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Abstracts of the Sixteenth Congress of the Cardiovascular Patient Care Center

doi: 10.1097/HPC.0b013e31829c0a0d
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The Development of an Emergent Cardiac Response Team

Melinda Loy, RN, BSN, CCRN-CMC, and Michael Bewley, RN, CCRN, University of Kansas Hospital, Kansas City, KS

Background/Objectives: Cardiac emergencies are innately difficult to manage, especially when patients need life-saving interventions. The infrequency of these cases leads to a gap in bedside nursing skills. In an effort to provide resources to nurses at the bedside, the Emergent Cardiac Resource Team was developed. This team’s charge is to coordinate needed emergent cardiac care and to escalate to a higher level of care when needed.

Methods: Upon the advisement of the Chest Pain Center’s Multidisciplinary Committee, the Emergent Cardiac Resource Team was built to support the immediate needs of the cardiac patient through system and staff support. These individuals are an extension of the Rapid Response Team. Consisting of the Physician, CICU Unit Coordinator, CVPCU Unit Coordinator, Respiratory Therapy, and 12-Lead EKG Technician, this team’s role is to quickly determine whether the patient is having an acute myocardial infarction or in need of emergent intervention. If so, they will act as the facilitator in caring and emergently transporting the patient to the Cardiac Catheterization Laboratory.

Results: The ECRT is an invaluable resource. In the last 15 months, they have been called into action 297 times for a total of 271 hours of support. Time is of the essence in treating the most deadly of heart attacks, ST-elevation myocardial infarction. Here, treatment success is measured in minutes. Their bedside leadership has led to an average 20-minute decrease in door to intervention time for this patient population. This is critical for the preservation of that patient’s heart muscle.

Conclusions: Development of the Emergent Cardiac Resource Team has proven to be a unique opportunity where positive patient outcomes are directly linked to the leadership of the bedside experts. Providing nurses at the bedside with a panel of experts in cardiac care allows for nursing to escalate care to a higher level of care or to call on experts when “something just does not feel right to them.” This team has facilitated countless opportunities for improving the quality of care through their dedication and support of cardiac-specific emergencies.

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Results of a 30-Day Drug-in-Hand Program

Ellen P. Probst, MSN, ARNP, RN-BC, NP-C, CHFN, Joel R. Garcia, MD, FACC, Roxanne E. Blanchard, RPh, and Abinette M. Soto, Pharm.D, Dr. P. Phillips Hospital, Orlando, FL

Background/Objectives: Before the start of the pilot in September 2011, Dr. P. Phillips Hospital provided only 7 days of medications for patients who qualify for our indigent program. The pilot program was conducted from September 1, 2011 to June 30, 2012. This pilot program expanded the current 7-day program to 30 days of approved evidence-based cardiac medications to indigent patients on discharge at no charge. By doing this, it would allow adequate time for these patients to access primary care, and other programs that may be available to assist them with their medication needs and follow up appointments. This also would aid in decreasing readmission rates. The following recommendation was developed by a multidisciplinary team with respect to medications to meet an overall goal of providing ALL Heart Failure patients with 30 days of evidence-based approved cardiac medications at time of discharge at a nominal expense to the organization. Pharmacy Consult Team reviewed the following (for indigent patients who qualified for this 30-day program only): number of patients qualifying for the program and estimated costs associated with the program. Before the pilot initiation, it was estimated that less than 2% of our prescription volume would be from true indigent patients. The average drug cost was expected to be $50 per indigent patient.

