Improving Care Processes for Patients with Possible Acute Coronary - - PowerPoint PPT Presentation

Improving Care Processes for Patients with Possible Acute Coronary Syndrome (ICARE-ACS)

Patients with p potential A ACS CS

ACS 20%

Non-ACS 80%

Time 12+ 8 6 4 2 10

MT 22.09.14

ED Ward

Patients w with p potential A ACS

ACS 20% Non-ACS 80%

Time Low Risk 35% Intermediate Risk 25% Highest Risk 20% 12+ 8 6 4 2 10

MT 22.09.14

ED Ward

ADP = Accelerated decision-making pathways

• ADAPT (modified TIMI score)
• EDACS (Emergency Department Assessment of Chest-pain Score)
• HEART
• Modified HEART (HAR)
• European society of cardiology
• Vancouver
• Manchester score MACS
• ALL BRING FORWARD TIMEPOINT OF 2ND TROPONIN SAMPLE FOR LOW-RISK PATIENTS TO 1,2,OR 3 HRS

Phases of ICARE-ACS related to specific studies that formed the evidence base for the project

NZ chest pain pathway implementation:

• 1. A clear clinical pathway documentation process
• 2. a structured and reproducible process of ACS risk stratification (e.g. clinical score)
• 3. guidance for consistency of sampling time-points for performing cTn and ECG testing (e.g.
• n arrival and after a further specified timepoint(s).
• 4. guidance about how to combine clinical risk stratification, and ECG and troponin testing

with a structure on how to guide patient management (admission, discharge and further investigations)

• 5. guidance and timeframes for performing follow-up testing; e.g. stress testing
• 6. guidance for selection of patients for telemetry and removal from telemetry
• 7. clear discharge planning, which includes patient education and lifestyle modification advice

(where appropriate).

• 8. A robust quality assurance program

CSANZ - 2016

• 2.4.1 Use of clinical assessment pathways
• Recommendation: A patient presenting with acute chest pain
• r other symptoms suggestive of an ACS should receive care

guided by an evidence-based Suspected ACS Assessment Protocol that includes formal risk stratification. (NHMRC Level

• f Evidence (LOE): IA; GRADE strength of recommendation:

Strong).

HYPOTHESIS

• That the introduction of ACS clinical assessment framework

incorporating an Accelerated Diagnostic Pathway (ADP) will….

• increase the proportion of patients safely discharged home within 6

hours of presentation to ED.

INCLUSION

• Adults (≥18 years of age)
• Serial troponin testing for possible ACS as indicated by a

cardiac troponin test performed during initial assessment in the ED with a 2nd test performed within 24 hours of attendance.

• Data extraction scripts prospectively written into local

laboratory information systems

SETTING

• 7 NZ HOSPITALS
• Deliberately, different sizes, demographics, troponin assays

Details of ICARE-ACS pilot and national implementation stakeholder involvement

Risk process stratification

Risk scores Hospital TroponinAs say Timing for low risk Threshol ds (ng/L) ECG to exit pathway Clinical Decision Aid score Low Intermediat e High Wairarapa Hs-cTnT 0h & 2h ≥14 Ischemic changes not known to be old EDACS <16 ≥16 North Shore TnI 0 & 2h§ ≥40 Ischemic change on ECG mTIMI* 1-3 ≥4 Waitakere TnI 0 & 2h§ ≥40 Ischemic change on ECG mTIMI* 1-3 ≥4 Middlemore Hs-cTnI 0 & 3h ≥26 Dynamic ST changes EDACS <16 Only Low risk go down the pathway Waikato Hs-cTnT 0h & 2h ≥14 Ischemic changes not known to be old EDACS <16 ≥16 & mTIMI<4 ≥16 & mTIMI≥4 Wellington Hs-cTnT 0h & 2h ≥14 Ischemic changes not known to be old EDACS <16 ≥16 Hutt Hs-cTnT 0h & 2h ≥14 Ischemic changes not known to be old EDACS <16 ≥16

RESULTS

• Data collected on 31,332 patients
• 11,529 patients pre-implementation
• 19,803 patients post-implementation

Pre Post n Female (%) Maori (%) MACE in 30d (%) 11,529 19,807 46.5 45.6 10.4 10.5 13.6 12.9

Demographics of patients with two troponin measurements within 24 hours

Pre-ADP Post-ADP Hospital n Females Mean age (SD) Maori n Females Mean age (SD) Maori Wairarapa 284 42.3% 70.2 (16.0) 3.2% 395 41.8% 69.6 (15.2) 1.5% North Shore 2820 48.4% 66.8 (16.8) 4.9% 2514 47.9% 66.2 (16.7) 4.7% Waitakere 1355 49.2% 63.4 (17.4) 9.9% 1409 47.7% 63.8 (11.8) 11.8% Middlemore 3465 46.1% 61.9 (16.1) 14.2% 3135 43.6% 63.1 (16.0) 13.4% Waikato 1495 45.3% 66.8 (15.9) 15.1% 5039 44.5% 66.8 (16.0) 15.9% Wellington 1266 43.8% 67.6 (15.2) 7.4% 2320 45.3% 66.2 (15.6) 7.5% Hutt 844 44.8% 67.2 (15.4) 12.2% 1738 44.6% 65.4 (15.9) 12.0%

