Effects of critical pathway on the management of patients with ST-elevation acute myocardial infarction in an emergency department

The Use of Clinical Pathways in Emergency Departments: A Scoping Review

Introduction

Clinical pathways (CPWs) are evidence-based, standardised, clinical management plans that are designed to deliver a sequence of clinical interventions to improve the efficiency and effectiveness of healthcare. The aim of this study was to identify and summarise the current available evidence on the use of CPWs in emergency departments (EDs).

Study design

A literature search was conducted in Scopus, Embase, Emcare, and PubMed academic databases. The search strategy was guided by Arksey and O'Malley's framework and results reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews Checklist. Studies were included if they reported empirical data either qualitatively or quantitatively, studied the use of CPW practices, and reported on the use of at least one CPW activity.

Results

Sixty-four articles were eligible for the scoping review. Variation and quality of treatment, resource utilisation and time to treatment were identified as the three main patient and organisational outcomes from the use of CPWs. Three main categories of barriers to use were identified: Organisational environment factors, Healthcare professional-related factors, and CPW operational issues.

Conclusions

CPW implementation has wide positive patient and organisational outcomes in the ED. Whilst no single strategy would result in implementing CPWs in the ED settings successfully, broad engagement with clinicians of all disciplines who use the pathways and involvement of multidisciplinary teams in implementation is vital to increase visibility of the CPW.

The effect of acute coronary syndrome care pathways on in-hospital patients: A systematic review

BACKGROUND

Health care institutions need to construct management strategies for patients diagnosed with acute coronary syndrome (ACS) that focus on evidence-based treatments, adherence to treatment guidelines, and organized care. These help to reduce variations as well as the mortality and morbidity rates, which indicates the critical need for standardized care and adherence to evidence-based practices for patients hospitalized with ACS. The care pathways translate research and guidelines into clinical practice to close the gap between the guidelines and the clinical practices.

OBJECTIVES

This review focuses on identifying the indicators used to evaluate ACS care pathways and their effect on the care process and clinical outcomes.

METHODS

This review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The systematic research was conducted using five research databases. Two groups were created by dividing the studies according to their year of publication. The first group included those studies published from 1997 to 2007 ("Group 1"), while the second included those published from 2008 to 2018 ("Group 2"). Selected studies were screened using the Effective Public Health Practice Project (EPHPP) quality assessment tool.

RESULTS

Seventeen studies were included in this review. One study was a randomized controlled trial, 14 were predesigns and postdesigns, and two were longitudinal observational designs. The Group 1 studies demonstrated that ACS care pathways had a positive effect on reducing the length of the hospital stay and the door-to-balloon times. Similar effects were observed for the Group 2 studies.

CONCLUSION

Implementing ACS care pathway helps to organize care processes and decrease treatment delays as well as improve the patient outcomes without adverse consequences for patients or additional resources and costs. While the current level of evidence is inadequate to warrant a formal recommendation, there is a need for more studies with an emphasis on well-designed randomization to measure patient outcomes.

Value-based assessment of implementing a Pulmonary Embolism Response Team (PERT)

PERTs are a new, multidisciplinary approach to PE care. They were conceived to efficiently identify and risk stratify PE patients and standardize care delivery. More research needs to be conducted to assess the effects that PERTs have had on PE care. This study sought to determine the effects of a PERT on quality and overall value of care. This was a retrospective study of all patients 18 years of age or older who presented with a principal diagnosis of an acute PE based on available ICD codes from January 1, 2010 to December 31, 2018. Patients who did not have an imaging study, i.e., CTPA or ECHO, available were excluded. Patients were divided into pre- (before October 2015) and post-PERT eras (after October 2015) and stratified based on the presence of right heart strain/dysfunction on imaging. All quality outcomes were extracted from the EMR, and cost outcomes were provided by the financial department. 530 individuals (226 pre-PERT and 304 post-PERT) were identified for analysis. Quality outcomes improved between the eras; most notably in-hospital mortality decreased (16.5 vs. 9.6) and hospital LOS decreased (7.7 vs. 4.4) (p < 0.05). Total cost of care also decreased a statistically significant amount between the eras. The implementation of a PERT improved quality and cost of care, resulting in improved value. We hypothesize that this may be due to more timely identification and risk stratification leading to earlier interventions and streamlined decision making, but further research is required to validate these findings in larger cohorts.

Emergency Response in the Ambulatory Surgery Center

As more surgeries are moving out of the hospital setting, effective emergency response in freestanding ambulatory surgery centers requires organized preparedness. Rapid, consistent emergency response can be challenged by their rarity of occurrence, fast-paced environment, and relative lack of resources. Anesthesiologists who practice in these settings must be aware of the differences between the management of an anesthetic emergency in the hospital with virtually unlimited resources and staff, versus an ambulatory surgery center with limited resources and slightly different goal: stabilization and transfer of care. Regular simulation-based training schedules are effective for ambulatory surgery center preparedness for emergency response.

Effectiveness of a multidisciplinary critical pathway based on a computerised physician order entry system for ST-segment elevation myocardial infarction management in the emergency department: a retrospective observational study

OBJECTIVES

The purpose of this study was to investigate whether a multidisciplinary organised critical pathway (CP) for ST-segment elevation myocardial infarction (STEMI) management can significantly attenuate differences in the duration from emergency department (ED) arrival to evaluation and treatment, regardless of the arrival time, by eliminating off-hour and weekend effects.

DESIGN

Retrospective observational cohort study.

SETTING

2 tertiary academic hospitals.

PARTICIPANTS

Consecutive patients in the Fast Interrogation Rule for STEMI (FIRST) program.

INTERVENTIONS

A study was conducted on patients in the FIRST program, which uses a computerised physician order entry (CPOE) system. The patient demographics, time intervals and clinical outcomes were analysed based on the arrival time at the ED: group 1, normal working hours on weekdays; group 2, off-hours on weekdays; group 3, normal working hours on weekends; and group 4, off-hours on weekends.

PRIMARY AND SECONDARY OUTCOME MEASURES

Clinical outcomes categorised according to 30-day mortality, in-hospital mortality and the length of stay.

RESULTS

The duration from door-to-data or FIRST activation did not differ significantly among the 4 groups. The median duration between arrival and balloon placement during percutaneous coronary intervention did not significantly exceed 90 min, and the proportions (89.6-95.1%) of patients with door-to-balloon times within 90 min did not significantly differ among the 4 groups, regardless of the ED arrival time (p=0.147). Moreover, no differences in the 30-day (p=0.8173) and in-hospital mortality (p=0.9107) were observed in patients with STEMI.

CONCLUSIONS

A multidisciplinary CP for STEMI based on a CPOE system can effectively decrease disparities in the door-to-data duration and proportions of patients with door-to-balloon times within 90 min, regardless of the ED arrival time. The application of a multidisciplinary CP may also help attenuate off-hour and weekend effects in STEMI clinical outcomes.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.