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Zhou Z, Hsu KS, Eason J, Kauh B, Duchesne J, Desta M, Cranford W, Woodworth A, Moore JD, Stearley ST, Gupta VA. Improvement of Emergency Department Chest Pain Evaluation Using Hs-cTnT and a Risk Stratification Pathway. J Emerg Med 2024; 66:e660-e669. [PMID: 38789352 DOI: 10.1016/j.jemermed.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/22/2024] [Accepted: 02/02/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Chest pain is among the most common reasons for presentation to the emergency department (ED) worldwide. Additional studies on most cost-effective ways of differentiating serious vs. benign causes of chest pain are needed. OBJECTIVES Our study aimed to evaluate the effectiveness of a novel risk stratification pathway utilizing 5th generation high-sensitivity cardiac troponin T assay (Hs-cTnT) and HEART score (History, Electrocardiogram, Age, Risk factors, Troponin) in assessing nontraumatic chest pain patients in reducing ED resource utilization. METHODS A retrospective chart review was performed 6 months prior to and after the implementation of a novel risk stratification pathway that combined hs-cTnT with HEART score to guide evaluation of adult patients presenting with nontraumatic chest pain at a large academic quaternary care ED. Primary outcome was ED length of stay (LOS); secondary outcomes included cardiology consult rates, admission rates, number of ED boarders, and number of eloped patients. RESULTS A total of 1707 patients and 1529 patients were included pre- and postimplementation, respectively. Median overall ED LOS decreased from 317 to 286 min, an absolute reduction of 31 min (95% confidence interval 22-41 min), after pathway implementation (p < 0.001). Furthermore, cardiology consult rate decreased from 26.9% to 16.0% (p < 0.0001), rate of admission decreased from 30.1% to 22.7% (p < 0.0001), and number of ED boarders as a proportion of all nontraumatic chest pain patients decreased from 25.13% preimplementation to 18.63% postimplementation (p < 0.0001). CONCLUSIONS Implementation of our novel chest pain pathway improved numerous ED throughput metrics in the evaluation of nontraumatic chest pain patients.
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Affiliation(s)
- Zhengqiu Zhou
- Department of Emergency Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Kevin S Hsu
- Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Joshua Eason
- Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Brian Kauh
- Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Joshua Duchesne
- Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Mikiyas Desta
- College of Medicine, University of Kentucky, Lexington, Kentucky
| | - William Cranford
- Department of Biostatistics, University of Kentucky, Lexington, Kentucky
| | - Alison Woodworth
- Department of Pathology and Laboratory Medicine, University of Kentucky, Lexington, Kentucky
| | - James D Moore
- Department of Emergency Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Seth T Stearley
- Department of Emergency Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Vedant A Gupta
- Gill Heart and Vascular Institute, Division of Cardiovascular Medicine, College of Medicine, University of Kentucky, Lexington, Kentucky.
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Tyner RJ, Whittington MD, Patterson VP, Ho M, Pincus S, Wiler JL, Michael SS. Differences in cardiac testing resource utilization using two different risk stratification schemes. Am J Emerg Med 2023; 65:179-184. [PMID: 36641961 DOI: 10.1016/j.ajem.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Assess whether changing an emergency department (ED) chest pain pathway from utilizing the Thrombolysis in Myocardial Infarction (TIMI) score for risk stratification to an approach utilizing the History, EKG, Age, Risk, Troponin (HEART) score was associated with reductions in healthcare resource utilization. METHODS A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications evaluated all ED patients with a chest pain encounter from 8/2015 to 7/2019 at a large academic medical center. We included patients age ≥ 18 with negative troponin testing discharged from the ED. Our standardized care pathway utilized TIMI for risk stratification until 09/2017 and HEART thereafter. We evaluated patients undergoing hospital-based cardiac diagnostic testing (CDT), length of stay (LOS), and 30-day Major Adverse Cardiovascular Events (MACE) at the intervention site before and after the pathway change and compared these outcomes to a similar control site within the health system for the difference-in-differences specification. RESULTS During the study period, 6.3% (450 of 7117) of patients in the TIMI cohort and 7.2% (546 of 7623) in the HEART cohort among 400,965 total ED visits underwent CDT. In a multivariable analysis, transition to the HEART pathway was associated with greater odds of receiving CDT (odds ratio 2.88 [95% CI 1.21 to 6.86]), a reduction in LOS of 34 min (95% CI 2.2 to 67.6), and no significant difference in 30-day MACE. CONCLUSION The transition from TIMI to HEART was associated with mixed consequences for healthcare resource utilization, including increased CDT but reduced length of stay.