Methods: A pharmacy consult is generated for ALL patients with ACTIVE heart failure or a history of heart failure. Pharmacists provide these patients with a formal consultation session for medication education and review of their discharge instruction for medication errors. Patients are excluded from consultation if the patient is transferred to another hospital or skilled nursing facility, hospice, expired or refused consultation. If a patient refuses, the direct care RN informs pharmacy, so they may intercept and offer education over the phone or at bedside depending on pharmacist availability. If patient is TRUE INDIGENT, then a SOCIAL WORKER Consult shall be initiated to assess whether patient qualifies for the 30-Day Drug-in-Hand Program. Indigent patients approved by social worker are given 30 days of evidenced-based approved cardiac medications as appropriate without charge PRIOR to being discharged. The pharmacy notifies the clinical team of patients who qualify for the program for separate review and tracks clinical outcomes. Other patients who have insurance coverage also receive pharmacy consultation and are offered to go home with DRUG-IN-HAND to improve adherence to medications and bridge them to their next follow-up appointment in hopes of preventing a readmission. Follow-up appointments are scheduled by nursing floors before discharge with their Primary Care Physician/Cardiologist or Heart Failure Clinic Nurse Practitioner within 7 days of discharge. Appointment date and time are documented on the patient’s discharge instructions. A Pharmacy Consult will be entered as an order for all heart failure patients admitted (identified as: “DPH Pharmacy Consult–DPH Outpatient HF”). Once discharge prescriptions are written, direct care nurse fax all prescriptions to DPH Scripts Pharmacy to be filled before consultation along with an approximate discharge time window. DPH Scripts Pharmacy obtains permission from patient before consultation to fill their medications so patient may go home with DRUG-IN-HAND (Ultimate Goal!). Direct care nurse will discharge patient with all appropriate discharge paperwork and send patient to the DPH Scripts PHARMACY for formal consultation and medication education. It is recommended that support family/caregivers accompany patient for consultation and not get car until consultation is complete. Pill boxes will be used as a tool to help reinforce daily medication adherence.

Results: Total Heart Failure Patients: 563 Number of Eligible Pharmacy Consults: 435 Number of Eligible Pharmacy Consults Completed: 259 Total Number of Indigent Patients: 27 Indigent Cost: TOTAL: $447.60 Average Cost per Indigent Patient: $19.46 30-day readmission rate for Indigent Patients: 1 indigent patient/435 eligible consults (0.0023%).

Conclusions: It was estimated that the cost for providing indigent patients with 30 days of cardiac medications in hand would be approximately $50 per person. Average cost per indigent patient was $19.46. This was a significant cost savings of $30.54 per indigent patient. In addition, as an organization, we have developed best practices in having the Heart Failure Pharmacy 30-Day Drug-in-Hand Program assist with better core measures outcomes and reducing heart failure to heart failure readmissions. Dr. P. Phillips Hospital is now piloting a bedside pharmacist consultation program that will educate and fill medications at bedside before discharge.

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Prevalence and Implications of Severe Anxiety in Emergency Department Patients With Chest Pain

Julio Schwarz, MD, Adesh Prashad, and David E. Winchester, MD, MS, Malcom Randall VAMC, Gainesville, FL

Background/Objectives: Although chest pain is a common symptom for patients in emergency department, the majority of etiologies are noncardiac. Anxiety can manifest with sensations of discomfort in the chest which may result in patients seeking emergency care. The objective of this investigation is to determine the prevalence of anxiety and any pertinent differences between chest pain patients with and without severe anxiety symptoms.

Methods: Data were collected prospectively in the Chest Pain Evaluation Center (CPEC) Registry. This registry enrolls patients with chest pain and low cardiac risk who are evaluated in a protocol-driven CPEC in a single academic medical center. Patients complete the Generalized Anxiety Disorder-7 (GAD-7) standardized instrument which screens for and categorizes anxiety symptoms into absent, mild, moderate, and severe categories. Patients with severe anxiety were compared with all other CPEC Registry patients for differences in demographics, medical history, and outcomes.

Results: Follow-up data at 30 days were available for 151 patients. Of these, 15% (n = 22) had GAD-7 scores of 15 or greater, indicating severe anxiety symptoms. No significant differences were noted in demographic or medical history elements, except for tobacco use, which was more prevalent in the severe anxiety group (50.0% vs. 18.6%; P < 0.0001). Patient reported severity of angina on a 10-point scale was greater in the severe anxiety group (7.7 vs. 6.3; P < 0.002), however, clinician assigned angina classification was not significantly different. Of the patients with severe anxiety based on the GAD-7, only 54.5% self-reported anxiety as a diagnosis and only 27.3% reported use of antianxiety medications. Use of treadmill stress testing, computed tomography coronary angiography, hospital admission, return emergency department visits, and follow-up with a physician were all similar between the 2 groups.

