Rationale for Critical Pathways in Acute Coronary Syndromes
Critical pathways are standardized protocols for the management of specific disorders that aim to optimize and streamline patient care.1,2 Other names used for such programs are “clinical pathways” or simply “protocols,” such as acute myocardial infarction (AMI) protocols used in the emergency department to reduce time to treatment with thrombolysis.3 “True” critical pathways detail processes of care and potential inefficiencies for more complex medical procedures, such as coronary artery bypass surgery.2 Some pathways are algorithms and treatment recommendations focusing on improving compliance with evidence-based medicine and have more relevance in the ambulatory setting (e.g., hypertension or hyperlipidemia).4 Critical pathways were first developed for industry as a tool to streamline production processes.5 Applied in medicine, critical pathways initially emerged as a means to reduce length of hospitalization, but they soon were recognized as an important tool for improving quality of care. Critical pathways can help improve appropriate use of medications and treatments, improve patient triage to the appropriate level of care, and limit the use of unnecessary tests to reduce costs and allow savings to be allocated to other treatments that have been found to be beneficial (Table 1).
In particular, for patients with acute coronary syndromes (ACS), critical pathways are needed because many patients do not receive evidence-based therapies and there is wide variation in care. Aspirin, heparin, and beta-blockers have been shown to improve outcomes in ACS, and their use was recommended in national guidelines released in 1994 and 2000.6,7 However, the National Registry of Myocardial Infarction (240,989 patients) showed that only 63% of patients with non-ST-segment elevation MI received aspirin.8 In the Thrombolysis in Myocardial Infarction III (TIMI III) and Global Unstable Angina Registry And Treatment Evaluation (GUARANTEE) registries of unstable angina and non-ST-segment elevation MI, 80% of patients received aspirin.9,10 In TIMI III and GUARANTEE, heparin was used in 60% of patients; also, beta-blocker therapy was underused. Variation in the use of tests, such as laboratory panels and echocardiograms, has been well seen in the assessment of chest pain. Finally, newer medications, including low molecular weight heparin, clopidogrel, and glycoprotein IIb/IIIa inhibitors, have been shown to improve outcomes in unstable angina/non-ST elevation ACS.11–14 These newer medications are recommended in the recently released guidelines of the American College of Cardiology/American Heart Association (ACC/AHA).7
Other opportunities for improvement in ACS are hospital length of stay and utilization of intensive care and coronary care units (CCU). Hospitalizations for ACS ranged from 8 to 9 days in registries in the mid 1990s.9 A decade ago, admission to the CCU was standard for patients with unstable angina and MI. In the GUARANTEE registry, 40% of patients with unstable angina and non-ST-segment elevation MI were admitted to the CCU. 10 Current recommendations are to restrict CCU admissions to patients who are at higher risk (ST-segment elevation MI, hemodynamic compromise, or other complications).7,15
Critical Pathways Can Improve Care
Performance data on critical pathways in cardiology are beginning to emerge and show that these pathways can lead to improved outcomes. Several studies have evaluated critical pathways in cardiac surgery and have demonstrated that they reduce length of stay and costs.16 Studies of chest pain protocols have shown that they reduced length of stay, missed MIs, hospital admissions, and hospital costs.17–20 A thrombolysis protocol for AMI decreased door-to-drug time by 50%.21
The Guidelines Applied in Practice (GAP) project of the ACC was implemented in 10 hospitals in Michigan and led to improvements in several performance measures, as reported by Kim Eagle,22 MD, at the 2001 scientific sessions of the ACC in Orlando. Dr Eagle's group put together materials designed to make it easier for hospitals to put the ACC/AHA AMI guidelines into practice; these materials included a critical pathway, standard orders, pocket cards, chart stickers, and patient handouts. Implementation of the protocols and pathways led to improvements in utilization of appropriate medications: beta-blocker use rose from 65% of patients to 77%; aspirin use in the hospital, from 76% to 87%; and aspirin use at discharge, from 81% to 93%.22
Another hospital-based quality improvement program, the Cardiac Hospital Atherosclerosis Management Program (CHAMP), used a treatment algorithm to increase utilization of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and statins for secondary prevention.4 They were able to dramatically improve compliance with secondary prevention measures and were able to show improve achievement of cholesterol lowering to a goal of low-density lipoprotein cholesterol.
