Critical pathway improves arrival-in-cath-lab interval for patients with acute myocardial infarction in the emergency department

Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.

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.

Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review

AIM

To analyse the evidence regarding indicators affected by clinical pathways (CPW) in hospitals and offer suggestions for conducting comprehensive systematic reviews.

METHODS

We conducted a systematic scoping review and searched the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, OVID, Science Direct, ProQuest, EMBASE and PubMed. We also reviewed the reference lists of included studies. The criteria for inclusion of studies included experimental and quasi-experimental studies, implementing CPW in secondary and tertiary hospitals and investigating at least one indicator. Quality of included studies was assessed by two authors independently using the Critical Appraisal Skills Program for clinical trials and cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies.

RESULTS

Forty-seven out of 2191 studies met the eligibility and inclusion criteria. The majority of included studies had pretest-posttest quasi-experimental design and had been done in developed countries, especially the United States. The investigation of evidence resulted in identifying 62 indicators which were classified into three categories: input indicators, process and output indicators and outcome indicators. Outcome indicators were more frequent than other indicators. Complication rate, hospital costs and length of hospital stay were dominant in their own category. Indicators such as quality of life and adherence to guidelines have been considered in studies that were done in recent years.

CONCLUSION

Implementing CPW can affect different types of indicators such as input, process, output and outcome indicators, although outcome indicators capture more attention than other indicators. Patient-related indicators were dominant outcome indicators, whereas professional indicators and organizational factors were considered less extensively. WHAT IS KNOWN ABOUT THE TOPIC?: WHAT DOES THIS ARTICLE ADD?

Effects of Clinical Pathways: Do They Work?

Objective:

Evaluation of the effect of implementing clinical pathways is a relatively new field in health care research. Little is known about the way in which practice is influenced by the implementation of clinical pathways, and to what degree. This review takes significant steps in answering these questions by describing the parameters that are used in literature as indicators to evaluate clinical pathways.

Methods:

A Medline-based review of literature published between 2000 and 2002 was carried out using the keywords ‘clinical pathway’, ‘critical pathway’, ‘care map’, ‘care pathway’ and ‘integrated care pathway’. Articles were selected if they contained any form of evaluation, outcome or indicator concerning the use of clinical pathways. This included all types of research design and sample size. A total of 200 articles were selected. Relevant data were summarized using the following characteristics: country of origin, clinical field of expertise, research design, sample size, clinical outcome indicators, service indicators, team indicators, process indicators and financial indicators. For each domain a positive, negative or ‘no effect’ conclusion was recorded. Excel® and Statistica® were used to obtain percentages and graphics.

Results:

A total of 34% of the articles on clinical pathways contained some form of evaluation concerning the effect of the implementation. Out of these articles, clinical outcome was emphasized in 65.5%, financial effects in 53%) and process effects were investigated by 50% of the studies. Team and service effects were discussed less often (24% and 18.5%), respectively). For clinical outcome, team, process and financial effects a variety of indicators were recorded. Service effects were almost always measured as ‘patient satisfaction’. The majority of the literature concluded that positive effects result from the implementation of clinical pathways.

Conclusion:

On a macro level clinical pathways result globally in positive effects. Negative results, however, were also present in the literature. In particular for process, team and service evaluation concerning the use of clinical pathways there is still a great need for research.

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

BACKGROUND AIMS

Critical pathways (CP) are clinical management plans that provide the sequence and timing of actions of medical staff. The main goal of a CP is to provide optimal patient care and to improve time-effectiveness. Current guidelines for the treatment of ST-segment elevation myocardial infarction (STEMI) recommend a door-to-balloon time of <90 minutes for patients undergoing primary percutaneous coronary intervention (PCI). The aim of this study was to identify the effects of CP on the management of patients with STEMI in an emergency department.