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Affiliation(s)
- Robin J Tyner
- Department of Emergency Medicine, University of Colorado School of Medicine.
| | - Melanie D Whittington
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus; Navigation Lab, Data Science to Patient Value/ACCORDS, University of Colorado School of Medicine
| | - Vanessa P Patterson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus; Navigation Lab, Data Science to Patient Value/ACCORDS, University of Colorado School of Medicine
| | - Michael Ho
- Navigation Lab, Data Science to Patient Value/ACCORDS, University of Colorado School of Medicine; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine
| | - Sharon Pincus
- Navigation Lab, Data Science to Patient Value/ACCORDS, University of Colorado School of Medicine
| | - Jennifer L Wiler
- Department of Emergency Medicine, University of Colorado School of Medicine; The CU Denver Business School
| | - Sean S Michael
- Department of Emergency Medicine, University of Colorado School of Medicine; The CU Denver Business School
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Harnessing Electronic Medical Records in Cardiovascular Clinical Practice and Research. J Cardiovasc Transl Res 2022:10.1007/s12265-022-10313-1. [DOI: 10.1007/s12265-022-10313-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/29/2022] [Indexed: 10/14/2022]
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Bean G, Krishnan U, Stone JR, Khan M, Silva A. Utilization of Chest Pain Decision Aids in a Community Hospital Emergency Department: A Mixed-methods Implementation Study. Crit Pathw Cardiol 2021; 20:192-207. [PMID: 34570011 DOI: 10.1097/hpc.0000000000000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Chest pain is a common reason for emergency department (ED) visits. Evidence-based decision aids assessing risk for an adverse cardiac event are underused in community hospital emergency care. This study explored the acceptability, barriers, facilitators, and potential strategies for implementation of the HEART Score risk stratification tool, accelerated diagnostic pathway, and shared decision-making visual aid with physicians and chest pain patients ages >45 in a community hospital ED. METHODS Single center, mixed-methods study. (1) Physician semistructured interviews using The Consolidated Framework for Implementation Research for systematic analysis. (2) Patient and physician surveys. (3) 16-week intervention of physician training and pilot testing of decision aids with ED patients. RESULTS Physician interviews (n = 19); key facilitators: electronic medical record decision support, ease of use, risk stratification and disposition support, and shared decision-making training. Key barriers: time constraints, patient ability, and/or willingness to participate in shared decision-making, lack of integration with medical record and change in practice workflow. Patient study participants (n = 184) with a survey response rate of 92% (n = 170). Most patients (85%) were satisfied with the shared decision-making visual aid. Physicians surveyed (n = 84) with a response rate of 50% (n = 42). Most physicians, 95% (n = 40), support use of the HEART Score, with limited acceptance of the shared decision-making visual aid of 57% (n = 24). CONCLUSIONS Using evidence-based chest pain decision aids in a community hospital ED is feasible and acceptable. Key barriers and facilitators for implementation were identified. Further research in community hospitals is needed to verify findings, examine generalizability, and test implementation strategies.