Thus, based on variations in care and the need to improve quality while reducing unnecessary use of resources, a strong rationale exists for using critical pathways in the management of ACS. Protocols and pathways succeeded in improving door-to-needle time in AMI and in increasing utilization of appropriate medications. The extension of these principles to unstable angina and non-ST-segment elevation MI is the goal of the Acute Coronary Syndromes: Acute Cardiac Team to Implement Optimal Treatments Now (ACS ACTION) program.
Approach to Critical Pathways
The approach to a critical pathway involves three phases: pathway development, implementation, and maintenance (continuous quality improvement) (Table 2). Each phase has different components and approaches. This section goes through the process for each step.
Developing a pathway involves a five-step process (Table 3): first to identify the problem, then assemble the team, assess the existing process, review the data, and disseminate a draft pathway for input and revision to final pathway. The details of each step are outlined in the following sections.
Identify the Problem
Development of a pathway begins with identifying the problem, such as underuse of newly available effective therapies (clopidogrel, glycoprotein IIb/IIIa inhibitors, and low molecular weight heparin) and underutilization of existing therapies (aspirin, heparin, and beta-blockers) for ACS.
Assemble the Team
The team should be multidisciplinary and include representatives from all groups that would be affected by the pathways and whose buy-in would be needed for implementation. For example, an unstable angina pathway committee should include representatives from cardiology (interventional and noninterventional), emergency medicine, nursing, cardiac surgery, noninvasive laboratory, pharmacy, cardiac rehabilitation, social service, case management, and dietary service.23 A smaller group can be useful to do the initial draft. At Virginia Commonwealth University/Medical College of Virginia, organization of a multidisciplinary Acute Cardiac Team (ACT) was one of the key elements in the success of chest pain critical pathways.19 This was a multidisciplinary team of emergency physicians, cardiologists, and lab and nursing staff who participated in the decision making (Figure 1). A draft agenda for the first meeting of this group to develop a pathway is provided in Table 4.
Assess the Existing Process
This step first involves an assessment of current emergency department and cardiology practice for ACS. The committee should undertake an inventory of procedures, protocols, and pathways that are currently in place. A checklist is provided to assist with this process (Table 5). Some committees may want to undertake a more detailed analysis, consisting of a review of medical records to identify critical intermediate outcomes, rate-limiting steps, and high-cost areas on which to focus their efforts.2
Review the Data
The committee should review the literature to identify best practices and optimal processes of care. For ACS, new guidelines from the ACC/AHA and new studies define the optimal therapies and approach to risk stratification and management strategies.7 In brief, the ACC/AHA guidelines provide specific recommendations for the early risk stratification, immediate medical management, and hospital care of patients with ACS. These guidelines provide a clinical risk stratification algorithm, review the role of the electrocardiogram, serum markers (such as troponins), and functional testing, and they outline an acute ischemia pathway. Recommendations for antiischemic therapy and antithrombotic therapy are spelled out, as are the indications for early invasive or early conservative management strategies.
Determine the Pathway Format and Disseminate a Draft Pathway
Although the format of critical pathways may vary, an important feature is a time task matrix in which specific tasks are organized along a timeline. 2 There is a spectrum of pathways, ranging from a form that takes the place of the medical record to a simple checklist. Critical pathways may help reduce charting in more complicated situations. If the pathway format is too difficult to follow, it will not be used.
Reviewing the draft pathway with the committee and getting buy-in from all parties is an important step. At Medical College of Virginia, instituting the protocol involves a multidisciplinary approach to decision-making involving emergency medicine, cardiology, nursing, and laboratory personnel. With so many constituencies, it is important to have respect for everyone's perspective. Buy-in is obtained by consensus meetings with acceptance of group decisions. To maximize the impact of the first announcement, the rollout should take a “Big Bang” approach.