Conclusions: Using a standardized, validated instrument for diagnosing anxiety, severe anxiety was not rare in patients with low-risk chest pain. Self-awareness and medical treatment of anxiety, however, was poor. Test choices for the evaluation of chest pain and clinical outcomes were similar for patient with and without anxiety. Overall, these results suggest that although the evaluation of chest pain may not differ based on the presence of severe anxiety, subsequent treatment of anxiety has significant room for improvement.

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Prehospital ST-Elevation Myocardial Infarction–Focused Education Program

Joseph Sabato, MD, and Tracy Graham, MD, Shands Jacksonville, Jacksonville, FL

Background/Objectives: Participation in long-distance running races has nearly doubled over the last decade. Although running and fitness are important factors in long-term health, there is a small but important risk of cardiac arrest. This increase in participation has been accompanied by an increase in race-related cardiac arrest and dysfunction. The incidence of cardiac arrest was found to be 1 in every 50,000 runners participating in marathons and 1 in every 100,000 participating in half-marathons. The strongest predictor of survival was initiation of bystander administered CPR. Unfortunately, not all running cardiac arrest victims receive timely bystander CPR at sporting events or other venues with less than half receiving CPR before Emergency Medical Services arrival.

Methods: Our goal was to increase public awareness about the impact that bystander CPR can have on mortality while also teaching proper hands-only technique. The GATE River Run is the largest 15K running race in the United States with over 20,000 participants yearly. Current American Heart Association recommendations endorse Hands-Only CPR as the preferred method for bystander CPR. Hands-Only CPR has been demonstrated to increase CPR use in cardiac arrest and in some studies result in increased survival. We developed a 2-minute CPR training program based on AHA guidelines and recruited and trained volunteers as Hands-Only CPR instructors. We educated the runners and their families at the health and fitness expo the days before the run and during the run. Teaching was done through direct interaction and practice on mannequins. Participants were also given pamphlets with the information to review at a later time.

Results: The concept of hands-only bystander CPR is a new concept endorsed by the American Heart Association and no longer involves mouth-to-mouth resuscitation. Participants were surprised to learn the new technique and were educated on cardiac arrest and long-distance running. Over 300 participants were trained and had the opportunity to practice the technique throughout the weekend. Education was condensed to a 90 second 2-minute or less program with hands-on CPR practice teaching point eliminating the need for a time-consuming endeavor for the lay person.

Conclusions: We were able to devise and implement a brief training in CPR, which was easily deployed to a large running expo. With the increased incidence of cardiac arrest at long-distance running events and improved mortality with bystander CPR, the public must become more educated on this simple, fast, noninvasive technique. Many running events have exhibitions leading up to the races providing the perfect platform for education. The 2-minute CPR program offered by the Take Heart First Coast volunteers continues to partner with first Place Sports multiple running events and expos throughout 2012. By not only teaching the technique but also allowing the opportunity for practice, we hoped to improve retention and confidence. We believe that continued promotion of this technique will lead to rapid implementation of CPR and increased survival.

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A Multidisciplinary Approach for the Heart Failure Patient

Katherine Lalor RN, BSN, and Debbie Hupe-Cyr, RN, Certified Chest Pain Coordinator, Lee Memorial Health System, Fort Myers, FL

Background/Objectives: One in five patients with heart failure (HF) is readmitted to the hospital within 12 months of discharge the highest rate among any discharge diagnosis. A HF unit was established within a community hospital in south Florida that focused on decreasing readmissions through improving the quality of care. Reallocating resources available within the hospital provided an opportunity to develop a multidisciplinary approach. The purpose of this HF unit was to explore best practices, develop a HF algorithm and implement processes within a multidisciplinary group. This promotes standardization of the plan of care, the medical therapy regime, and patient education.