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Affiliation(s)
- Glenn Bean
- From the Department of Preventive Cardiology, Pulse Heart Institute, Tacoma General Hospital, Tacoma, WA
| | - Uma Krishnan
- Department of Cardiology, Pulse Heart Institute, Tacoma, WA
| | - Jason R Stone
- Emergency Department, Good Samaritan Hospital, Puyallup, WA
| | - Madiha Khan
- Department of Hospital Medicine, Good Samaritan Hospital, Puyallup, WA
| | - Angela Silva
- Institute for Research and Innovation, MultiCare Health System, Tacoma, WA
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Matuskowitz AJ, Obeid JS, Jennings L, Bayer RR, Ramakrishnan V, Schoepf UJ, Jauch EC. Feasibility and Impact of the Combined Application of Coronary CT Angiography With the HEART Pathway in Patients With Suspected Acute Coronary Syndrome. Crit Pathw Cardiol 2021; 20:185-191. [PMID: 33660627 PMCID: PMC8408286 DOI: 10.1097/hpc.0000000000000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/23/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND This study examines the feasibility and utility of integrating coronary computed tomography angiography and the HEART Pathway into a novel accelerated diagnostic protocol-called HEART-CT-and assesses its impact as an optional interactive decision support tool (smart form) in the electronic health record. METHODS This was a retrospective observational study performed in 2 adult emergency departments (ED) among patients evaluated for suspected acute coronary syndrome. Primary outcomes included the rate of discharge from the ED following HEART-CT Smart Form use, 30-day major adverse cardiac events (MACE), and ED length of stay (LOS). Hypothesis-generating outcomes included the rate of Smart Form use by ED providers and whether adhering to the HEART-CT recommendations was associated with improved outcomes. RESULTS The study included 672 subjects, 78.1% of whom were discharged from the ED. HEART-CT identified 76.7% of patients with increased risk HEAR scores as safe for discharge. No patients identified as low risk by HEART-CT had MACE within 30 days. Total mean ED LOS was 4.6 hours. ED providers used the HEART-CT smart form in 19.7% of eligible patients. ED providers who followed the HEART-CT recommendations had 3.41 times higher odds of ED discharging patients with increased risk HEAR scores than nonadherent providers (95% CI, 2.20-5.27). CONCLUSIONS HEART-CT reclassified a large proportion of patients as safe for discharge, maintained a high sensitivity for detecting 30-day MACE, and had an acceptable ED LOS. Future studies should test the extent to which more automated clinical decision support improves provider adoption and clinical outcomes of HEART-CT.
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Affiliation(s)
- Andrew J. Matuskowitz
- From the Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC
| | - Jihad S. Obeid
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Lindsey Jennings
- From the Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC
| | - Richard R. Bayer
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | | | - U. Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC
| | - Edward C. Jauch
- From the Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC
- Mission Research Institute, Mission Health, Asheville, NC
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Smulowitz PB, O'Malley AJ, McWilliams JM, Zaborski L, Landon BE. Variation in Rates of Hospital Admission from the Emergency Department Among Medicare Patients at the Regional, Hospital, and Physician Levels. Ann Emerg Med 2021; 78:474-483. [PMID: 34148659 DOI: 10.1016/j.annemergmed.2021.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Rates of admission from the emergency department (ED) vary widely across regions of the country, hospitals within regions, and physicians within hospitals. Our objective was to determine the extent to which variation in admission decisions was described by differences in admission rates at these 3 levels. This understanding will serve to better target interventions to modify rates of admission where appropriate. METHODS In this cross-sectional observational cohort study, we analyzed Medicare fee-for-service claims for ED visits from 2012 to 2015 in a 20% random sample of beneficiaries. We first estimated the total regional-, hospital-, and physician-level variations in rates of admission and their proportions of the total variation after adjusting for patient and each level's covariates. We then estimated the extent to which each level's characteristics accounted for variation at that respective level. RESULTS Our study sample included 5,778,218 visits with 45,491 physicians at 3,480 EDs across 306 hospital referral regions. The mean rate of admission was 38.9% and ranged from 21.4% to 53.0% for physicians at the 10th and 90th percentile of the distribution, respectively. The residual (unexplained) variations at the regional, hospital, and physician levels were 13.3% (95% confidence interval [CI], 11.2 to 15.5%), 60.1% (57.1 to 62.9%), and 26.7% (26.4 to 26.9%), respectively. Regional, hospital, and physician characteristics accounted for 9.1% (95% CI, -5.6 to 23.8%), 51.1% (48.8 to 53.5%), and 2.7% (1.3 to 4.1%), respectively, of the explained variation at their respective levels. CONCLUSION Within-area variation, both across hospitals within a region and across physicians within a hospital, is a more substantial component of observed variation in admission rates from the ED than regional level variation. These findings suggest that variation in admission rates is at least in part related to institutional norms and cultures as well as heterogeneity of physician decisionmaking within hospitals, both of which could be targets of interventions to modify rates of admission.
