QUALITY IMPROVEMENT REPORT
Implementation of a rapid chest pain protocol in the emergency department: A quality improvement project Azalea Marie Bunch, DNP, APRN-ENP (Emergency NP)1 , A. Renee Leasure, PhD, APRN-CNS, CCRN (Associate Professor)2 , Cathrin Carithers, DNP, APRN-FNP-C (Director)3 , Robert E. Burnette Jr., MD (Physician)4 , & Michael Scott Berryman Sr., EMT-P (Battalion Chief)5 1
Emergency Department, TeamHeath Memorial Hermann Health Care System, Huntsville and The Woodlands, Texas College of Nursing, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 3 Doctor of Nursing Practice Program, University of Arkansas for Medical Sciences, Little Rock, Arkansas 4 Emergency Department, Memorial Hermann, Houston, Texas 5 Woodlands Fire Department, Woodlands, Texas 2
Keywords Emergency department; cardiac biomarkers; chest pain; screening; protocol; quality improvement. Correspondence Azalea Marie Bunch, DNP, APRN-ENP, 2312 Hollowbrook Lane, Conroe, TX 77384. Tel: 936-271-9525 (home), 291-396-4589 (work), 936-444-8697 (cell); Fax: 936-271-9525; E-mail: [email protected] Received: 17 June 2014; accepted: 4 March 2015 doi: 10.1002/2327-6924.12260
Abstract Purpose: The purpose of this quality improvement (QI) project is to compare the effectiveness of a rapid 90-min chest pain screening and evaluation protocol to a 120-min screening and evaluation protocol in determining patient readiness for hospital admission or discharge home. Data Sources: The existing chest pain protocol utilized in the emergency department (ED) was revised based on a review of current research changing initial screening and reevaluation times from 120 to 90 min. A prospective comparative study of patients presenting to the ED with chest pain was performed comparing the existing chest pain protocol of 120 min (standard care) with a rapid screening evaluation protocol of 90 min. A total of 128 patients presenting to an ED in Texas with chest pain comprised the sample for this study. Conclusions: There was a significant difference in the number of minutes between the groups for readiness for disposition. The average time from chest pain evaluation to readiness for disposition home, observation, or admission decreased from an average of 191 min in the standard care group to an average of 118 min in the rapid screening group. Implications for practice: Use of the rapid screening and evaluation protocol decreased the time to disposition by an average of 73 min, which enhanced ED flow without influencing disposition and patient safety.
Acute coronary syndrome (ACS) frequently presents with chest pain (Go et al., 2014). Cardiac disorders to consider in the presence of chest pain include ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina. ST is a segment tracing on an electrocardiogram used to identify acute myocardial infarction (Diercks et al., 2012). The evaluation of chest pain utilizes a three pronged approach—history and physical assessment, electrocardiogram (ECG), and cardiac biomarkers. History and physical assessment findings assist in the differentiation between cardiac and noncardiac causes of chest pain. The 12 lead ECG is used to differentiate a STEMI from a NSTEMI. Cardiac biomarkers (creatine kinase MB [CKMB], myoglobin, and troponin I) assist in the differentiation between a Journal of the American Association of Nurse Practitioners 28 (2016) 75–83 C 2015 American Association of Nurse Practitioners
NSTEMI and unstable angina (UA). Cardiac biomarkers are elevated in STEMI and NSTEMI. The estimated healthcare expenditures associated with emergent evaluation of chest pain exceeds $10 billion dollars per year (Jois-Bilowich & Tyndall, 2010). Two percent to 8% of patients that present with symptoms of ACS are misdiagnosed and discharged home inappropriately, thereby increasing mortality rates (Dadkhah et al., 2007). The ineffective evaluation and management in the emergency department (ED) of chest pain caused by ACS has resulted in unwarranted hospitalizations and futile utilization of emergency services, leading to overcrowding, treatment delays, and a reduction in optimal healthcare outcomes, as well as concerns regarding potential litigation (Go et al., 2014; Lee & Goldman, 2000). 75
