The impact of emergency department structure and care processes in delivering care for non-ST-segment elevation acute coronary syndromes

'Who does this patient belong to?' boundary work and the re/making of (NSTEMI) heart attack patients

This ethnography within ten English and Welsh hospitals explores the significance of boundary work and the impacts of this work on the quality of care experienced by heart attack patients who have suspected non-ST segment elevation myocardial infarction (NSTEMI) /non-ST elevation acute coronary syndrome. Beginning with the initial identification and prioritisation of patients, boundary work informed negotiations over responsibility for patients, their transfer and admission to different wards, and their access to specific domains in order to receive diagnostic tests and treatment. In order to navigate boundaries successfully and for their clinical needs to be more easily recognised by staff, a patient needed to become a stable boundary object. Ongoing uncertainty in fixing their clinical classification, was a key reason why many NSTEMI patients faltered as boundary objects. Viewing NSTEMI patients as boundary objects helps to articulate the critical and ongoing process of classification and categorisation in the creation and maintenance of boundary objects. We show the essential, but hidden, role of boundary actors in making and re-making patients into boundary objects. Physical location was critical and the parallel processes of exclusion and restriction of boundary object status can lead to marginalisation of some patients and inequalities of care (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme

Background

Electronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.

Objective

To evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.

Design

Epidemiological cohort, health informatics, health economics and ethnographic approaches were used.

Setting

230 NHS hospitals and 226 general practices in England and Wales.

Participants

Up to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.

Main outcome measures

Quality of care, fatal and non-fatal cardiovascular disease (CVD) events.

Data platform and methods

We created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.

Results

CALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.

Conclusions

Emerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.

Future work

The vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.

Study registration

CALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).

Aligning the planets: The role of nurses in the care of patients with non-ST elevation myocardial infarction

Background

Studies have shown variation in care for patients with non‐ST elevation myocardial infarction (NSTEMI), including in the roles of specialist and advanced practice nurses in diagnosis, treatment and coordination of care.

Aim

The aim of this study was to describe the roles and responsibilities of specialist and advanced practice nurses in providing care for patients with NSTEMI.

Methods

Secondary analysis of observational field notes and interviews from an ethnographic study of variation in care for NSTEMI patients in 10 UK hospitals conducted 2011–2012. Data were thematically analysed to identify key concepts and themes related to the roles of specialist nurses.

Results

Seven of 10 hospitals had roles for specialist nurses in NSTEMI care. The major theme related to high demand and the complexity of patients and organizations (‘Aligning the planets’). In this theme, nurses contributed to improving services or compensating for deficiencies (‘Making the system work versus making up for the system’). Data collection for audit could take precedence over time with patients (‘Paying worship to the paper’). Nurses expressed a sense of ownership of cardiovascular patients that drove their desire to provide quality of care (‘They are our patients’).

Neutrophil gelatinase associated lipocalin in acute kidney injury

BACKGROUND

Neutrophil gelatinase-associated lipocalin (NGAL) is a member of the lipocalin family of proteins. Usually, NGAL is produced and secreted by kidney tubule cells at low levels, but the amount produced and secreted into the urine and serum increases dramatically after ischemic, septic, or nephrotoxic injury of the kidneys. The purpose of our review article is to summarize the role of NGAL in acute kidney injury (AKI), emergent, and intensive care.

METHODS

A PubMed search was performed (only English-language articles concerning human subjects were considered) using each of the following search term combinations: neutrophil gelatinase-associated lipocalin OR NGAL and acute kidney injury OR AKI; cardiac surgery; heart failure OR cardiology; intensive care; emergency department OR emergency medicine; nephropathy OR nephrotoxicity and transplantation.

RESULTS

The results of our search yielded 339 articles. Of the 339 articles, 160 were eligible for review based on the predefined criteria for inclusion.

CONCLUSION

Based on the evidence reviewed, it is clear that patient NGAL level is an appropriate, sensitive, and specific early biomarker of AKI caused by a variety of different etiologies. It is advised that a multidisciplinary group of experts come together to make recommendations and propose a consensus of clinical procedures to advance the most efficacious NGAL monitoring protocol for early detection and treatment of patients with AKI.

Provider attitudes toward clinical protocols in obstetrics

The Johns Hopkins Oxytocin Protocol (JHOP) Survey was distributed to clinical labor and delivery staff to compare obstetrical providers' attitudes toward clinical protocols and the JHOP. Agreement by registered nurses (RNs), physicians in training (PIT), and attending physicians (APs) and certified nurse midwives (CNMs) was assessed with each of 4 attitudinal statements regarding whether clinical protocol and JHOP use result in better practice and are important to ensure patient safety. Odds of agreement with positive statements regarding clinical protocols did not differ significantly among groups. Odds of agreement with JHOP use resulting in better practice also did not differ significantly among provider groups. Odds of agreement with the JHOP being important to ensure patient safety were lower for the AP/CNM group compared with the RN group. Clinical protocol use is generally well received by obstetrical providers; however, differences exist in provider attitudes toward the use of an institutional oxytocin protocol.

A call to ACTION (acute coronary treatment and intervention outcomes network): a national effort to promote timely clinical feedback and support continuous quality improvement for acute myocardial infarction

BACKGROUND

There is a recognized need for a national unified registry to track presenting features, care, and outcomes for patients with acute myocardial infarction. To address this need, the American Heart Association's Get With the Guidelines-Coronary Artery Disease program joined the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry to create the National Cardiovascular Data Registry ACTION-Get With the Guidelines (AR-G) in June of 2008. This article outlines the objectives, operational structure, patient population, data elements, data collection methodology, and reporting components of this landmark registry.

