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Zilinyi RS, Fertel BS, Chang BC, Abrukin L, Suh EH, Sayan OR, McCarty M, Stant JA, Chuich T, Smyth ET, Neuberg G, Collins MB, Kirtane AJ, Moses J, Rabbani L. Updating a Healthcare System-wide Clinical Pathway for Managing Chest Pain and Acute Coronary Syndromes. Crit Pathw Cardiol 2023; 22:103-109. [PMID: 37782621 DOI: 10.1097/hpc.0000000000000334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Clinical pathways are useful tools for conveying and reinforcing best practices to standardize care and optimize patient outcomes across myriad conditions. The NewYork-Presbyterian Healthcare System has utilized a clinical chest pain pathway for more than 20 years to facilitate the timely recognition and management of patients presenting with chest pain syndromes and acute coronary syndromes. This chest pain pathway is regularly updated by an expanding group of key stakeholders, which has extended from the Columbia University Irving Medical Center to encompass the entire regional healthcare system, which includes 8 hospitals. In this 2023 update of the NewYork-Presbyterian clinical chest pain pathway, we present the key changes to the healthcare system-wide clinical chest pain pathway.
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Affiliation(s)
- Robert S Zilinyi
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Baruch S Fertel
- Quality and Patient Safety, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Betty C Chang
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Liliya Abrukin
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Edward H Suh
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Osman R Sayan
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Matthew McCarty
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Jennifer A Stant
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | | | - Emily T Smyth
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY
| | - Gerald Neuberg
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Allen Hospital, New York, NY
| | - Michael B Collins
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Ajay J Kirtane
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - Jeffrey Moses
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
| | - LeRoy Rabbani
- From the Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
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Zilinyi RS, Stant JA, Sayan OR, Collins MB, Rabbani LE. Twenty Years of an Institutional Chest Pain Pathway: What's Come and What's Yet to Come. Crit Pathw Cardiol 2023; 22:41-44. [PMID: 37220657 DOI: 10.1097/hpc.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Acute coronary syndromes (ACS) remain one of the leading causes of cardiovascular morbidity and mortality in the United States and around the world. Because of the acute nature of ACS presentations, timely identification, risk stratification, and intervention are of the utmost importance. Twenty years ago, we published the first iteration of our institutional chest pain clinical pathway in this journal, which separated patients presenting with chest pain into one of the 4 levels of decreasing acuity, with associated actions and interventions for providers based on the level. This chest pain clinical pathway has undergone regular review and updates under a collaborative team of cardiologists, emergency department physicians, cardiac nurse practitioners, and other associated stakeholders in the treatment of patients presenting with chest pain. This review will discuss the key changes that our institutional chest pain algorithm has undergone over the last 2 decades and what the future holds for chest pain algorithms.
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Affiliation(s)
- Robert S Zilinyi
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Jennifer A Stant
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Osman R Sayan
- Department of Emergency Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Michael B Collins
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - LeRoy E Rabbani
- From the Department of Medicine, Division of Cardiology, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
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Zhu Z, Islam S, Bergmann SR. Effectiveness and outcomes of a nurse practitioner–run chest pain evaluation unit. J Am Assoc Nurse Pract 2016; 28:591-595. [DOI: 10.1002/2327-6924.12377] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/21/2016] [Indexed: 11/06/2022]
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Wessler JD, Stant J, Duru S, Rabbani L, Kirtane AJ. Updates to the ACCF/AHA and ESC STEMI and NSTEMI guidelines: putting guidelines into clinical practice. Am J Cardiol 2015; 115:23A-8A. [PMID: 25728971 DOI: 10.1016/j.amjcard.2015.01.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jeffrey D Wessler
- Department of Medicine, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York
| | - Jennifer Stant
- Division of Cardiology, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York
| | - Safiye Duru
- Division of Cardiology, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York
| | - LeRoy Rabbani
- Division of Cardiology, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York
| | - Ajay J Kirtane
- Division of Cardiology, Columbia University Medical Center New York-Presbyterian Hospital, New York, New York.