Rapid chest pain protocol
A. M. Bunch et al.
Chest Pain; Suspected Acute Coronary Syndrome
Triage into Accelerated Chest Pain Pathway
Diagnostic Tests: ECG, Chest X-Ray (arrival 3 = high risk
TIMI, Thrombolysis in Myocardial Infarction; NSTEMI, non-ST-elevation myocardial infarction. Number of checks = TIMI Score__________________
Cullen et al. (2013) tested a 2-h accelerated diagnostic protocol that used baseline and 2-h TnI results, ECG, and TIMI risk scores extended to include ࣘ1 in patients presenting to the ED with chest pain. Findings demonstrated that the incorporation of a TIMI risk score of ࣘ1 doubled the proportion of ED patients who were at low risk while maintaining >99% sensitivity and negative predictive value for adverse events. In another study, the utility of hsTnT assays at baseline and 90 min were compared using banked serum samples from 465 patients who presented to the ED with complaints of chest pain. The hsTnT assay testing at baseline and 90 min was able to identify every AMI case (n = 12) with a sensitivity of 100% and specificity of 94.5% (Schreiber, Agbo, & Wu, 2012). Patient’s risk factors were determined using the TIMI, a risk stratification score for unstable angina or NSTEMI (Table 1). A TIMI score has been shown to be a predictor of an ischemic event (Antman et al., 2000). The tool was designed to be easily hand calculated at patient presentation and categorizes patients’ risk for death and ischemic events at 14 days. The predictor variables were derived from a data set of subjects who participated in the TIMI 11B and ESSENCE (Efficacy and Safety of Subcutaneous Enoxaparin in Unstable Angina and Non-Q-Wave MI) Trials. From a merged
78
database of 7081 subject records, seven predictor variables were identified and scored as either absent (0) or present (1) and summed to provide a risk score. The TIMI tool encompasses seven criteria: (a) age 65 or older, (b) three or more risk factors for coronary artery disease, (c) aspirin use in the past 7 days, (d) significant coronary stenosis, (e) severe angina, (f) ST-segment deviation of 0.05mV or greater on ECG, and (g) increased troponin and/or CKMB (Storrow et al., 2006). TIMI risk scores have been compared to tools such as the GRACE (Global Registry of Acute Coronary Events). Although both tools were found to have similar results, the GRACE had a more labor-intensive scoring system that was a deterrent to use (Cullen et al., 2013; Lee, Chang, Matsuura, Marcoon, & Hollander, 2011; Lyon, Morris, Caesar, Gray, & Gray, 2007). While developed to predict 14-day cardiovascular events, TIMI risk stratification has since demonstrated the ability to discriminate and predict risk for 30-day cardiovascular events and mortality (Chase et al., 2006; Pollack, Sites, Shofer, Sease, & Hollander, 2006); however, investigators have recommended the TIMI not be used in isolation, but rather as part of a decision tree for ED chest pain patients (Chase et al., 2006; Conway Morris, Caesar, Gray, & Gray, 2006). Disposition of patients with negative biomarkers was determined by categorization of the patients’ risks of ACS using the TIMI risk score evaluation tool. Low-risk patients with a TIMI score of 0– 1 were discharged home to follow-up with their primary care provider/cardiologist. In patients’ with an intermediate risk TIMI score of 2–3, a stress test was ordered with disposition home if negative or a cardiology consult if positive with an ECG or cardiac catheterization. A cardiology consult was ordered for those with a high-risk TIMI score of >3 and those patients were admitted for observation. Patients with positive TnI were admitted for observation and a cardiology consult ordered. Cardiac troponins are chemical biomarkers of myocardial necrosis, which can be detected from a serum blood sample rather than through more complex and expensive diagnostic tests, such as coronary CT or stress testing (de Groot, Verdoorn, Lameijer, & van der Velden, 2013; Ottinger & Nash, 2013). Positive results may be seen in patients with diseases, such as heart failure, renal failure, and pulmonary embolism. Thus, serial testing is recommended to differentiate between an acute and chronic disease process (Chin et al., 2012; Thygesen, Alpert et al., 2012a; Wu, 2006). In an acute situation, troponin elevations will be demonstrated with serial testing (Goodacre et al., 2011; Thygesen, Mair et al., 2012; Wu, 2006). Troponin has been successfully used as the only diagnostic biomarker in the evaluation of chest pain in other studies (Aldous, Richards et al., 2012; Cullen et al., 2014).