METHODS AND RESULTS

The AR-G was launched in January of 2007. The registry is led by a team of volunteers from the American Heart Association and the American College of Cardiology, and its data coordinating center resides at the Duke Clinical Research Institute. As of December 2008, 344 US hospitals already contributed detailed clinical information on 103 890 myocardial infarction patients (inclusive of 39% ST-segment myocardial infarction and 61% non-ST-segment myocardial infarction patients). Overall data quality has been excellent, with <5% clinical fields missing. Site quality improvement efforts are supported via detailed quarterly feedback reports, routine web educational programs, and sharing of "best practice" clinical support tools.

CONCLUSIONS

The AR-G represents a unified, national, acute myocardial infarction registry and supports a robust quality improvement effort designed to encourage evidence-based acute myocardial infarction care and, ultimately, improve patient outcomes.

The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain

OBJECTIVES

While emergency department (ED) crowding is a worldwide problem, few studies have demonstrated associations between crowding and outcomes. The authors examined whether ED crowding was associated with adverse cardiovascular outcomes in patients with chest pain syndromes (chest pain or related complaints of possible cardiac origin).

METHODS

A retrospective analysis was performed for patients >or=30 years of age with chest pain syndrome admitted to a tertiary care academic hospital from 1999 through 2006. The authors compared rates of inpatient adverse outcomes from ED triage to hospital discharge, defined as delayed acute myocardial infarction (AMI), heart failure, hypotension, dysrhythmias, and cardiac arrest, which occurred after ED arrival using five separate crowding measures.

RESULTS

Among 4,574 patients, 251 (4%) patients developed adverse outcomes after ED arrival; 803 (18%) had documented acute coronary syndrome (ACS), and of those, 273 (34%) had AMI. Compared to less crowded times, ACS patients experienced more adverse outcomes at the highest waiting room census (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.3 to 11.0) and patient-hours (OR = 5.2, 95% CI = 2.0 to 13.6) and trended toward more adverse outcomes during time of high ED occupancy (OR = 3.1, 95% CI = 1.0 to 9.3). Adverse outcomes were not significantly more frequent during times with the highest number of admitted patients (OR = 1.6, 95% CI = 0.6 to 4.1) or the highest trailing mean length of stay (LOS) for admitted patients transferred to inpatient beds within 6 hours (OR = 1.5, 95% CI = 0.5 to 4.0). Patients with non-ACS chest pain experienced more adverse outcomes during the highest waiting room census (OR = 3.5, 95% CI = 1.4 to 8.4) and patient-hours (OR = 4.3, 95% CI = 2.6 to 7.3), but not occupancy (OR = 1.8, 95% CI = 0.9 to 3.3), number of admitted patients (OR = 0.6, 95% CI 0.4 to 1.1), or trailing LOS for admitted patients (OR = 1.2, 95% CI = 0.6 to 2.0).

CONCLUSIONS

There was an association between some measures of ED crowding and a higher risk of adverse cardiovascular outcomes in patients with both ACS-related and non-ACS-related chest pain syndrome.

The rationale for an acute heart failure syndromes clinical trials network

BACKGROUND

Clinical trials involving novel therapies treating acute heart failure syndromes (AHFS) have shown limited success with regard to both efficacy and safety. As a direct result, outcomes have changed little over time and AHFS remains a disease process associated with largely no change in hospitalization rates (80%), hospital length of stay (median 4.5 days), and in-hospital (4-7%) and 60-day mortality (10%). Despite extensive emergency department (ED) involvement during the initial phase of AHFS management, clinical trials have enrolled patients after the ED phase of management, up to 48 hours after initial therapy, long after many patients have experienced significant beneficial effects of standard therapy. As standard therapy has provided symptomatic improvement in up to 70% of patients in these trials, it is not surprising that investigational agents started after 24 to 48 hours of standard therapy have shown limited clinical efficacy when compared with standard therapy.

METHODS AND RESULTS

The ability to screen, enroll, and randomize in the emergency setting is fundamental. The unique environment, the ethical complexities of enrollment in emergency-based research, and the need for rapid and standardized study-compliant care represent key challenges to active recruitment in AHFS studies. Specifically, the ability to identify and enroll a large cohort of AHFS patients early (<6 hours) in their presentation has been cited as the primary barrier to the appropriate design of clinical trials that includes this early window.

CONCLUSIONS

In response, we have created a network of dedicated academic physicians with experience in clinical trials and acute management of heart failure who together can surmount this barrier and provide a framework for conducting early trials in AHFS.

GP IIb-IIIa inhibitors administered upstream: evidence for improved outcomes with conventional and newer antithrombotic agents?

Glycoprotein IIb-IIIa inhibitors provide the most benefit in patients with non-ST-elevation acute coronary syndromes and high-risk features and in those who undergo early invasive treatment. Current guidelines recommend glycoprotein IIb-IIIa inhibition in these patients but offer little guidance as to timing of initiation. Preliminary data suggest superior outcomes with upstream initiation (upon admission to a medical facility) compared with delayed initiation (in the catheterization laboratory, just before percutaneous coronary intervention). The availability of new antiplatelet and antithrombotic drugs renders even more complex the question of the best strategy.