ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway

Autor: Andrew To, Peter M. George, Chris Frampton, John W. Pickering, Joanne M. Deely, Christopher M. Florkowski, Gerard Devlin, Oliver P. Thomas, Timothy J.E. Matthews, Sally Aldous, Mark Simmonds, Andre P.J. Cromhout, Anthony Scott, Bradley F. Peckler, W. Frank Peacock, A. Mark Richards, Laura Chapman, Louise Poynton, G. Luke Larkin, S. Andrew Aitken, Michael Ardagh, Nicholaas C. van Pelt, John W.N. Bonning, Rosie Callender, Richard M. Makower, Allan S. Jaffe, Kate E. Allan, Jeremy M. Dryden, Stephen Du Toit, Louise Cullen, David Smyth, William A. Parsonage, Jonathan P. Christiansen, Martin Than, Katherine A. Ferrier, Kim Yates, Richard W. Troughton, Gregory J. Hamilton, Sarah J. Lord, Andrew J. Kerr
Rok vydání: 2017
Předmět:
Male
Pediatrics
medicine.medical_specialty
Acute coronary syndrome
Time Factors
Clinical Decision-Making
030204 cardiovascular system & hematology
Risk Assessment
03 medical and health sciences
Electrocardiography
0302 clinical medicine
Clinical pathway
Predictive Value of Tests
Risk Factors
Physiology (medical)
Acute care
medicine
Prevalence
Humans
030212 general & internal medicine
Acute Coronary Syndrome
Adverse effect
Aged
Quality Indicators
Health Care
Aged
80 and over
business.industry
Odds ratio
Emergency department
Length of Stay
Middle Aged
medicine.disease
Prognosis
Quality Improvement
Confidence interval
Troponin
Clinical trial
Hospitalization
Emergency medicine
Critical Pathways
Female
Cardiology Service
Hospital
Cardiology and Cardiovascular Medicine
business
Emergency Service
Hospital
Biomarkers
New Zealand
Zdroj: Circulation. 137(4)
ISSN: 1524-4539
Popis: Background: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. Methods: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation Results: There were 11 529 participants in the preimplementation phase (range, 284–3465) and 19 803 in the postimplementation phase (range, 395–5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%–37.7%) to 18.4% (6.8%–43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3–2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4–3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P =0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. Conclusions: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. Clinical Trial Registration: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.
Databáze: OpenAIRE
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