Implementing the pathway can be challenging and, if not handled well, can lead to barriers to utilization. All staff involved in any component of the pathway must be educated about it; this includes nonparticipants who may be affected by the pathway. Misconceptions need to be dispelled. Questions about repercussions from failure to follow the pathway should be addressed. Roles and responsibilities must be clearly defined for all staff involved in implementation of the pathway. 2
Pathways may be implemented in several ways. The pathway may be sent to physicians and nurses and presented at appropriate staff meetings, with implementation depending on voluntary participation. Another means of encouraging pathway use would be e-mail reminders triggered by admission diagnosis or monthly reminders to physicians and nurses. Or, there could be independent screening of all admissions with copies of the pathway placed in the chart. Some hospitals have used designated case managers to evaluate each patient and ensure that the pathway is carried out. This obviously has the drawback of requiring additional resources from the hospital.
An effective method of implementing a pathway is to release it in the form of a set of standard orders. Standard orders may be printed for use in the emergency department or in an electronic format. Tools such as wall chart, pocket cards, and simple checklists can help to implement critical pathways.
Figure 2 shows a simple “cardiac checklist” for unstable angina and non-ST-segment elevation MI. This checklist could be used in two ways: physicians could keep a copy on a small index card and scan the list when writing admission orders or the checklist could be used to develop standard orders for a patient with ACS. The ACC GAP project demonstrated the effectiveness of simple tools, such as pocket cards, wall charts, and standard orders, in increasing utilization of appropriate medications for AMI.22
The newest type of tool is the TIMI Risk Calculator developed for the Palm handheld device (Palm, Inc., Santa Clara, CA) (Figure 3). This tool is an interactive tool that allows physicians to calculate the TIMI Risk Score for an individual patient. It then provides outcomes for the patient from several large trials and shows the benefits of new therapies-notably clopidogrel, low molecular weight heparin, glycoprotein IIb/IIIa inhibition, and an early invasive strategy-all tailored to the patient's risk. The Palm program also provides the recommendation from the ACC/AHA Unstable Angina and non-ST Elevation Myocardial Infarction Guideline for management of the patient based on his/her risk score. The newest version includes the ST elevation MI risk scores in addition to the Unstable Angina and non-ST Elevation Myocardial Infarction risk score.
Along with putting the pathway in place, a continuous quality improvement process must be instituted to monitor the pathway's use and effectiveness. Data must be collected and analyzed and processes must be refined to achieve the improvement in outcomes and resource utilization.2 At Virginia Commonwealth University/Medical College of Virginia the continuous quality improvement program has the following elements: dedicated quality improvement staff (one nurse practitioner, two full-time data technicians); an integrated chest pain patient database maintained on all level I to IV patients capturing demographic, process, and outcome variables from multiple sources; and discreet, timely feedback to physicians and nurses regarding their care of cardiac patients. The team keeps up with weekly multidisciplinary continuous quality improvement case conferences, daily CCU morning nuclear imaging rounds, monthly emergency department cardiac case reviews, and Grand Rounds presentations. The frequency of such meetings should be tailored to the institution. A sample quality improvement team agenda is provided in Table 6.
The monitoring of data can be through established registries (such as the National Registry of Myocardial Infarction [NRMI]) or newer initiatives (such as the AHA's Get With the Guidelines program) or the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) program. Alternatively, a more streamlined registry form can be a helpful tool to assist with a regular review process. The form should collect key data points that can be analyzed to improve performance. A sample ACS registry form is provided in Figure 4. As part of the maintenance process, the team should be reviewing new therapies and treatments and considering modification or updating of the pathway to improve and keep it current.
Critical pathways offer great potential to improve outcomes. This ACS ACTION program is an overview of the process of developing and implementing a pathway, with an ACS pathway as the template. It is designed to help institutions go through the process step by step, with the ultimate goal of implementing in guidelines into practice.
The pathway materials are adapted from the ACS ACTION program booklet developed by the authors in conjunction with the Academy for Healthcare Education, with permission, copyright 2001, Academy for Healthcare Education, New York.
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© 2002 Lippincott Williams & Wilkins, Inc.
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