Methods: Participants for the aggregate data review were a sample of patients who were seeking treatment for HF. An inpatient hospital unit was established to cohort patients with suspected acutely decompensated HF. A nurse-led multidisciplinary team was assembled to integrate multiple aspects of HF disease management and execute a high-quality cost effective plan of care. The multidisciplinary team meets daily. Participants include; the HF coordinator (acting as team leader), HF unit nursing staff, a clinical pharmacist, the case manager, Care Transition nurse, dietician, palliative care nurse practitioner, respiratory therapist, home health nurse, physical therapist, and a medical coding specialist. An attending cardiologist, hospitalist, and a physician group nurse attend periodically. The team reviews each patient, utilizing a detailed algorithm developed within the hospital; this encompasses subjective data, objective date, assessment, and the plan (a S.O.A.P. note), to ensure all needs are met. Discharged patients are followed-up with a scripted phone call along with a visit by our care transition coaches to assess the patients understanding of the education and ensure compliance, helping to reduce unnecessary readmissions.

Results: A total of 107 patients over a three month time period were treated on the HF unit. The primary end points include a decrease in readmission rates and improved compliance with HF core measures. Of the 107 patients on the HF unit, 12 patients (11%) were readmitted within 30 days of discharge. This compares to the hospitals fourth quarter (July 2012 - September 2012) readmission rate of 23% and a first quarter fiscal year (FY) 2012 readmission rate of 25%. With a readmission rate of 11%, the cohorted HF patients showed a 14% decrease from the national average of 25% for 30 day readmission. The HF unit also improved the hospitals core measure compliance for heart failure HF-1 (discharge instructions) and HF-3 (ACEI or ARB for Left Ventricle Systolic Dysfunction). Core measure HF-1 for FY 2012 (October 1, 2011 - September 30, 2012) was at 70.9% compliance, improving in the first thirty one days of FY 2013 to 87.5%. The core measure of HF-3 improved from 88.6% (FY 2012) to 100% (first 31 days of FY 2013).

Conclusions: This aggregate data review suggests that utilizing a multidisciplinary team approach with a standardized practice for patient care optimizes therapeutic outcomes resulting in a decrease in the readmission rate for patients with HF. Based on the findings of this aggregate review; the multidisciplinary team rounds are also effective for the improvement of HF core measure compliance. It is our opinion that this is achieved in large part by improved communication, education and standardization of care.

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Rates of Emergent Percutaneous Coronary Intervention in Patients With Left Bundle Branch Block Transported to Percutaneous Coronary Intervention Hospitals

Matt S. Friedman, MD, Matt S. Friedman, MD, Bradley J. Kaufman, MD, MPH, John Freese, MD, Kevin G. Munjal, MD, James Braun, MA, and Robert A. Silverman, MD, MS, Mount Sinai Medical Center, NY, NY

Background/Objectives: Guidelines recommend that patients with symptoms of acute myocardial infarction (AMI) and electrocardiogram (ECG) demonstrating ST-elevation myocardial infarction (STEMI) or a new or presumably new left bundle branch block (LBBB) be treated emergently with fibrinolytic therapy or percutaneous coronary intervention (PCI). The Emergency Medical Services (EMS) system in New York City (NYC) selectively transports patients with these criteria to a hospital capable of performing PCI. This study sought to determine whether these 2 groups were receiving the same level of treatment.

Methods: Since March 16, 2009, 9-1-1 NYC paramedics transmit ECG’s for all patients with clinical signs of myocardial infarction and a paramedic interpretation of STEMI or LBBB to on-line medical control for physician interpretation. Upon verification, patients bypass the closest hospital and are transported directly to a PCI hospital with prearrival notification to the ED and in some cases to the cardiologist as well. All patients transported to a PCI hospital as part of this initiative were prospectively tracked as to whether they received emergent catheterization and if so, whether a revascularization procedure was performed. We calculated rates of catheterization and revascularization for those whose prehospital ECG demonstrated STEMI and those with new or presumably new LBBB.

