“Change is hard”

supertrack flow
Oh for the simple days. A patient came in and all you needed to do was recognize sick from not sick and who needed to be admitted. OK a slight exaggeration, but we got the patient to a certain point and someone else took over the care.
Now life is much more complicated.  Rather than a dichotomous choice we are required to know what the patient is likely to need in the next 1 to 2 days. We often need to determine the Who, What, and When instead of just the Where.
Take chest pain for example. Up until recently our ED had as diagnostic tools only EKG and cardiac markers to complement physician evaluation. Our choices were stark:  send the patient home or admit them for additional workup.
As the fear of missing an MI was large and close follow up often difficult to arrange admission was a default choice for many of our patients (35% of chest pain patients over the age of 35 were typically admitted).
ED Sign
Then forces within and beyond our control began to catalyze change:
  • Insurance companies intensified denials of admissions that were solely for diagnostic chest pain workup. They Reasoned that these could be accomplished in different settings (including in the ED, during observation, or as an outpatient).
  • Increased demand for our hospital’s telemetry beds as local hospitals closed their inpatient units.
  • The decision to defer establishment of a non-ED based observation program at our facility.
and provide opportunities in the care of patients with lower risk chest pain:
  • Better evidence based risk stratification coming from published trials.
  • High sensitivity troponins that help better risk stratify low risk patients.
  • CT Hearts (Calcium scoring) that significantly reduce post test probability of ischemic cause of chest pain.
  • Most importantly improved care coordination with cardiology including immediate outpatient followup and stress testing.

So now our choices for lower risk chest pain are numerous and require additional skill sets. The simple stay or go has been replaced by:

  • Send home after risk stratification using high sensitivity troponin.
  • Stay longer and get additional testing (CT heart).
  • Discharge after a normal prolonged ED work up for close cardiology follow up.
  • ED Observation including serial troponins and cardiac stress testing.
  • Admission if EKG, troponins, or risk stratification (high TIMI score) warrant a more extended evaluation.

We developed LOW RISK CHEST PAIN GUIDELINES to optimize flow and reduce admissions for diagnostic evaluation only. For the docs this requires a deeper knowledge of the extended evaluation of chest pain along with how to interpret diagnostic tests previously little used by them (calcium scoring, exercise and cardiolyte stress tests).

Also as some patients stay longer (for ED Observation lasting 16+ hours) the nurses will have to adapt to different set of patient needs and care coordination (including daily meds).

The percent of patients admitted to the hospital from our ED was already on the decline (See below). This is a reasonable step forward in that trend.  Will this have the desired effect of safely reducing admissions?

Will this lead to additional guidelines targeting other types of previously admitted conditions?

Will my head explode just thinking about this?  Stay tuned. 🙂


Adult admits