Pre-ADP Post-ADP Hospital n Females Mean age (SD) Maori n Females Mean age (SD) Maori Wairarapa 284 42.3% 70.2 (16.0) 3.2% 395 41.8% 69.6 (15.2) 1.5% North Shore 2820 48.4% 66.8 (16.8) 4.9% 2514 47.9% 66.2 (16.7) 4.7% Waitakere 1355 49.2% 63.4 (17.4) 9.9% 1409 47.7% 63.8 (11.8) 11.8% Middlemore 3465 46.1% 61.9 (16.1) 14.2% 3135 43.6% 63.1 (16.0) 13.4% Waikato 1495 45.3% 66.8 (15.9) 15.1% 5039 44.5% 66.8 (16.0) 15.9% Wellington 1266 43.8% 67.6 (15.2) 7.4% 2320 45.3% 66.2 (15.6) 7.5% Hutt 844 44.8% 67.2 (15.4) 12.2% 1738 44.6% 65.4 (15.9) 12.0%

Demographics of patients with two troponin measurements within 24 hours

Time between two troponins

Hospital Pre-ADP Time between troponin measurements (h) Post-ADP Time between troponin measurements (h) Wairarapa 3.8 (2.8-7.3) 3.3 (2.4-4.9) North Shore 6.2 (5.8-7.2) 6.0 (4.4-6.7) Waitakere 6.2 (5.6-7.1) 6.1 (5.1-6.8) Middlemore 6.0 (5.0-6.8) 6.0 (4.6-6.6) Waikato 4.7 (3.8-6.23) 3.8 (2.5-5.4) Wellington 4.6 (3.3-6.4) 3.3 (2.3-5.2) Hutt 3.3 (3.0-4.1) 2.7 (2.1-3.3)

Time difference between the first two troponin measures.

Pre-ADP Post-ADP Absolute Difference Hospital LoS MACE in 30d No MACE in 30 d Proportion <6h (%) MACE in 30d No MACE in 30 d Proportion <6h (%) Wairarapa >6h 39 142 53 188 ≤6h 103 36.3% 1 153 39.0% 2.7% North Shore >6h 417 2326 291 1946 ≤6h 77 2.7% 1 276 11.5% 8.8% Waitakere >6h 144 1138 123 1116 ≤6h 73 5.4% 170 12.1% 6.7% Middlemore >6h 511 2778 447 2481 ≤6h 176 5.1% 207 6.8% 1.7% Waikato >6h 176 1230 759 3518 ≤6h 1 88 6.0% 5 754 15.1% 9.1% Wellington >6h 179 962 288 1143 ≤6h 125 9.9% 2 887 38.3% 28.4% Hutt >6h 92 434 186 791 ≤6h 4 314 37.7% 4 757 43.8% 6.1%

Primary Outcome: 2x2s of MACE and Discharge within 6h

Forest Plot of the Odds Ratio for each hospital. An OR>1 indicates increased odds of being discharged within 6 hours.

Secondary Outcomes: Length of Stay

Pre-ADP Post-ADP Hospital Hospital LoS (days) Hospital LoS (days) p Wairarapa 0.8 (0.2-2.3) 0.6 (0.2-2.3) 0.44 North Shore 1.2 (0.7-3.9) 1.1(0.5-3.3) <0.001 Waitakere 1.1 (0.7-2.2) 1.1(0.5-2.7) 0.20 Middlemore 1.1 (0.7-3.1) 1.1(0.7-3.3) 0.29 Waikato 1.2 (0.6-3.1) 1.2 (0.3-3.4) 0.006 Wellington 0.9 (0.4-2.8) 0.7 (0.2-2.1) <0.001 Hutt 0.4 (0.2-2.3) 0.3 (0.2-2) <0.001

Length of hospital stay for non-ACS patients

Non-ACS patients

Median reduction length of stay =

2.9 h (2.4-3.4)

SAFETY

PRE POST

Sensitivity

99.7 (99.3-99.9) 99.4 (99.0-99.7)

Negative predictive value

99.5 (98.8-99.8) 99.6 (99.3-99.7)

P=0.28

• NO PATIENT MANAGED ACCORDING

TO PATHWAY HAD MACE

CONCLUSION

• ACS assessment pathways are EFFECTIVE and SAFE in real life practice
• ALL Australasian hospitals should be using them