CRITICAL/CLINICAL PATHWAYS ACUTE CORONARY SYNDROMES National Heart Attack Alert Program (NHAAP) CRITICAL/CLINICAL PATHWAYS FOR THE TREATMENT OF PATIENTS WITH ACUTE CORONARY SYNDROMES I am very pleased to present an overview of the National Heart Attack Alert Program (NHAAP) and to highlight some of its history, educational recommendations, achievements, and future directions. (The speaker may wish to add a personal comment concerning his or her involvement with the program.)

Critical Pathways Standardized protocols for care Strict definition Full list of all tasks, tracks variances Broader definition Includes clinical protocols (NHAAP 4D’s) Diagnostic pathways - Chest Pain Centers Treatment pathways - Thrombolysis

TABLE 1: Goals of Critical Pathways Increase use of recommended medical therapies (e.g., aspirin) Decrease use of unnecessary tests. Decrease hospital length of stay Increase participation in clinical research Improve patient care and decrease costs.

Need ad Rationale for Critical Pathways Underutilization of recommended medications (e.g. Aspirin) Overutilization of procedures Length of stay, # ICU days Quality of care measures (door-to-drug, door-to-balloon times)

TABLE 2: Steps In The Development And Implementation Of Critical Pathways Identify problems ( practice variation) Identify working committee/task force to develop path Distribute draft Critical Pathway to all personnel and departments involved. Revise based on approach. Implement pathway Collect and monitor data on pathway performance. Modify the pathway as needed to further improve performance.

Methods of Implementation of Pathways Specific case manager for each Pt High compliance, high cost Standardized order sheets, Pocket guides “Championing” - Grand rounds Recent study -> similar improvements in care with either formal or simpler pathways (Holmboe, ES et al. Am J Med 1999;107:324-31.)

Goal: < 30 Minutes NHAAP Ann Emerg Med 1994;23:311-29.

W. Rogers, personal communication

Door-to-Needle Time vs. Mortality NRMI-2: Thrombolysis Door-to-Needle Time vs. Mortality P=0.0001 P=0.01 P=NS 1.23 1.11 1.03 N=28,624 33,867 11,616 10,316 Cannon CP ACC 2000

BWH ED Checklist Orders for ACS ST  MI-Angioplasty ST  MI- Thrombolysis 1 2 Clinical Acute MI Acute MI EKG ST elevation/New LBBB ST elevation/New LBBB Goals Call Cath lab <20 min Door to Needle <30 min Leave ED <30 min (Actual_ _ _) Door to Balloon <90 min (Actual_ _ _) Tests CBC, CMP, PT/PTT CBC, CMP, PT/PTT CK-MB CPK/MB Lipid profile Lipid profile Medications ASA 325mg chew ASA 325mg chew Heparin IV r-PA 10U & 10U in 30 min IV dose: 60U/kg bolus, 12U/kg/hr infusion Metoprolol IV Heparin IV Clopidogrel 300 mg PO Metoprolol IV/PO NTG PRN NTG PRN

Univ. Cincinnati “Heart ER” Symptoms suspicious for ACS ECG changes of AMI or UA Nondiagnostic ECG Treat and Admit Consider rest nuclear imaging in patients able to be injected during pain Positive Negative 6-hour CPC evaluation Serial cardiac markers 0, 3, 6 hours ST-segment trend monitoring Discharge with followup Negative ECG exercise stress test Discharge

NHAAP Web site - Critical Pathways NHAAP review paper Annotated literature review with figures Example critical pathways Downloadable slides Possible links to other sites

Conclusions Critical pathways hold great promise to improve the quality of care, clinical outcomes and the cost-effectiveness Several levels of complexity Primary focus should be on improving the quality of care Further research is needed to better define the true worth of these tools. NHAAP web page examples of specific pathways, to facilitate the use

What To Do If You Think You Are Having a Heart Attack: Patient Advisory Form What To Do If You Think You Are Having a Heart Attack: Recognize how you may feel – List of symptoms Take medication as instructed – Aspirin, nitroglycerin Act if symptoms continue for more than 15 minutes Call EMS phone number wherever you are Go to the location of the nearest full-service ED Patients must be clear about the actions they should take if AMI symptoms occur, including taking nitroglycerin (if prescribed), taking aspirin, and calling EMS. The working group has developed a Patient Advisory Form for health care providers to give their high-risk patients and their families or significant others. Patients should be encouraged to put it in a prominent place, especially near the telephone. The form reviews the most common symptoms of AMI, medication instructions regarding aspirin and nitroglycerin, and what to do if symptoms persist, and it has places to write in critical phone numbers. As part of the instructions given to all high-risk patients, it is important to emphasize that patients should call EMS, via 9-1-1 or a seven-digit emergency telephone number, rather than their own physician if symptoms suggestive of AMI persist beyond 15 minutes. Arrival at the emergency department in a private vehicle can delay the process of triage and assessment of trauma patients and can ultimately increase the delay between symptom onset and initiation of treatment. In contrast, when patients can have ECGs done in transit and give histories to EMS personnel, time to treatment is decreased. Dracup K,et al. Ann Intern Med 1997;126:645-651.

National Heart Attack Alert Program (NHAAP) Recommendations: Summary Use standardized MI and ACS protocols Door-to-Drug time < 30 mins, door-to-balloon 90+30 mins ED/Chest Pain Centers appear effective Evaluate and Integrate new technologies in pathways Use CQI: Analyze processes of care to eliminate delays and refine protocols Community Planning to establish “Chain of Survival” for cardiac arrest/AMI; Expand use of 9-1-1 Educate “high-risk” patients on timely presentation NHAAP: Phone: 301-592-8573 http://www.nhlbi.nih.gov

NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality P=NS P=NS P=0.01 P=0.0007 P=0.0003 1.62 1.61 1.41 1.14 1.15 N=2,230 5,734 6,616 4,461 2,627 5,412 Cannon CP, et al Circulation 1999;100:I-360.