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Affiliation(s)
- Peter B Smulowitz
- Department of Emergency Medicine, Harvard Medical School, Boston, MA.
| | - A James O'Malley
- Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - Lawrence Zaborski
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Ridgway JP, Robicsek A, Shah N, Smith BA, Singh K, Semel J, Acree ME, Grant J, Ravichandran U, Peterson LR. A Randomized Controlled Trial of an Electronic Clinical Decision Support Tool for Inpatient Antimicrobial Stewardship. Clin Infect Dis 2021; 72:e265-e271. [PMID: 32712674 DOI: 10.1093/cid/ciaa1048] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The weighted incidence syndromic combination antibiogram (WISCA) is an antimicrobial stewardship tool that utilizes electronic medical record data to provide real-time clinical decision support regarding empiric antibiotic prescription in the hospital setting. The aim of this study was to determine the impact of WISCA utilization for empiric antibiotic prescription on hospital length of stay (LOS). METHODS We performed a crossover randomized controlled trial of the WISCA tool at 4 hospitals. Study participants included adult inpatients receiving empiric antibiotics for urinary tract infection (UTI), abdominal-biliary infection (ABI), pneumonia, or nonpurulent cellulitis. Antimicrobial stewardship (ASP) physicians utilized WISCA and clinical guidelines to provide empiric antibiotic recommendations. The primary outcome was LOS. Secondary outcomes included 30-day mortality, 30-day readmission, Clostridioides difficile infection, acquisition of multidrug-resistant gram-negative organism (MDRO), and antibiotics costs. RESULTS In total, 6849 participants enrolled in the study. There were no overall differences in outcomes among the intervention versus control groups. Participants with cellulitis in the intervention group had significantly shorter mean LOS compared to participants with cellulitis in the control group (coefficient estimate = 0.53 [-0.97, -0.09], P = .0186). For patients with community acquired pneumonia (CAP), the intervention group had significantly lower odds of 30-day mortality compared to the control group (adjusted odds ratio [aOR] .58, 95% confidence interval [CI], .396, .854, P = .02). CONCLUSIONS Use of WISCA was not associated with improved outcomes for UTI and ABI. Guidelines-based interventions were associated with decreased LOS for cellulitis and decreased mortality for CAP.
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Affiliation(s)
- Jessica P Ridgway
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ari Robicsek
- Providence St. Joseph Health, Seattle, Washington, USA
| | - Nirav Shah
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Becky A Smith
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Kamaljit Singh
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Jeffery Semel
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Jennifer Grant
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | | | - Lance R Peterson
- Pritzer School of Medicine, University of Chicago, Chicago, Illinois, USA
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Smulowitz PB, O’Malley AJ, Zaborski L, McWilliams JM, Landon BE. Variation In Emergency Department Admission Rates Among Medicare Patients: Does The Physician Matter? Health Aff (Millwood) 2021; 40:251-257. [DOI: 10.1377/hlthaff.2020.00670] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Peter B. Smulowitz
- Peter B. Smulowitz is an assistant professor of emergency medicine in the Department of Emergency Medicine at Beth Israel Deaconess Medical Center, in Boston, Massachusetts, and chief medical officer at Milford Regional Medical Center, in Milford, Massachusetts
| | - A. James O’Malley
- A. James O’Malley is a professor of biomedical data science at the Dartmouth Institute for Health Policy and Clinical Practice and in the Department of Biomedical Data Science at the Geisel School of Medicine at Dartmouth, in Hanover, New Hampshire
| | - Lawrence Zaborski
- Lawrence Zaborski is a senior statistical programmer in the Department of Health Care Policy at Harvard Medical School, in Boston
| | - J. Michael McWilliams
- J. Michael McWilliams is the Warren Alpert Foundation Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School and a professor of medicine and general internist at Brigham and Women’s Hospital, in Boston, Massachusetts
| | - Bruce E. Landon
- Bruce E. Landon is a professor of health care policy in the Department of Health Care Policy at Harvard Medical School and a professor of medicine and practicing internist at Beth Israel Deaconess Medical Center
