Low-risk Chest Pain Pathway: A Market Plan

Low-risk Chest Pain Pathway: A Market Plan

Executive Summary

Chest pain is a common cause of hospitalization and annually accounts for more than 600,000 hospitalizations per year and $3.7 billion per year. (Penumetsa et al., 2012). Chest pain hospitalizations account for more than $3.7 billion in hospital costs (Penumetsa et al., 2012). Northwestern Memorial Hospital Emergency Department (NMHED)  functions as a chest pain center that assesses and admits patients for acute coronary syndrome (ACS) several times a day. Standard protocol for patients with rule out ACS is observation admission for an exercise stress test. However, this patient population may not always benefit from admission and may be better off with close-follow up. The goal of the low-risk chest pain pathway is to discharge a patient home from the ED with a scheduled stress echo within 72 hours and a primary care appointment within a week.

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As the cost of hospitalization increases, payers and insurance companies are often looking for ways to cut costs. Paying for observation stays in the hospital are one of the costs usually not covered by Medicare or other insurers (Kangovi et al., 2015). Additionally, a major problem that Emergency departments have been facing is overcrowding. The inpatient beds are often full, leaving patients waiting hours or days for an inpatient bed. This pathway would remove those patients from waiting in the ED, freeing up beds for other patients. It would also improve patient follow up with a scheduled stress test and primary care appointment within the same week. Many individuals who seek care from the ED don’t have primary care providers and this would provide these patients the opportunity to establish care with a primary care provider.

In order for this plan to occur, approval is needed from stress lab and cardiology. A team of nurse practitioners also needs to be hired to float between the ED, stress lab, and PCP. The goal is to establish a team of nurse practitioners who have an interest in cardiology to see these patients with a internal medicine provider. Once the stress labs gives their approval, they will hold five, 8 am stress echo spots Monday through Friday. If the echo is abnormal, the patient will meet with the nurse practitioner and cardiologist. If the echo is within normal limits, the patient will meet with the internal medicine provider and the nurse practitioner. When a patient is deemed eligible by the ED team for the pathway, according to the HEART score, the nurse practitioner team member will meet them in the ED, explain the pathway and then see them in clinic again within the week. The nurse practitioner team will be vital in the continuity of care for these patients.

The goal of this project is to decrease observation admits for low-risk chest pain patients, establish primary care providers for ED patients, improve continuity of care, get stress echos within timely manners, decrease ED overcrowding, and decrease the number of ED boarding patients.

Low-risk Chest Pain Pathway: A Market Plan

Discription of the Environment

Chest pain is a common cause of hospitalization and annually accounts for more than 600,000 hospitalizations per year (Penumetsa et al., 2012). Chest pain hospitalizations account for more than $3.7 billion in hospital costs (Penumetsa et al., 2012). Northwestern Memorial Hospital Emergency Department (NMHED)  functions as a chest pain center that assesses and admits patients for acute coronary syndrome (ACS) several times a day. Standard protocol for patients with rule out ACS is observation admission for an exercise stress test. However, this patient population may not always benefit from admission and may be better off with close-follow up. As a chest pain center, NMHED often holds boarding patients as they wait for available observation beds. Boarding patients decreases patient satisfaction and decreases the efficiency of the ED. If a standard protocol was present for the low risk, rule out ACS patients, these patients may be able to avoid admission, which would increase efficiency and improve patient satisfaction.

Identification of Key Customers

The question at hand is what makes a patient low risk for ACS. Penumetsa (2012) believes that patients whose presentation does not reveal acute ischemia with nonanginal pain are considered low risk for ACS in the short term. Penumetsa (2012) believes that negative serial enzyme levels such as troponins and nonanginal pain can confirm that there is no active ischemia as well. Penumetsa found that patients discharged home with negative troponin results on serial testing have very low mortality at 30 days. The rate of major cardiac events at 30 days was 0.9%. Penumetsa’s research found that negative enzyme levels rule out current myocardial infarction (MI) and stress tests can be utilized to rule out MIs in the future (2012).

The HEART score is used to identify high risk chest pain patients in the ED (Poldevaart et al., 2017). HEART stands for history, ECG, age, risk factors, and troponin. With a cardiac history, a patients can obtain between 0 to 2 points, from non-suspicious to highly suspicious. For the ECG, again is a 0 to 2 point scale with 0 points for a normal ECG, 1 point for nonspecific repolarization, and 2 points for significant ST-depression. For age, 0 points if less than 45 years ol, 1 point for an age between 45 to 65 years old and 2 points for an age older than 65 years old. Risk factors are specific to coronary artery disease (CAD) and include diabetes, smoker, hypertension, hyperlipidemia, family history of CAD, and obesity. For three or more risk factors, 2 points are acquired. 1 point for 1 or 2 risk factors and 0 points for no risk factors. For greater than three times the normal troponin limit, patients gain 2 points. For one to three times the normal troponin limit then patients obtain 1 point. No points are gained for less than the normal limit. Based on the totalled points discharge, observation, or early invasive intervention is recommended.  Based upon the HEART algorithm, patients with a score between 0 and 3 have a 2.5% chance of major adverse cardiac events (MACE) over the next 6 weeks and are recommended to be discharged home. Patients with a score between 4 and 6 have 20.3% of MACE over the next 6 weeks and are recommended to be admitted for clinical observation. Patients with a score greater than 6 have a 72.7% of MACE over the next 6 weeks and are recommended for early invasive intervention (Poldevaart et al., 2017).

