1. Quality Improvement Program: Chest Pain Outpatient Testing
Initial Concept and Strong Support from
Daniel Himelic, MD
Facility Medical Director
St. Elizabeth’s Hospital

2. Chest Pain Workup Background Outpatient Chest Pain Program
Documentation
Patient Education

3. Chest Pain Historical Data
Most chest pain is not cardiac in nature ( 75-85%)
No good screening rule (e.g. PERC) for non-testing
High risk, high litigation cohort

4. Nidus of Reflexive Admission
Pope study in 2002
11,000 ED chest pain pt’s 48h follow up
8% MI and 9% unstable angina overall.
2% of MIs missed which was 0.18% of population
Study Problems
CKMB, not Troponin
Listed as failure to diagnose leading to aggressive admission and observation

5. FHS Internal Data on CP
Avg 168 (5.6pt) admits per day with stress tests
Avg LOS 1.78 d
Possible 9.97 beds per day in system
No current system to coordinate outpatient stress test/follow up
July 2014-March 2015

6. HEART Score Clinically based risk stratification rule
Designed for ED patient population unlike TIMI
Prospectively validated in multiple studies
Recognized by TeamHealth Patient Safety Organization as a useful screening tool

7. Prospective Validation: Backus (2013)
2440 patients with chest pain
Ten EDs in the Netherlands
Evaluated for MACE within 6 weeks
MACE included AMI, PCI, CABG, death
HEART score used as compared to GRACE and TIMI with 6 week follow up

9. Prospective Validation: Results
Low HEART Scores (0-3)
36.4% of patients
1.7% MACE
Moderate HEART Scores (4-6)
16.6% MACE
High HEART Scores (>7)
50.1% MACE

10. Prospective Validation: Risk Factors Reviewed
Percentage of patients in each element of the HEART Score by whether they had MACE or not
Points 1 2
MACE No
Yes
History
45.5
8.6
31.1
27.0
23.3
64.4
EKG
66.8
36.1
19.2
21.1
14.0
42.8
Age
19.0
3.7
43.5
42.0
37.5
54.3 RF
11.2
4.9
36.8
28.5
52.0
66.6
Troponin
92.1
53.6
4.5
13.5
3.4
32.9

11. US Retrospective Validation: Mahler 2011
Tertiary Residency Training Program (Wake Forest)
CDU Patient population 1070 patients
Results
Low HEART scores (0-3) had 0.6% MACE
High HEART Scres (>3) had 4.2% MACE
OR of 7.92
Limitations = Pre-selected population of CDU patients, not all ED

12. Outpatient Chest Pain Program (One Sample Option)

13. Risk Stratification Program
HEART score to identify low risk
<3 gets outpatient evaluation
>3 traditional admission or treatment
Critical Elements
Labs – Drawn in ED prior to discharge
Outpatient Stress and Appointment
Arranged via SJMC HUC log book

14. ED Labs Drawn and send DO NOT Hemaglobin A1C LAB102
Direct and LDL Cholesterol LAB90
DO NOT
Worry about fasting
Wait for results

15. Select Stress Test Need Stress test and
MUST BE WITHIN 72 HOURS
Medical Follow up for risk stratification

16. Documentation

17. Dot Phrase
See attached documents for samples to create your own dot phrases / system algorithms for:
Heart Score Inclusion
Chest Pain Follow up Documentation
Includes the guidelines and shared decision making conversation

18. Quality Follow Up
CQIP will review all admissions and discharges with a diagnosis of chest pain looking at:
Heart Score
Disposition
Results of studies
Provide feedback on aggregate data on utilization and results
Sentinel events or issues should be sent to Nathan Schlicher at for dissemination to the larger group

19. Education

20. Patient Education Sample forms for the following are included
Patient Instruction sheet for stress test
Patient Instruction sheet on where to go
Patient Handout
Physician Instructions on arranging program
Additional examples can be provided upon request

21. References
1.Meyer MC, Mooney RP, Sekera AK. A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing.Ann Emerg Med. 2006;47(5):435.e1-3.
2. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac i schemia in the emergency department. N. Engl. J. Med. 2000;342(16):
3. Scheuermeyer FX, Innes G, Grafstein E, et al. Safety and Efficiency of a Chest Pain Diagnostic Algorithm With Selective Outpatient Stress Testing for Emergency Department Patients With Potential Ischemic Chest Pain. Annals of Emergency Medicine Available at:
4. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC. Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines. JAMA: The Journal of the American Medical Association. 2009;301(8):
5. Hess, et al. The Chest Pain Chose Decision Aid: A Randomized Trial. Circ Cardiovasc Qual Outcomes. 2012:5:
6. Backus, et. al., A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology 168 (2013)