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Safavi KC, Li SX, Dharmarajan K, Venkatesh AK, Strait KM, Lin H, Lowe TJ, Fazel R, Nallamothu BK, Krumholz HM. Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes. JAMA Intern Med 2014; 174:546-53. [PMID: 24515551 PMCID: PMC5459406 DOI: 10.1001/jamainternmed.2013.14407] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Current guidelines allow substantial discretion in use of noninvasive cardiac imaging for patients without acute myocardial infarction (AMI) who are being evaluated for ischemia. Imaging use may affect downstream testing and outcomes. OBJECTIVE To characterize hospital variation in use of noninvasive cardiac imaging and the association of imaging use with downstream testing, interventions, and outcomes. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of hospitals using 2010 administrative data from Premier, Inc, including patients with suspected ischemia on initial evaluation who were seen in the emergency department, observation unit, or inpatient ward; received at least 1 cardiac biomarker test on day 0 or 1; and had a principal discharge diagnosis for a common cause of chest discomfort, a sign or symptom of cardiac ischemia, and/or a comorbidity associated with coronary disease. We excluded patients with AMI. MAIN OUTCOMES AND MEASURES At each hospital, the proportion of patients who received noninvasive imaging to identify cardiac ischemia and the subsequent rates of admission, coronary angiography, and revascularization procedures. RESULTS We identified 549,078 patients at 224 hospitals. The median (interquartile range) hospital noninvasive imaging rate was 19.8% (10.9%-27.7%); range, 0.2% to 55.7%. Median hospital imaging rates by quartile were Q1, 6.0%; Q2, 15.9%; Q3, 23.5%; Q4, 34.8%. Compared with Q1, Q4 hospitals had higher rates of admission (Q1, 32.1% vs Q4, 40.0%), downstream coronary angiogram (Q1, 1.2% vs Q4, 4.9%), and revascularization procedures (Q1, 0.5% vs Q4, 1.9%). Hospitals in Q4 had a lower yield of revascularization for noninvasive imaging (Q1, 7.6% vs Q4, 5.4%) and for angiograms (Q1, 41.2% vs Q4, 38.8%). P <.001 for all comparisons. Readmission rates to the same hospital for AMI within 2 months were not different by quartiles (P = .51). Approximately 23% of variation in imaging use was attributable to the behavior of individual hospitals. CONCLUSIONS AND RELEVANCE Hospitals vary in their use of noninvasive cardiac imaging in patients with suspected ischemia who do not have AMI. Hospitals with higher imaging rates did not have substantially different rates of therapeutic interventions or lower readmission rates for AMI but were more likely to admit patients and perform angiography.
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Affiliation(s)
- Kyan C Safavi
- Yale University School of Medicine, New Haven, Connecticut
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut3Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Kumar Dharmarajan
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut4Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut6Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Kelly M Strait
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut3Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Haiqun Lin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut7Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | | | - Reza Fazel
- Division of Cardiology, Department of Medicine, Emory University School of Medicine and Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia
| | - Brahmajee K Nallamothu
- Veterans Affairs Health Services Research and Development Center of Excellence, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan11Department of Internal Medicine, University of Michigan, Ann Arbor 12Center for Healthcare Outcomes and Poli
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut3Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut6Robert Wood Johnson Foundation Cli