Results: From March 16, 2009 to December 31, 2009, the on-line medical control physician verified STEMI in 957 patients, of which hospital outcome information was obtained for 682 patients. The physician verified LBBB in 290 patients, of which hospital outcome information was obtained for 190 patients. An additional 332 ECG’s were transmitted to on-line medical control as part of this initiative, but did not demonstrate STEMI or LBBB per physician determination. All patients who were determined to meet STEMI or LBBB criteria were selectively transported by EMS to a PCI hospital. Two hundred thirty-one (33.9%) patients with STEMI were emergently taken to the catheterization laboratory and 197 (28.9%) had revascularization performed. Eight (4.2%) of the patients with LBBB went emergently to the catheterization laboratory and 3 (1.6%) had revascularization performed.

Conclusions: Despite current guidelines recommending patients with new or presumably new LBBB be treated similar to those with STEMI (ie, receive fibrinolysis or PCI), this data shows that a very small proportion of LBBB patients transported by EMS to a PCI hospital in NYC were actually catheterized emergently. Yet, recent studies report the incidence of AMI in LBBB patients to range from 7% to 30%. Further investigation is needed to determine why LBBB patients, 23% of all patients transported to PCI centers, rarely received emergent catheterization despite presenting with AMI symptoms. Perhaps, a majority of these patients had previously diagnosed LBBB, but without a truly integrated EMS—Hospital—Catheterization Laboratory system, that information is not known at the time of patient contact. Until then, EMS systems might need to reconsider selectively transporting patients with LBBB to PCI hospitals.

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Telemedicine Network in the Largest Brazilian Private Health Care Provider: The First Year of Experience for Teleconsultation in Cardiology

Pedro Gabriel Melo De Barros E Silva, MD, Thiago Macedo: Antonio Baruzzi, Jose Teixeira, Marcelo Jamus; Valter Furlan, Hospital Totalcor, SAO Paulo, Brazil

Background/Objectives: Brazil faces major problems impacting public and private health systems due to the lack of adequate communication between peripheral and central hospitals. These issues can slow down and sometimes harm the flow of emergency care. Faced with the task of ensuring equal access to healthcare for all clients, a telemedicine program was developed for use by the largest Brazilian private health care provider (Amil). The program is based on teleconsultations involving emergency departments, general and referral hospitals. Currently, it comprises 13 emergency departments and 17 hospitals, covering 5 different cities. The platform is composed of high-resolution videoconferencing equipment and it is used for teleconsultations in 4 medical specialties (cardiology, neurology, obstetrics, and gynecology) available 24 hours a day and provided by specialists in 3 reference hospitals. This study aims to give an overview of Amil’s telemedicine program in the service responsible for answering all teleconsultations in cardiology during the first year of complete use.

Methods: Retrospective study of all calls made consecutively from January to August 2012 to the cardiology reference service. A cardiologist at the reference hospital emergency room is called by a beep activated remotely by a Web site available in all sites of the telemedicine network and has 5 minutes to answer the call after the first activation of the beep. This cardiologist provides teleconsultations to medical doctors of other hospitals 24 hours a day, 7 days a week. The discussion is based on the clinical history inquired by the specialist, graphical methods (eg, electrocardiogram) and laboratory results shared by the telecommunication system. The telemedicine equipment allows transmission in high definition making easier the discussion of clinical cases and evaluation of electrocardiogram. All data related to the teleconsultations were collected using a standardized form by both physicians involved, who each inserted the data into a central database managed by the telemedicine coordinator. This coordinator monitored the reliability of the information inserted confronting the data inserted by both physicians. This study used the information of the central database and was conducted in accordance with the principles described in the Declaration of Helsinki. The current research was approved by our institutional review board. Descriptive statistics were calculated using SPSS (Statistical Package for the Social Sciences, Chicago, IL) version 20.0 and included point estimates with respective 95% confidence intervals (CIs).

