Improving Care Processes for Patients with Possible Acute Coronary Syndrome ( ICARE-ACS )
Patients with p potential A ACS CS ACS 20% Non-ACS 80% 0 2 4 6 ED 8 Ward 10 12+ Time MT 22.09.14
Patients w with p potential A ACS ACS 20% Non-ACS 80% 0 2 Low Risk 35% 4 Intermediate Risk 6 ED 25% 8 Ward 10 Highest Risk 12+ 20% Time MT 22.09.14
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 2 ND 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. on 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 or 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 of 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 2 nd 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 scores Hospital ECG to exit pathway Clinical Low Intermediat High TroponinAs Timing for Threshol Decision e say low risk ds (ng/L) Aid score Ischemic changes not Wairarapa Hs-cTnT 0h & 2h ≥14 EDACS <16 ≥16 known to be old Ischemic change on North Shore TnI 0 & 2h § ≥40 mTIMI* 0 1-3 ≥4 ECG Ischemic change on 0 & 2h § Waitakere TnI ≥40 mTIMI* 0 1-3 ≥4 ECG Only Low risk go down the Middlemore Hs-cTnI 0 & 3h ≥26 Dynamic ST changes EDACS <16 pathway Ischemic changes not ≥16 & ≥16 & Waikato Hs-cTnT 0h & 2h ≥14 EDACS <16 known to be old mTIMI<4 mTIMI≥4 Ischemic changes not Wellington Hs-cTnT 0h & 2h ≥14 EDACS <16 ≥16 known to be old Ischemic changes not Hutt Hs-cTnT 0h & 2h ≥14 EDACS <16 ≥16 known to be old Risk process stratification
RESULTS • Data collected on 31,332 patients • 11,529 patients pre-implementation • 19,803 patients post-implementation
Pre Post n 11,529 19,807 46.5 Female (%) 45.6 10.4 Maori (%) 10.5 13.6 MACE in 30d (%) 12.9
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
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
Hospital Pre-ADP Post-ADP Time between troponin measurements (h) 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 between two troponins
Time difference between the first two troponin measures.
Absolute Pre-ADP Post-ADP Difference MACE in No MACE in Proportion MACE in No MACE in Proportion Hospital LoS 30d 30 d <6h (%) 30d 30 d <6h (%) >6h 39 142 Wairarapa 53 188 2.7% ≤6h 0 103 36.3% 1 153 39.0% >6h 417 2326 North Shore 291 1946 8.8% ≤6h 0 77 2.7% 1 276 11.5% >6h 144 1138 Waitakere 123 1116 6.7% ≤6h 0 73 5.4% 0 170 12.1% >6h 511 2778 Middlemore 447 2481 1.7% ≤6h 0 176 5.1% 0 207 6.8% >6h 176 1230 Waikato 759 3518 9.1% ≤6h 1 88 6.0% 5 754 15.1% >6h 179 962 Wellington 288 1143 28.4% ≤6h 0 125 9.9% 2 887 38.3% >6h 92 434 Hutt 186 791 6.1% ≤6h 4 314 37.7% 4 757 43.8% 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.
Pre-ADP Post-ADP Hospital Hospital LoS (days) Hospital LoS (days) p 0.44 Wairarapa 0.8 (0.2-2.3) 0.6 (0.2-2.3) <0.001 North Shore 1.2 (0.7-3.9) 1.1(0.5-3.3) 0.20 Waitakere 1.1 (0.7-2.2) 1.1(0.5-2.7) 0.29 Middlemore 1.1 (0.7-3.1) 1.1(0.7-3.3) 0.006 Waikato 1.2 (0.6-3.1) 1.2 (0.3-3.4) <0.001 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) Secondary Outcomes: Length of Stay
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 99.7 (99.3-99.9) 99.4 (99.0-99.7) Sensitivity P=0.28 99.5 (98.8-99.8) 99.6 (99.3-99.7) Negative predictive value
• 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
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