Rapid chest pain protocol
A. M. Bunch et al.
Context The concept of context encompasses (a) receptive context, (b) culture, and (c) leadership as it applies to the environment in which the proposed change occurs (McCormack et al., 2002; Rycroft-Malone, Harvey et al., 2004). Receptive context includes physical, social, cultural, structural, system, and professional networks in which boundaries should be acknowledged and clearly defined. Appropriate decision-making processes, power and authority, and pertinent resources should be utilized to identify and strategically define goals, key practice changes, and patient issues. Organizational culture plays a key role in providing an environment conducive to learning and receptive to change. The rate and success of adoption and implementation of EBP protocols rely on the characteristics of the organization, particularly with regard to innovation and research. Important to the success of the project is building a culture receptive to change. Factors in support of change included cost savings, positive patient outcomes, and adherence to current ACC/AHA recommendations for turnaround times for cardiac biomarkers. The idea of the implementation of an accelerated critical pathway/protocol for patients presenting to the ED complaining of chest pain was addressed at one of the monthly ED meetings to obtain perceptions of clinicians, nursing, and ancillary staff and to develop an action plan. Individual champions for the use of POC testing were identified, which facilitated successful protocol implementation.
Facilitation There are two types of implementation purposes, taskoriented and organizational purpose. The implementation of an accelerated 90-min chest pain protocol falls within the realms of a task-oriented purpose (Rycroft-Malone, Harvey et al., 2004). An interprofessional team comprised of ED personnel, cardiologists, cardiac catheter laboratory personnel, and ancillary and administrative staff guided project implementation. The task-oriented purpose of the team was to review the evidence for the proposed practice change, identify essential elements, and address potential barriers or obstacles that would hinder progression of the protocol implementation. The obstacles/barriers for integration of the evidencebased 90-min accelerated chest pain protocol were multifactorial: (a) deviation from traditional practice protocols resulting in fear of litigation, (b) loss of revenue to ancillary department (central laboratory), (c) time and tracking necessary for quality checks of the iSTAT (Abbott point of
care) device, and (d) underutilization of information technology (IT) systems. Fear of litigation stemmed from the deviation from traditional chest pain protocols. Patients with AMI who are mistakenly discharged home from the ED have short-term mortality rates approaching 25% as compared to mortality rates of 2.1% for patients who are admitted (Lee & Goldman, 2000). Thus, 30-day follow-up data were collected for each patient discharged home who participated in the study in order to detect any patients who should have been admitted to either the observation unit or an inpatient bed. The concern for loss of revenue from ancillary services (central laboratory) posed a challenge with cardiac biomarker testing being shifted to the ED with bedside POC testing. This barrier was circumvented by negotiations between the director of the central laboratory and the interprofessional committee. A decision was made to keep the revenue from POC testing in the central laboratory providing the laboratory would maintain oversight of the quality control process. Implementation of the 90-min accelerated chest pain protocol that included bedside POC cardiac biomarkers was facilitated by several factors. A review of the current literature that compared turnaround time and diagnostic accuracy of central laboratory and POC cardiac biomarkers performed with the iSTAT device was conducted. In addition, the iSTAT device has Food and Drug Administration (FDA) approval, which alleviated concerns regarding diagnostic accuracy. Education of ED staff on the use of the iSTAT device was also performed by an iSTAT representative. ED staff members were receptive to the change and attended on-site in-services offered each shift with hands on training. Web-based refresher courses and a 24-h helpline were available for staff members to obtain responses to questions, concerns, or potential problems that arose during implementation.
Methods Design and ethical considerations This project was conducted using a pre- and postprotocol intervention design. This project received Institutional Review Board approval.
