Chest Pain Centers:

How Do We Make Them Better?

Richard A Chazal, MD, FACC

Medical Director, Heart and Vascular Institute

Lee Memorial Health System, Fort Myers, Florida

Vice President, ACC

Cardiovascular Summit, Orlando, January 2015

Disclosures

• None

Chest Pain Centers (CPC):

Goals

• Improved patient care

• Improved physician efficiency

• Improved ER and facility management

How To Make CPC’s Better

• Science/Guideline/AUC driven

• Dedicated Unit

• Facilitation by ACP’S

• Physician Champion

• Buy in from Hospital System (ROI)

• Buy in from Physicians (quality, efficiency)

Case Study:

Lee Memorial Health System

Heart and Vascular Institute (HVI)

• Guideline driven

• Physician directed

• Facilitated by Advanced Care Team Members

(ACP’s)

Three Strategies

• Political: Open participation by cardiologists;

ongoing involvement of hospitalists

• Economic: Time efficiency (and

reimbursement) for physicians; cost effective

for hospital system

• Quality: Guideline and AUC based; data

tracked

ACS Clinical

Pathway for CDU

Rapid Risk Stratification History

Physical Exam

EKG

POC Troponin

High Risk

TIMI score 5-7

(Positive Troponin or ischemic EKG changes)

Low Risk

TIMI score 0-2

EKG normal or unchanged

Initial cardiac biomarkers normal

Moderate Risk

TIMI score 3-4

EKG normal or unchanged

Initial cardiac biomarkers normal

Admit to PCU Place in CDU Observation Status

PA/ARNP initiates protocols

* PA/ARNP can do TIMI score

Diagnostics: Troponin @ 0,3,6

EKG @ 0,6

Elevated cardiac enzymes?

Recurrent chest pain?

EKG changes consistent with ischemia?

Cardiologist notified

Admit to PCU

D/C home with follow up with PCP or Cardiologist

Cardiologist performs Stress Test

Stress Test

Negative?

Cardiologist notified

Admit to PCU

Discharge with outpt stress test scheduled

within 72 hours

Y

N

OR

Y

N

N

Regular Treadmill Stress

• Low risk patients

• Able to walk on a treadmill

• Interpretable EKG

* No LBBB * No resting ST segment depression * No digoxin

Coronary CTA

• Re-current admissions with CP and normal stress test within the

past 12 months

• Normal renal function

• Able to get heart rate below 75

• Normal sinus rhythm

• Be able to tolerate beta blockers and nitroglycerin

• (? Age/ calcium score)

Nuclear Stress Testing • Moderate to High risk patients

• Known CAD (previous stents, CABG)

• ECG not interpretable

(LBBB, >1mm ST ↓, digoxin)

Treadmill

• Able to walk on a treadmill

Lexiscan

• LBBB

•Unable to walk or fall risk

Stress Echo

• Pregnant

•Structural disease (valve disease)

•Concerns about LV function

Outcomes

Chest Pain Centers Data

LOS Reduction 2013-2014

• HPMC 293 days saved (October 2013 –September 2014)

• CCH 203 days saved (January – September 2014)

• GCMC 200 days saved (February – September 2014)

• 696 total days saved with 174 beds made available (ALOS 4 days)

Compliance With Protocol: 90%

Challenges: Real and Potential

• Physician buy-in/politics

• Availability of quality APC’s

• Data

• Physician outliers

• “The Gap”

FACC