Utilizing the HEART algorithm, NMHED can identify low risk rule out ACS patients who may be better suited for discharge than observation admission.

Describe productive/service with advantages

The historical miss rate for undiagnosed acute myocardial infarction in the ED is 2% to 4% (Amsterdam et al., 2014). Current practices bring the miss rate below 1%. That being said, current practices lead to increased rates of hospital admission and additional diagnostic testing which has been accruing more than $3 billion in annual hospital costs. The 2014 American Heart Association guidelines recommend non-invasive cardiac testing within 72 hours of presentation with negative cardiac markers and non-ischemic ECGs. Admission for cardiac stress test are found to be overutilized in the ED for low-risk chest pain due to the longer lengths of stay, greater costs, and more radiation exposure that occur with these patients. In the era of national health care reform, there is a push for universal healthcare cost savings and quality improvement, and discharging low risk patients with close follow up supports these goals. Utilizing the HEART score to identify low-risk patient can help support this goal (Amsterdam et al., 2014).

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Additionally, with the rising cost for admission there is a lack of funding for observation admissions (Kangovi et al., 2015). Medicare views observation admissions as an outpatient status so patients often accrue large medical bills after observation admissions since they are paying out of pocket. Research has shown that observation admissions are at least 6% more expensive for patients than inpatient admissions. Early discharge from the ED would prevent these patients from accruing large medical bills (Kangovi et al., 2015) as well as decrease the patient load for the ED and observation units.

Additionally, a lot of patients are discharged from the hospital and ED without proper follow-up. Meeting with the nurse practitioner and making the appointments to see them in the clinic within the week will promote continuity of care and improve patient follow-up after discharge.

Objective and goals linked to the mission

The objectives and goals of this mission are to first identify patients with chest pain in the ED who are low risk according to the HEART score but need some sort of cardiac imaging or testing due to their age, family history, or presenting signs and symptoms. The goal is to properly identify these patients, deem them safe for discharge home if possible, and schedule follow up diagnostic imaging and primary care appointments. The goal of this pathway is to provide patients with prompt diagnostic imaging and urgent follow-up, as well as decrease the patient load on the ED and observation units, and to decrease health care costs.

Key strategies, tasks and actions including party cost, outcomes, and completion date

The key strategies and tasks include getting all interdepartmental groups together and on the same page for the workings and procedure of the pathway. In order for this plan to occur, approval is needed from stress lab and cardiology. A team of nurse practitioners also needs to be hired to float between the ED, stress lab, and PCP. The goal is to establish a team of nurse practitioners who have an interest in cardiology to see these patients with a internal medicine provider. Once the stress labs gives their approval, they will hold five, 8 am stress echo spots Monday through Friday. If the echo is abnormal, the patient will meet with the nurse practitioner and cardiologist. If the echo is within normal limits, the patient will meet with the internal medicine provider and the nurse practitioner. When a patient is deemed eligible by the ED team for the pathway, according to the HEART score, the nurse practitioner team member will meet them in the ED, explain the pathway and then see them in clinic again within the week. The nurse practitioner team will be vital in the continuity of care for these patients.

The upfront cost will include hiring and training the nurse practitioner or physician assistant team. The estimate for time of planning to roll out of the pathway is about 6 months, 3 to hire the new team and then 3 months to train the new team. It is estimated that the cost of this NP or PA team will be about $1,200,000/year, paying each team member $150,000/year and estimating that we will need four day time and four evening/night team members.

Recommendations

To start rolling out this pathway, first conversations need to occur between the ED, stress lab, cardiology team, and internal medicine team. Once a pathway plan is approved, then we can start looking to hiring the advanced practice team to float between the ED, cardiology, and internal medicine departments for these pathway patients.

References

• Amsterdam, A. et al., (2014). 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(1). doi: 10.1161/CIR.0000000000000134.
• Kangovi S., Cafardi S., Smith R., Kulkarni R., Grande D. (2015). Patient Costs for Observation Care. Journal of Hospital Medicine 11(1). doi:10.1002/jhm.2436
• Penumetsa S. C., Mallidi J., Friderici J.L., Hiser W., Rothberg M.B. Outcomes of Patients Admitted for Observation of Chest Pain. Archives of Internal Medicine, 172(11):873–877. doi:10.1001/archinternmed.2012.940
• Poldevaart, J. M., Langedijk, M., Backus, B. E., Dekker, I., Six, A. J., Doevendans, P. A., Hoes, A. W., & Reitsma, J. B. (2017). Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. International Journal of Cardiology, 227(1): 656-661. doi: 10.1016/j.ijcard.2016.10.080