says Napoli.
"Also, up until that point, it had been difficult to identify a particular group of physicians who would, in a way, take ownership of this standardized observation period," adds Napoli. "So one of the main things [the chest pain unit] accomplished was it provided a way to give this group of patients a home, if you will, that used the skills of the particular group we involved — emergency medicine and cardiology."
As with the Shands unit, the chest pain unit at Rhode Island Hospital has significantly reduced the amount of time patients need to spend in the hospital. The average LOS for a patent admitted to chest pain unit is now about 16 hours, says Napoli. However, the approach has also eliminated variation in how these patients were traditionally cared for. "Now we have a process where there is a clear step-by-step progression of their care," he says. "This has allowed a much faster arrival-to-disposition time for individuals, and it enables them to receive all the necessary components of their care."
Process measures that assess the relative efficiency of care are important, but Napoli stresses that the gold standard should involve seeing how patients who have been cared for in the chest pain unit are doing 30 days after discharge. "Even if they do well during their observation stay, that doesn't mean [the visit] was a success at preventing a major adverse cardiovascular event (MAC)," he says. "The whole point of admitting these individuals to the chest pain unit is to insure that they are not having unstable angina."
Consequently, Napoli has implemented a process whereby all patients are contacted 30 days after discharge from the chest pain unit to see how they are doing, and the results, thus far, suggest the chest pain unit is working well. "We have an extremely low rate of adverse outcomes," he says, reporting that in the last set of data that was collected, roughly three in every 1,000 patients treated in the chest pain unit had an adverse cardiovascular event at 30 days post discharge. "Since that data was reported, we haven't seen any adverse outcomes at 30 days, so the rate is probably even lower now because we generally see about 1,600 patients in the chest pain unit every year," says Napoli.
Troy Privette, MD, the director of the chest pain unit at Palmetto Health Richland in Columbia, SC, agrees that in addition to expediting care, chest pain units clearly have the potential to improve care. "It's a benefit that we are doing a lot more screening and tests on cardiac patients than in the past," he says, noting that many of the patients who are admitted to the chest pain unit may not have met the criteria for admission to the hospital previously, and yet, some of them end up having a positive work-up. "We are picking up positive tests in people who would have been ruled negative just based on predictive screening."
The chest pain unit at Richland Hospital has been operating for nearly a decade, and it averages about 10 patients a day, which is about half of all the patients who come into the ED with chest pain, says Privette. "We are there 24/7, and we can keep the work-up rolling. The unit has basically shortened what used to be a 2- or 3-day process to about 18 hours," he says. "Patients are really happy with it. We get a lot of requests from patients who want to stay in the unit rather than go upstairs."
However, Privette stresses that the key to the success of any chest pain unit is a good working relationship between the emergency department and cardiology because the two departments must work together in order to expedite care. Jois agrees with Privette, noting that hospital and ED managers who are interested in implementing a chest pain unit need to take the time to nurture buy-in and support from other departments, especially cardiology and radiology.
"[At Shands], there has been a lot of involvement and support from cardiology. They send us treadmill support staff to come over and run the treadmills in the confines of the unit," says Jois. "You cannot do this as an isolated person in the ED."
Chest pain units guided by a 'clear plan of action'
Not all chest pain units operate within the walls of the ED, and policies can vary. Many units, however, follow a similar process for identifying patients who are suitable for this type of care, and then providing enough testing and evaluation so that an underlying cardiac problem can be picked up or ruled out when a patient's status is not immediately clarified through the initial electrocardiogram (EKG). "Obviously you are teasing out patients who have an asthma exacerbation, pneumonia, or a chest wall contusion," explains Preeti Jois, MD, medical director of the chest pain ER at Shands Critical Care Center in Gainesville, FL. "Those are not going to be people you put in the chest pain unit."
Typically, patients referred to chest pain units will have serial blood markers drawn, repetitive EKGs, and they will undergo stress testing or sometimes cardiac computed tomography (CT), says Jois. And in many chest pain units, patients receive a cardiac consultation before they leave, so they are equipped with targeted education and they are connected with a specialist for any needed follow-up care.
"It is an easy population to define, and an easy population to provide a fairly regimented care plan for," explains Anthony Napoli, MD, the director of the chest pain unit at Rhode Island Hospital in Providence, RI. "Most facilities have an opportunity to improve the care of these individuals and improve the timeliness with which they get this care because this is something that, unlike other medical diagnoses, lends itself to a fairly clear plan of action."
While you don't necessarily need dedicated space, Napoli stresses that it is important to have staff who are geared toward the care of this patient group, and a leader who oversees the unit. "You need someone who will take charge of evaluating the process you have implemented and who will insure that patients have effective outcomes," he says.
A key factor that you can't get around is that you need to have a high enough census of patients to justify creation of a chest pain unit, stresses Troy Privette, MD, director of the chest pain unit at Palmetto Health Richland in Columbia, SC. "If you don't have a fairly large chest pain population coming through your ED, it is probably not going to be worth the time, expense, and the structure to set it up," he says. "But for those who do have significant volume, it is definitely worth the time and effort."