Setting and sampling criteria The setting for this QI project was a 15-bed single acute care hospital ED in a suburb of a large metropolitan area. A power analysis was performed to determine sample size using an independent t-test with p
Implementation of a rapid chest pain protocol in the emergency department: A quality improvement project Azalea Marie Bunch, DNP, APRN-ENP (Emergency NP)1 , A. Renee Leasure, PhD, APRN-CNS, CCRN (Associate Professor)2 , Cathrin Carithers, DNP, APRN-FNP-C (Director)3 , Robert E. Burnette Jr., MD (Physician)4 , & Michael Scott Berryman Sr., EMT-P (Battalion Chief)5 1
Emergency Department, TeamHeath Memorial Hermann Health Care System, Huntsville and The Woodlands, Texas College of Nursing, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma 3 Doctor of Nursing Practice Program, University of Arkansas for Medical Sciences, Little Rock, Arkansas 4 Emergency Department, Memorial Hermann, Houston, Texas 5 Woodlands Fire Department, Woodlands, Texas 2
Keywords Emergency department; cardiac biomarkers; chest pain; screening; protocol; quality improvement. Correspondence Azalea Marie Bunch, DNP, APRN-ENP, 2312 Hollowbrook Lane, Conroe, TX 77384. Tel: 936-271-9525 (home), 291-396-4589 (work), 936-444-8697 (cell); Fax: 936-271-9525; E-mail: [email protected] Received: 17 June 2014; accepted: 4 March 2015 doi: 10.1002/2327-6924.12260
Abstract Purpose: The purpose of this quality improvement (QI) project is to compare the effectiveness of a rapid 90-min chest pain screening and evaluation protocol to a 120-min screening and evaluation protocol in determining patient readiness for hospital admission or discharge home. Data Sources: The existing chest pain protocol utilized in the emergency department (ED) was revised based on a review of current research changing initial screening and reevaluation times from 120 to 90 min. A prospective comparative study of patients presenting to the ED with chest pain was performed comparing the existing chest pain protocol of 120 min (standard care) with a rapid screening evaluation protocol of 90 min. A total of 128 patients presenting to an ED in Texas with chest pain comprised the sample for this study. Conclusions: There was a significant difference in the number of minutes between the groups for readiness for disposition. The average time from chest pain evaluation to readiness for disposition home, observation, or admission decreased from an average of 191 min in the standard care group to an average of 118 min in the rapid screening group. Implications for practice: Use of the rapid screening and evaluation protocol decreased the time to disposition by an average of 73 min, which enhanced ED flow without influencing disposition and patient safety.
Acute coronary syndrome (ACS) frequently presents with chest pain (Go et al., 2014). Cardiac disorders to consider in the presence of chest pain include ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina. ST is a segment tracing on an electrocardiogram used to identify acute myocardial infarction (Diercks et al., 2012). The evaluation of chest pain utilizes a three pronged approach—history and physical assessment, electrocardiogram (ECG), and cardiac biomarkers. History and physical assessment findings assist in the differentiation between cardiac and noncardiac causes of chest pain. The 12 lead ECG is used to differentiate a STEMI from a NSTEMI. Cardiac biomarkers (creatine kinase MB [CKMB], myoglobin, and troponin I) assist in the differentiation between a Journal of the American Association of Nurse Practitioners 28 (2016) 75–83 C 2015 American Association of Nurse Practitioners
NSTEMI and unstable angina (UA). Cardiac biomarkers are elevated in STEMI and NSTEMI. The estimated healthcare expenditures associated with emergent evaluation of chest pain exceeds $10 billion dollars per year (Jois-Bilowich & Tyndall, 2010). Two percent to 8% of patients that present with symptoms of ACS are misdiagnosed and discharged home inappropriately, thereby increasing mortality rates (Dadkhah et al., 2007). The ineffective evaluation and management in the emergency department (ED) of chest pain caused by ACS has resulted in unwarranted hospitalizations and futile utilization of emergency services, leading to overcrowding, treatment delays, and a reduction in optimal healthcare outcomes, as well as concerns regarding potential litigation (Go et al., 2014; Lee & Goldman, 2000). 75