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Dhaliwal JS, Goss F, Whittington MD, Bookman K, Ho PM, Zane R, Wiler J. Reduced admission rates and resource utilization for chest pain patients using an electronic health record-embedded clinical pathway in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1602-1613. [PMID: 33392569 PMCID: PMC7771814 DOI: 10.1002/emp2.12308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Assess the impact of an electronic health record (EHR)-embedded clinical pathway (ePATH) as compared to a paper-based clinical decision support tool on outcomes for patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS). METHODS A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications to evaluate the impact of an EHR-embedded clinical pathway between April 2013 and July 2017. The intervention was implemented in February 2016 at a large academic tertiary hospital and compared to a local community hospital without the intervention. Eligible patients included adults (>18 years) presenting to the ED with chest pain who had a troponin ordered within 2 hours of arrival and a chest pain-related diagnosis. Patients with initial evidence of acute myocardial infarction were excluded. Primary outcomes included rates of admission and stress testing, hospital length of stay, and occurrence of major adverse cardiac events. RESULTS On average, there were 170 chest pain visits per month at the intervention site. The frequency of hospital admission (unadjusted 28.2% to 20.9%, P < 0.001) and stress testing (unadjusted 15.8% to 12.7%, P < 0.001) significantly declined after ePATH implementation. After comparison with the comparator site, ePATH was still associated with a significant reduction in hospital admissions (-10.79%, P < 0.001) and stress testing (-6.05%, P < 0.001). Hospital length of stay and rates of major adverse cardiac events did not significantly change. CONCLUSIONS Implementation of ePATH for patients presenting to the ED with chest pain was associated with safe reductions in hospital admission and stress testing. ePATH appears to be an effective tool for implementing evidence-based guidelines for ED patients with chest pain.
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Affiliation(s)
- Jasmeet S. Dhaliwal
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Foster Goss
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Melanie D. Whittington
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
- Data Science to Patient Value ProgramUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Kelly Bookman
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - P. Michael Ho
- Data Science to Patient Value ProgramUniversity of Colorado School of MedicineAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Richard Zane
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- UCHealth CARE Innovation CenterAuroraColoradoUSA
| | - Jennifer Wiler
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- UCHealth CARE Innovation CenterAuroraColoradoUSA
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Point-of-Care Diagnosis of Acute Myocardial Infarction in Central Vietnam: International Exchange, Needs Assessment, and Spatial Care Paths. POINT OF CARE 2018; 17:73-92. [PMID: 30245595 PMCID: PMC6135481 DOI: 10.1097/poc.0000000000000167] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental digital content is available in the text. Objectives Objectives were to (a) advance point-of-care (POC) education, international exchange, and culture; (b) report needs assessment survey results from Thua Thien Hue Province, Central Vietnam; (c) determine diagnostic capabilities in regional health care districts of the small-world network of Hue University Medical Center; and (d) recommend Spatial Care Paths that accelerate the care of acute myocardial infarction (AMI) patients. Methods We organized progressively focused, intensive, and interactive lectures, workshops, and investigative teamwork over a 2-year period. We surveyed hospital staff in person to determine the status of diagnostic testing at 15 hospitals in 7 districts. Questions focused on cardiac rapid response, prediabetes/diabetes, infectious diseases, and other serious challenges, including epidemic preparedness. Results Educational exchange revealed a nationwide shortage of POC coordinators. Throughout the province, ambulances transfer patients primarily between hospitals, rarely picking up from homes. No helicopter rescue was available. Ambulance travel times from distant sites to referral hospitals were excessive, longer in costal and mountainous areas. Most hospitals (92.3%) used electrocardiogram and creatine phosphokinase-MB isoenzyme to diagnose AMI. Cardiac troponin I/T testing was performed only at large referral hospitals. Conclusions Central Vietnam must improve rapid diagnosis and treatment of AMI patients. Early upstream POC cardiac troponin testing on Spatial Care Paths will expedite transfers directly to hospitals capable of intervening, improving outcomes following coronary occlusion. Point-of-care coordinator certification and financial support will enhance standards of care cost-effectively. Training young physicians pivots on high-value evidence-based learning when POC cardiac troponin T/cardiac troponin I biomarkers are in place for rapid decision making, especially in emergency rooms.
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