Gregory Gafni-Pappas1, Susanne D DeMeester2, Michael A Boyd3, Arun Ganti4, Adam M Nicholson5, Jeremy Albright6, Juan Wu7. 1. Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI, USA. Electronic address: ggafnipappas@epmg.com. 2. Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI, USA. Electronic address: sdemeester@epmg.com. 3. Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI, USA. 4. Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI, USA. Electronic address: gantia@med.umich.edu. 5. Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI, USA. Electronic address: adni@umich.edu. 6. Methods Consultants, Ypsilanti, MI, USA. Electronic address: jeremy@methodsconsultants.com. 7. Department of Research, St. Joseph Mercy Hospital, Ann Arbor, MI, USA. Electronic address: juan.wu@stjoeshealth.org.
Abstract
OBJECTIVE: The HAS-Choice pathway utilizes the HEART Score, an accelerated diagnostic protocol (ADP), and shared decision-making using a visual aid in the evaluation of chest pain patients. We seek to determine if our intervention can improve resource utilization in a community emergency department (ED) setting while maintaining safe patient care. METHODS: This was a single-center prospective cohort study with historical that included ED patients ≥21years old presenting with a primary complaint of chest pain in two time periods. The primary outcome was patient disposition. Secondary outcomes focused on 30-day ED bounce back and major adverse cardiac events (MACE). We used multivariate logistic regression to estimate the odds ratio (OR) and its 95% confidence interval (CI). RESULTS: In the pre-implementation period, the unadjusted disposition to inpatient, observation and discharge was 6.5%, 49.1% and 44.4%, respectively, whereas in the post period, the disposition was 4.8%, 41.5% and 53.7%, respectively (chi-square p<0.001). The adjusted odds of a patient being discharged was 40% higher (OR=1.40; 95% CI, 1.30, 1.51; p<0.001) in the post-implementation period. The adjusted odds of patient admission was 30% lower (OR=0.70; 95% CI, 0.60, 0.82; p<0.001) in the post-implementation period. The odds of 30-day ED bounce back did not statistically differ between the two periods. MACE rates were <1% in both periods, with a significant decrease in mortality in the post-implementation period. CONCLUSION: Our study suggests that implementation of a shared decision-making tool that integrates an ADP and the HEART score can safely decrease hospital admissions without an increase in MACE.
OBJECTIVE: The HAS-Choice pathway utilizes the HEART Score, an accelerated diagnostic protocol (ADP), and shared decision-making using a visual aid in the evaluation of chest painpatients. We seek to determine if our intervention can improve resource utilization in a community emergency department (ED) setting while maintaining safe patient care. METHODS: This was a single-center prospective cohort study with historical that included ED patients ≥21years old presenting with a primary complaint of chest pain in two time periods. The primary outcome was patient disposition. Secondary outcomes focused on 30-day ED bounce back and major adverse cardiac events (MACE). We used multivariate logistic regression to estimate the odds ratio (OR) and its 95% confidence interval (CI). RESULTS: In the pre-implementation period, the unadjusted disposition to inpatient, observation and discharge was 6.5%, 49.1% and 44.4%, respectively, whereas in the post period, the disposition was 4.8%, 41.5% and 53.7%, respectively (chi-square p<0.001). The adjusted odds of a patient being discharged was 40% higher (OR=1.40; 95% CI, 1.30, 1.51; p<0.001) in the post-implementation period. The adjusted odds of patient admission was 30% lower (OR=0.70; 95% CI, 0.60, 0.82; p<0.001) in the post-implementation period. The odds of 30-day ED bounce back did not statistically differ between the two periods. MACE rates were <1% in both periods, with a significant decrease in mortality in the post-implementation period. CONCLUSION: Our study suggests that implementation of a shared decision-making tool that integrates an ADP and the HEART score can safely decrease hospital admissions without an increase in MACE.
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