Rapid chest pain protocol
A. M. Bunch et al.
Chest Pain; Suspected Acute Coronary Syndrome
Triage into Accelerated Chest Pain Pathway
Diagnostic Tests: ECG, Chest X-Ray (arrival 3 = high risk
TIMI, Thrombolysis in Myocardial Infarction; NSTEMI, non-ST-elevation myocardial infarction. Number of checks = TIMI Score__________________
Cullen et al. (2013) tested a 2-h accelerated diagnostic protocol that used baseline and 2-h TnI results, ECG, and TIMI risk scores extended to include ࣘ1 in patients presenting to the ED with chest pain. Findings demonstrated that the incorporation of a TIMI risk score of ࣘ1 doubled the proportion of ED patients who were at low risk while maintaining >99% sensitivity and negative predictive value for adverse events. In another study, the utility of hsTnT assays at baseline and 90 min were compared using banked serum samples from 465 patients who presented to the ED with complaints of chest pain. The hsTnT assay testing at baseline and 90 min was able to identify every AMI case (n = 12) with a sensitivity of 100% and specificity of 94.5% (Schreiber, Agbo, & Wu, 2012). Patient’s risk factors were determined using the TIMI, a risk stratification score for unstable angina or NSTEMI (Table 1). A TIMI score has been shown to be a predictor of an ischemic event (Antman et al., 2000). The tool was designed to be easily hand calculated at patient presentation and categorizes patients’ risk for death and ischemic events at 14 days. The predictor variables were derived from a data set of subjects who participated in the TIMI 11B and ESSENCE (Efficacy and Safety of Subcutaneous Enoxaparin in Unstable Angina and Non-Q-Wave MI) Trials. From a merged
78
database of 7081 subject records, seven predictor variables were identified and scored as either absent (0) or present (1) and summed to provide a risk score. The TIMI tool encompasses seven criteria: (a) age 65 or older, (b) three or more risk factors for coronary artery disease, (c) aspirin use in the past 7 days, (d) significant coronary stenosis, (e) severe angina, (f) ST-segment deviation of 0.05mV or greater on ECG, and (g) increased troponin and/or CKMB (Storrow et al., 2006). TIMI risk scores have been compared to tools such as the GRACE (Global Registry of Acute Coronary Events). Although both tools were found to have similar results, the GRACE had a more labor-intensive scoring system that was a deterrent to use (Cullen et al., 2013; Lee, Chang, Matsuura, Marcoon, & Hollander, 2011; Lyon, Morris, Caesar, Gray, & Gray, 2007). While developed to predict 14-day cardiovascular events, TIMI risk stratification has since demonstrated the ability to discriminate and predict risk for 30-day cardiovascular events and mortality (Chase et al., 2006; Pollack, Sites, Shofer, Sease, & Hollander, 2006); however, investigators have recommended the TIMI not be used in isolation, but rather as part of a decision tree for ED chest pain patients (Chase et al., 2006; Conway Morris, Caesar, Gray, & Gray, 2006). Disposition of patients with negative biomarkers was determined by categorization of the patients’ risks of ACS using the TIMI risk score evaluation tool. Low-risk patients with a TIMI score of 0– 1 were discharged home to follow-up with their primary care provider/cardiologist. In patients’ with an intermediate risk TIMI score of 2–3, a stress test was ordered with disposition home if negative or a cardiology consult if positive with an ECG or cardiac catheterization. A cardiology consult was ordered for those with a high-risk TIMI score of >3 and those patients were admitted for observation. Patients with positive TnI were admitted for observation and a cardiology consult ordered. Cardiac troponins are chemical biomarkers of myocardial necrosis, which can be detected from a serum blood sample rather than through more complex and expensive diagnostic tests, such as coronary CT or stress testing (de Groot, Verdoorn, Lameijer, & van der Velden, 2013; Ottinger & Nash, 2013). Positive results may be seen in patients with diseases, such as heart failure, renal failure, and pulmonary embolism. Thus, serial testing is recommended to differentiate between an acute and chronic disease process (Chin et al., 2012; Thygesen, Alpert et al., 2012a; Wu, 2006). In an acute situation, troponin elevations will be demonstrated with serial testing (Goodacre et al., 2011; Thygesen, Mair et al., 2012; Wu, 2006). Troponin has been successfully used as the only diagnostic biomarker in the evaluation of chest pain in other studies (Aldous, Richards et al., 2012; Cullen et al., 2014).