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Biviano AB, Giglio J, Lazar EJ, Cooper M, Sullivan J, Hurley E, Sciacca RR, Tenenbaum J, Bergmann SR, Rabbani LE. Positive impact of an interdisciplinary chest pain initiative on traditionally underserved populations. Crit Pathw Cardiol 2005; 4:3-9. [PMID: 18340178 DOI: 10.1097/01.hpc.0000155273.96879.c9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND We assessed the clinical impact of an interdisciplinary, cardiac nurse practitioner-facilitated chest pain (CP) initiative that stresses an early invasive approach for patients with CP with acute coronary syndromes in traditionally underserved patient populations, including females, blacks, Hispanics, and patients older than 60 years. METHODS Two groups of patients were identified: Pre-CP initiative (December 1999-February 2000) and post-CP initiative (December 2000-February 2001). RESULTS Analysis of 714 patients revealed significantly more cardiac diagnoses post-CP initiative (61% pre-CP initiative vs. 73% post-CP initiative, P = 0.002), including in patients with myocardial infarction (MI) who were older than 60 years, females, and Hispanics. There was a significant increase in rates of cardiac catheterizations within 1 week of admission (10.5% vs. 20.4%, P <0.001), including in Hispanics. For rates of coronary artery stenting and/or bypass grafting (CABG), there was also a significant increase post-CP initiative (2.5% vs. 10.1%, P = 0.0005), as well as for Hispanics. Length of stay was significantly reduced for patients older than 60 years (8.3 vs. 5.8 days, P = 0.002). CONCLUSION Establishment of an interdisciplinary, cardiac nurse practitioner-facilitated CP initiative is associated with improvement in several clinical processes and outcomes: increased cardiac disease diagnosis in females, Hispanics, and patients older than 60 years; increased rates of cardiac catheterizations in Hispanic patients, increased rates of coronary artery stenting and/or CABG, particularly in Hispanic patients; and decreased length of stay in patients older than 60 years. These data support a targeted interdisciplinary CP initiative as a strategy to systematically enhance access to cardiovascular diagnosis in underserved patient populations.
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Goyal NK, Giglio J, Lorberbaum M, Hurley E, Stant J, Esposito F, Sciacca R, Apfelbaum M, Rabbani LE. A rapid-response alphanumeric paging design decreases door-to-balloon times in patients undergoing primary percutaneous coronary intervention for ST elevation acute myocardial infarction. Crit Pathw Cardiol 2004; 3:150-153. [PMID: 18340157 DOI: 10.1097/01.hpc.0000139463.57231.9f] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
INTRODUCTION In acute ST elevation myocardial infarction (STEMI), rapid reperfusion of the infarcted artery improves cardiovascular outcomes; however, many hospitals have difficulty achieving recommended times. We hypothesized that a Rapid-Response Alphanumeric Paging Design (RAPiD) would reduce door-to-balloon time for primary percutaneous coronary intervention (PCI) in STEMI. METHODS A chest pain algorithm and interdisciplinary team was established in December 2000. In August 2002, RAPiD was instituted to transmit the diagnosis and location of a STEMI to the chest pain team through a speed-dial button. All patients presenting to our emergency department from February 2002 through July 2003 with STEMI were included. Exclusion criteria included lack of chest pain, cardiopulmonary arrest before PCI, and catheterization or PCI not performed. Outside-referral STEMI, in-patient STEMI, and failed thrombolysis patients were excluded. Data was obtained from medical records. Log transform of door-to-balloon (DTB) times was performed. RESULTS Forty-seven events satisfied inclusion and exclusion criteria with 32 occurring after RAPiD (post-RAPiD). Fifteen events occurred during on-hours (8 am to 7 pm on weekdays). Mean untransformed DTB times pre- and post-RAPiD were 162 +/- 137 (standard deviation) minutes and 112 +/- 41 minutes. The main effects analysis of variance model showed a significant reduction in post-RAPiD DTB time (P = 0.03) with a mean reduction of 26% during off-hours and 20% during on-hours. The post-RAPiD estimate of mean DTB time, derived from the antilog of the log transform, was 96.7 minutes (95% confidence interval, 83.7-111.7). CONCLUSIONS The institution of RAPiD in a hospital with a preexisting chest pain algorithm significantly decreases DTB times so as to satisfy current ACC/AHA guidelines.
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Affiliation(s)
- Neil K Goyal
- Division of Cardiology, Columbia University Medical Center, New York Presbyterian Hospital and Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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