Results: From a total of 656 calls to the cardiologist in these 8 months, 62% of them were due to a definitive or suspected ACS (95% CI: 59%–66%) composed by 74 (11%, 95% CI: 9%–14%) cases of chest pain with no diagnosis, 144 (22%, 95% CI: 19%–25%) of unstable angina, and 136 (21%, 95% CI: 18%–24%) patients diagnosed as non–ST-elevation myocardial infarction. In 55 cases (8%, 95% CI: 6%–11%), the diagnosis by telemedicine was acute myocardial infarction with ST elevation and has been indicated fibrinolytic therapy in half of these cases (the others had contraindications to the drug and/or >12 hrs of chest pain). In 156 cases (24%, 95% CI: 21%–27%), after initial discussions, the patients were transferred based on the diagnosis of a complex situation and/or insufficient resources in the origin facility. In most of the cases, the cardiologist did not indicated transferals: In 82 cases (12%, 95% CI: 10%–15%) after discussing via telemedicine, it was oriented to discharge the patient, and in the remaining 418 cases (64%, 95% CI: 60%–67%), the choice was to observe the patient in the origin site.

Conclusions: The results of the first year of this innovative use of telemedicine on a daily basis in a large Brazilian healthcare system show that in only a quarter of the teleconsultations it was necessary to transfer the patient after clinical discussion and so this tool may had avoided many unnecessary transferals. Our results showed also that the major demand for consultation to the cardiologist is due to chest pain and ACS. Considering the percentage of potential candidates that did not receive fibrinolytic therapy, even with the resource of the telemedicine, it suggests that an education program to the patients about the importance of seeking medical care earlier and also training staff to correctly use telemedicine could possibly be necessary to achieve better results in bridging the gap between evidence and clinical practice in this Brazilian network.

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Optimizing ST-Elevation Myocardial Infarction Recognition at Every Portal

Christopher Stokes, MD, MBA, and David Burt, MD, University of Virginia Health System, Charlottesville, VA

Background/Objectives: The University of Virginia (UVA) is a 577-bed tertiary care academic medical center in Charlottesville, Virginia, with an accredited Chest Pain Center. UVA uses extensive training and systems-based protocols to optimize recognition and reperfusion of ST-segment elevation myocardial infarction (STEMI). There are 4 STEMI portals for patient entry: emergency department (ED) walk-in, Emergency Medical Services (EMS) transport, interhospital transport, and admitted inpatients who develop an inpatient STEMI. The inpatient STEMI portal is the fourth and final portal that sometimes has a paradoxically longer and catastrophic time to reperfusion. Prior literature has shown mean electrocardiogram (ECG) to reperfusion times as long as 418 minutes for nonprotocol inpatient STEMIs. The objective is to describe development and implementation of a protocol that optimizes inpatient STEMI reperfusion times using a systems-based approach and training tools already in use for the 3 other STEMI portals.

Methods: The interdisciplinary Chest Pain Steering Committee (CPSC) and Acute Coronary Syndrome Quality Support Team (ACS QST) reviewed inpatient STEMI cases with less than optimal reperfusion times and collaboratively developed an inpatient STEMI recognition protocol with 6 required steps. The 6 steps are recognition of chest pain and other ACS symptoms, ordering an ECG, performing the ECG, evaluating the ECG, acting on the findings, and quality overview. To train recognition of chest pain and other ACS symptoms, all inpatient nursing staff complete unit-specific education plans including on-line training modules and use of ACS symptom recognition cards. The second step is ordering the ECG. The electronic order entry system has a new single-click nursing-initiated ECG order described as the “Epic ECG easy order button,” which empowers the nurse to think of the ECG as the “additional vital sign” in any patient with new chest pain or ACS symptoms. The third step is performing the ECG. Nursing staff must pass a live ECG performance check-off. The fourth step is evaluating the ECG by a physician, which frequently causes delays in a large fragmented academic medical center. There is an ECG evaluation cascade with multiple redundancies through on-call Cardiologists and the ED to ensure physician ECG interpretation within 10 minutes. Residents will also complete required ECG STEMI training called “STEMI showdown” to develop STEMI recognition skills and promote resident culture change. The implementation of the entire protocol uses top-down administrative support, the resources of the Life Support Learning Center, the CPSC and ACS QST committees, and buy-in by each inpatient unit.