METHODS

The study population consisted of 175 patients undergoing primary PCI for STEMI who presented to the emergency department of Kangwon National University Hospital (Chuncheon, South Korea) with chest pain from July 1, 2005 to November 30, 2010. We retrospectively analyzed medication use, symptom onset-to-door times, door-to-balloon times, total ischemic times, and the reperfusion rate within 90 minutes. We also measured the 30-day and 1-year total mortality rates pre- and post-CP implementation.

RESULTS

The effects of CP implementation on the medication use outcomes in patients with acute myocardial infarction were increased between the pre- and post-CP patients groups. The median door-to-balloon time declined significantly from 85 to 64 minutes after CP implementation (P = 0.001), and the primary PCI rate within 90 minutes was significantly increased (57% vs. 79%, P = 0.01). However, the symptom to door time was not changed between the pre- and post-CP groups (150 minutes vs. 149 minutes; P = 0.841). Although the total ischemic time was decreased after CP implementation, it was not statistically insignificant (352.5 minutes vs. 281 minutes; P = 0.397). Moreover, the 30-day and 1-year total mortality rates of the 2 groups did not change (12.0% vs. 12.0%, P > 0.999; 13.0% vs. 17.3%, P = 0.425, respectively). However, the 1-year mortality rates of 2 groups based on a total ischemic time of 240 minutes, which was median value, decreased significantly from 19.0% to 9.0%. (P = 0. 018) CONCLUSION:: Implementation of a CP resulted in greater use of recommended medications and reductions in the median door-to-balloon time. However, it did not reduce the symptom onset-to-door time, total ischemic time, or the 30-day and 1-year mortality rates. Therefore, additional strategies are needed to reduce mortality in patients with acute myocardial infarction undergoing primary PCI.

Predictors of in-hospital delay to reperfusion in patients with acute myocardial infarction in Japan

The purpose of this study was to identify factors associated with in-hospital delay in patients with acute myocardial infarction (AMI) in Japan. In this observational study, 155 consecutive patients admitted with AMI to one of five urban hospitals were studied. The median door-to-needle time and door-to-catheterization-laboratory time was 19 min and 60 min, respectively. Three variables predicted door-to-catheterization-laboratory times >/= 60 min: failing to call an ambulance, direct admission to the hospital, and absence of diaphoresis (p < 0.05). These findings support the need for public education emphasizing the importance of calling an ambulance for AMI symptoms. Moreover, Japanese physicians should be aware that admitting patients directly to the hospital and bypassing the Emergency Department might increase delay to treatment.

Role of a critical pathway for door-to-CT-completion interval in the management of acute ischemic stroke patients in the emergency room

OBJECTIVE

Door-to-CT-completion interval (DCI) for acute ischemic stroke patients is one of the clinical indicators of quality assurance in an emergency room (ER). The aim was to clarify whether the critical pathway improves the DCI for acute stroke patients in the ER.

METHODS

The pathway describes each step in patient evaluation in sequence from the patient's arrival in the ER until the brain CT is completed. Whether to use the pathway when evaluating individual patients is left to the discretion of the physician. After excluding 8 cases with insufficient data, 52 cases diagnosed with acute stroke (29 males, 69.9 +/- 12.4 y/o) in the ER between January and February 2003 were retrospectively identified. A logistic regression analysis was used to assess the impact of application of the pathway on achievement of an acceptable DCI (<25 min).

RESULTS

The pathway was applied in 21.2% of the cases included in the study, and the median DCI was reduced from 48 minutes to 22 minutes as a result (P=0.02). Comparing them with the DCI, the probability values for ambulance use, consciousness disturbance, history of stroke, and application of the pathway in univariate analyses were less than 0.10. These variables were entered into the logistic analysis, which that indicated application of the pathway was the strongest variable related to acceptable DCI (OR: 10.92, 95% CI: 1.22 to 97.96).

CONCLUSION

Application of the pathway was associated with an improvement of the DCI. Use of the pathway will improve the quality of the process of care in the ER.