Rapid chest pain protocol
A. M. Bunch et al.
Context The concept of context encompasses (a) receptive context, (b) culture, and (c) leadership as it applies to the environment in which the proposed change occurs (McCormack et al., 2002; Rycroft-Malone, Harvey et al., 2004). Receptive context includes physical, social, cultural, structural, system, and professional networks in which boundaries should be acknowledged and clearly defined. Appropriate decision-making processes, power and authority, and pertinent resources should be utilized to identify and strategically define goals, key practice changes, and patient issues. Organizational culture plays a key role in providing an environment conducive to learning and receptive to change. The rate and success of adoption and implementation of EBP protocols rely on the characteristics of the organization, particularly with regard to innovation and research. Important to the success of the project is building a culture receptive to change. Factors in support of change included cost savings, positive patient outcomes, and adherence to current ACC/AHA recommendations for turnaround times for cardiac biomarkers. The idea of the implementation of an accelerated critical pathway/protocol for patients presenting to the ED complaining of chest pain was addressed at one of the monthly ED meetings to obtain perceptions of clinicians, nursing, and ancillary staff and to develop an action plan. Individual champions for the use of POC testing were identified, which facilitated successful protocol implementation.
Facilitation There are two types of implementation purposes, taskoriented and organizational purpose. The implementation of an accelerated 90-min chest pain protocol falls within the realms of a task-oriented purpose (Rycroft-Malone, Harvey et al., 2004). An interprofessional team comprised of ED personnel, cardiologists, cardiac catheter laboratory personnel, and ancillary and administrative staff guided project implementation. The task-oriented purpose of the team was to review the evidence for the proposed practice change, identify essential elements, and address potential barriers or obstacles that would hinder progression of the protocol implementation. The obstacles/barriers for integration of the evidencebased 90-min accelerated chest pain protocol were multifactorial: (a) deviation from traditional practice protocols resulting in fear of litigation, (b) loss of revenue to ancillary department (central laboratory), (c) time and tracking necessary for quality checks of the iSTAT (Abbott point of
care) device, and (d) underutilization of information technology (IT) systems. Fear of litigation stemmed from the deviation from traditional chest pain protocols. Patients with AMI who are mistakenly discharged home from the ED have short-term mortality rates approaching 25% as compared to mortality rates of 2.1% for patients who are admitted (Lee & Goldman, 2000). Thus, 30-day follow-up data were collected for each patient discharged home who participated in the study in order to detect any patients who should have been admitted to either the observation unit or an inpatient bed. The concern for loss of revenue from ancillary services (central laboratory) posed a challenge with cardiac biomarker testing being shifted to the ED with bedside POC testing. This barrier was circumvented by negotiations between the director of the central laboratory and the interprofessional committee. A decision was made to keep the revenue from POC testing in the central laboratory providing the laboratory would maintain oversight of the quality control process. Implementation of the 90-min accelerated chest pain protocol that included bedside POC cardiac biomarkers was facilitated by several factors. A review of the current literature that compared turnaround time and diagnostic accuracy of central laboratory and POC cardiac biomarkers performed with the iSTAT device was conducted. In addition, the iSTAT device has Food and Drug Administration (FDA) approval, which alleviated concerns regarding diagnostic accuracy. Education of ED staff on the use of the iSTAT device was also performed by an iSTAT representative. ED staff members were receptive to the change and attended on-site in-services offered each shift with hands on training. Web-based refresher courses and a 24-h helpline were available for staff members to obtain responses to questions, concerns, or potential problems that arose during implementation.
Methods Design and ethical considerations This project was conducted using a pre- and postprotocol intervention design. This project received Institutional Review Board approval.
Setting and sampling criteria The setting for this QI project was a 15-bed single acute care hospital ED in a suburb of a large metropolitan area. A power analysis was performed to determine sample size using an independent t-test with p