Results: UVA has already used extensive training tools including on-line training modules, ACS symptom recognition cards, and “STEMI showdown” live training with interactive audience response technology to optimize STEMI recognition in the 3 other STEMI portals. In the last 5 years, over 300 ED nurses and 200 EMS personnel from 20 EMS agencies have been trained. The 3 other portals have improved median door to balloon times to 57 minutes placing UVA in the top 3% among academic institutions. Training has even been provided to nonclinical staff, including registration, volunteers, and security staff, with distribution of ACS symptom recognition cards. The inpatient STEMI recognition protocol implementation is in the process of training over 767 inpatient nurses and 220 house staff. The protocol begins when any inpatient has new chest pain or other ACS symptoms, staff recognize symptoms, perform an ECG within 10 minutes, and page the physician for interpretation. If the physician is not available in 10 minutes, the ECG enters the evaluation cascade through Cardiology or Emergency Medicine for 10-minute interpretation. If the ECG indicates an STEMI alert, the catheterization laboratory is activated and the patient’s nurse may activate the Medical Emergency Team, an available in-house critical care Registered Nurse. The Medical Emergency Team Registered Nurse can initiate STEMI protocols and transport the patient to the catheterization laboratory.

Conclusions: This systems-based approach uses established training programs to optimize reperfusion time for the fourth and final portal, the inpatient STEMI. The developed process is a current work in progress in the implementation stage. Quality overview will be conducted by the CPSC and ACS QST committees. Further reports of outcomes are anticipated in future submissions.

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Implementation of an Inpatient Chest Pain Response

Kimberly Nelson, MSN, RN-BC, ACNS-BC, CCPC, and Michael Kontos, MD, FACC, FAHA, Virginia Commonwealth University Medical Center, Richmond, VA

Background/Objectives: Patients in the hospital regardless of admitting diagnosis can be at risk for acute coronary syndrome (ACS). A process was needed to address patients experiencing symptoms of chest pain while hospitalized, with a goal to protect valuable muscle by decreasing recognition to reperfusion time.

Methods: Recognition is the first step in the process. With 779 beds and 9000 staff, Early Heart Attack Care education is where we begin. All staff and volunteers participate in a learning module on Early Heart Attack Care and how to recognize ACS and respond regardless of location. If an inpatient is identified as having possible signs and symptoms of ACS, the provider is notified and an electrocardiogram (ECG) performed. ECG education for the nursing and care partner staff to validate accurate lead placement and acquisition of the ECG was implemented. The Rapid Response Team (RRT) includes a dedicated RRT nurse and a respiratory therapist to provide critical care consultation at the bedside. The RRT nurse is paged for the patient with chest pain to assist with early recognition of ACS. After assessment of the patient and review of the ECG, expert consultation is obtained through the newly developed Chest Pain Team for patients with cardiac ischemia or the Heart Alert Team for patients with a ST-segment myocardial infarction (STEMI). The Chest Pain Team includes the CICU Fellow and Cardiology Consult Fellow. If an STEMI is identified, the Heart Alert Team is paged using a virtual pager alerting the CICU Fellow and Resident, Cardiology Consult Fellow, CICU Nurse Practitioner, Catheterization Laboratory Team, and Nursing Clinical Administrator. Telepage operators were given scripting to assist with notification of the appropriate team. STEMI drill simulations were led by one of our RRT nurses and Chest Pain Coordinator throughout the organization. A mannequin was used with role playing to simulate the patient experiencing chest discomfort. Staff performed an ECG and walked through the process of early recognition and the steps to reperfusion. An on-line computer module was developed to notify staff of the new process in addition to the simulations done on the units. “Badge Buddies” including the signs and symptoms of ACS, example of ST elevation and the inpatient process were distributed. A modified process was developed for the ICU, postanesthesia care unit, and Cardiology Progressive Care Unit. For patients with symptoms of cardiac chest pain and an ECG with automated interpretation as ***Acute MI***, a Heart Alert was paged directly.

Results: The Inpatient Chest Pain process was implemented on February 14, 2012. In the first 6 months, 165 calls were made to RRT for chest pain. Of those calls, 36 resulted in Chest Pain Alerts and 2 Heart Alerts. Comprehensive data analysis from February, 2012 to February 2013 is currently being completed. In addition to the early recognition of ACS, 2 patients were identified as having a pulmonary embolism and received rapid treatment. Data is reviewed by the Chest Pain Committee to evaluate for opportunities for improvement and to celebrate successes.

