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Shared Decision Making Using the HEART Score and a Visual Aid in Patients Presenting with Chest Pain to a Community Emergency Department

Michael Boyd, MD and Arun Ganti, MD – Winners of the 2016 QIPS Resident Quality Award

Michael BoydArun GantiIn the United States, chest pain is one of the most common chief complaints, accounting for 5-8% of all Emergency Department visits. Classically, these patients have either been admitted to the hospital or observed in Chest Pain Observation Units. However, recent research suggests that many low risk chest pain patients can be discharged safely.

Our quality improvement project was performed at St. Joseph Mercy Hospital in Ann Arbor Michigan. It combined the HEART Score with a shared decision making visual aid in the evaluation of patients presenting to the ED with chest pain. The HEART Score is a validated risk stratification tool using history, EKG, risk factors, and cardiac biomarkers to classify patients presenting to the ED with chest pain and concern for Acute Coronary Syndrome (ACS) into low, moderate or high risk categories. This protocol follows the 2015 American Heart Association Guidelines which recommends cardiac troponins measured at 0 and 2 hours in “conjuncture with a clinical scoring system to identify patients at low-risk for a 30-day major adverse cardiac event (MACE) who may be safely discharged from the Emergency Department.”

In our QI project, Emergency Physicians calculated a HEART Score for each patient presenting to the ED with chest pain. A visual aid, developed for describing risk level based on the score (see figure 1), was presented to the patient. The physician and patient then engaged in Shared Decision Making regarding disposition (discharge, chest pain observation unit, or admission) based on the risk score. The visual aid is signed by both patient and physician; one copy is given to the patient and the other is scanned into the medical record.

The implementation of the combined HEART Score and Shared Decision Making instrument was piloted with a cohort of providers in our institution in December 2015. In the baseline control year of 2014, 4643 patients presented to the ED with chest pain, and 2716 patients (56.6%) were placed in observation. During the pilot implementation phase of our project in December of 2015, 132 patients presented with chest pain, and 34 patients (25.7%) were placed in observation, a 30.9% reduction in observation admissions (p < .0001). The discharge rate increased from 40.2% in 2014 to 74.2% during the pilot phase.

Due to its success, this care pathway has been implemented as the standard diagnostic and management pathway for patients presenting with chest pain at our institution. This quality improvement project incorporates best practice evidence with patient values to reduce unnecessary observation admissions, improve patient understanding of their condition, and allows shared medical decision making to be documented.

Figure 1 - Example of visual aid depicting moderate risk as calculated by the HEART score.
HEART Score

References:

  1. Hess E. The chest pain choice decision aid: a randomized trial.Circ Cardiovasc Qual Outcomes. 2012 May;5(3):251-9.
  2. Backus BE1, A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8.
  3. Flynn D et al. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med. 2012 Aug;19(8):959-67.
  4. Neumar RW et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S315-67



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