The Chest Pain Dance: Our Latest ER Craze
Posted on February 28, 2013
“Change is hard”
- 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.
- 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 The simple stay or go has been replaced by: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. 🙂