Conclusions: Organization and use of currently available resources provide support to staff in the recognition of ACS in adult inpatients. Rapid treatment through early identification is beneficial to patient outcomes improving quality care.

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Process Improvement of a Heart Failure Cohort in an Observation Unit

Margarita E. Pena, and Srujana Chakilam, St. John Hospital and Medical Center, Detroit, MI

Background/Objectives: The Society of Cardiovascular Patient Care has identified criteria for risk stratification of emergency department (ED) patients with acute decompensated heart failure (ADHF) that can be adequately managed in an observation unit (OU). The purpose of this quality improvement project is to prospectively identify this cohort of ED patients and implement collaborative process improvement measures to improve patient care, patient education, and follow-up after discharge. These patients will be compared with an historical control group for the following outcome measures: admission rate, length of stay (LOS) for discharged patients, and <30-day all-cause admission after OU discharge. As a secondary outcome, we sought to also estimate the readmission risk for the study cohort using a smart phone app calculator, which has been studied and its methods peer-reviewed, to study whether applicable for ADHF OU patients.

Methods: This is a prospective convenience quality improvement project of patients presenting to the ED from November 1, 2011 to October 31, 2012, with ADHF who were placed in the EDOU that is staffed by ED physicians. Patients were included in the cohort group if they met the following inclusion criteria: preexisting heart failure, non-ACS ECG or cardiac biomarkers, and SBP >100 at any time during their ED stay. Exclusion criteria included BUN >40, creatinine >3, and sodium <135 mm Hg. Only patients who were dispositioned during weekdays when the EDOU case managers were on site were included in the study. Physician education before and during the project included evidence-based didactic heart failure lectures that focused on risk stratification, early ED goal-directed therapy, and OU care and treatment goals. Specific OU ADHF order sets were used, which included a prechecked order for a cardiac echocardiogram if not in our computer system within 6 months. A cardiology consult was obtained on all study patients. An EDOU nursing process improvement involving in-depth patient education was implemented at the start of the project. Personalized education and discharge instructions along with an information packet were provided to all patients. The EDOU case manager evaluated all patients for possible homecare follow-up. Our hospital callback center was given names of at-risk patients who would require a phone call to ensure the patient had a follow-up appointment. The historical control included OU patients with the same inclusion and exclusion criteria placed in the same OU from November 1, 2010 to October 31, 2011. Data collected included patient demographics, laboratory tests, echocardiography reports, LOS, admission rate, and <30-day all-cause admission post-EDOU discharge. A readmission risk score was calculated for all patients with age 65 years and older using the Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE) readmission risk smartphone app calculator.

Results: There were 66 patients who met the cohort group criteria. Twenty required admission (30.3%). The average LOS for the discharged patients was 18.7%, and 6 patients were admitted within 3-days post-OU discharge (13%). Patients who were admitted tended to have a lower ejection fraction than those who were discharged; however, the difference was not statistically significant (34.7% ± 21.7% vs. 40.0% ± 22.1%, respectively, P = 0.4). Admitted patients and patients discharged with a <30 days admission had greater CORE readmission risk scores than patients who were discharged without <30-day admission (25.2 ± 3.7 vs. 21.7 ± 3.1, P = 0.01). Compared with the historical control group (n = 61), there was no significant difference in LOS among discharged patients (16.8 ± 8.3 hrs vs. 18.7 ± 8.9, respectively). The admission rate was higher in the historical control group (57.4% vs. 30.3%, P = 0.002) and the <30-day all-cause admission post-OU discharge (38.5% vs. 13%, P = 0.05).

Conclusions: Collaborative process improvement measures focusing on physician education, patient education, and follow-up in an appropriate cohort of ADHF patients placed in an EDOU resulted in a lower admission rate, and a lower all-cause less than 30-day readmission rate post-OU discharge compared with historical controls. The CORE readmission risk score was higher in patients requiring admission from the EDOU and discharged patients with a <30-day admission.

© 2013 by Lippincott Williams & Wilkins