Abstract
Despite the implementation of diagnostic and treatment algorithms for many common cardiovascular (CV) complaints, identifying low- and intermediate-risk cardiac patients presenting to the emergency department (ED) who could be managed without hospital admission remains difficult. We hypothesized that the presence of an attending cardiologist in the ED after normal working hours would decrease the proportion of these patients admitted to the hospital. We conducted a retrospective study of patients seen in the ED with cardiac diagnoses identified by ICD-9 codes during the time period when the cardiologist was available (6 p.m.–midnight) compared with patients seen at other times of the day in the 12 months before and after the consultation program was implemented. The primary outcome was disposition at the time of discharge from the ED. Logistic regression was used to model the primary outcome. A difference-in-differences approach was used as the primary statistical test .Following the start of the consultation program, the odds of discharge home from the ED with or without observation increased (OR 1.69, 95% CI [1.45–1.96]). There was a significant interaction between pre-/post-intervention status and time of day in the odds of discharge home from the ED (P = 0.04) suggesting an association between the consultation program and disposition patterns that is independent of concurrent programs aimed to reduce utilization. An ED-based cardiology consultation program may reduce the need for inpatient stays by identifying low- to intermediate-risk patients safe for discharge from the ED with or without a period of active management/observation.
Similar content being viewed by others
References
Dieleman JL, Baral R, Birger M et al (2016) us spending on personal health care and public health, 1996–2013. JAMA 316:2620–2627. https://doi.org/10.1001/jama.2016.16885
Schuur JD, Venkatesh AK (2012) The growing role of emergency departments in hospital admissions. N Engl J Med 367:391–393. https://doi.org/10.1056/NEJMp1204431
Farkouh ME, Smars PA, Reeder GS et al (1998) A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) Investigators. N Engl J Med 339:1882–1888. https://doi.org/10.1056/NEJM199812243392603
Bellew SD, Bremer ML, Kopecky SL et al (2016) Impact of an emergency department observation unit management algorithm for atrial fibrillation. J Am Heart Assoc 5:e002984. https://doi.org/10.1161/JAHA.115.002984
Grossman SA, Bar J, Fischer C et al (2012) Reducing admissions utilizing the boston syncope criteria. J Emerg Med 42:345–352. https://doi.org/10.1016/j.jemermed.2011.01.021
Collins SP, Lindsell CJ, Naftilan AJ et al (2009) Low-risk acute heart failure patients: external validation of the Society of Chest Pain Center’s recommendations. Crit Pathw Cardiol 8:99–103. https://doi.org/10.1097/HPC.0b013e3181b5a534
Mahler SA, Riley RF, Hiestand BC et al (2015) The HEART pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes 8:195–203. https://doi.org/10.1161/CIRCOUTCOMES.114.001384
Committee HFE, Peacock WF, Fonarow GC et al (2008) Society of chest pain centers recommendations for the evaluation and management of the observation stay acute heart failure patient: a report from the Society of Chest Pain Centers Acute Heart Failure Committee. Crit Pathw Cardiol 7:83–86. https://doi.org/10.1097/01.hpc.0000317706.54479.a4
Dubin J, Kiechle E, Wilson M et al (2017) Mean HEART scores for hospitalized chest pain patients are higher in more experienced providers. Am J Emerg Med 35:122–125. https://doi.org/10.1016/j.ajem.2016.10.037
Wu WK, Yiadom MYAB, Collins SP et al (2017) ) Documentation of HEART score discordance between emergency physician and cardiologist evaluations of ED patients with chest pain. Am J Emerg Med 35:132–135. https://doi.org/10.1016/j.ajem.2016.09.058
McCausland JB, Machi MS, Yealy DM (2010) Emergency physicians’ risk attitudes in acute decompensated heart failure patients. Acad Emerg Med 17:108–110. https://doi.org/10.1111/j.1553-2712.2009.00623.x
Scheuermeyer FX, Innes G, Grafstein E et al (2012) Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain. Ann Emerg Med 59:256–264.e3. https://doi.org/10.1016/j.annemergmed.2011.10.016
Napoli AM, Arrighi JA, Siket MS, Gibbs FJ (2012) Physician discretion is safe and may lower stress test utilization in emergency department chest pain unit patients. Crit Pathw Cardiol J Evid Based Med 11:26–31. https://doi.org/10.1097/HPC.0b013e3182457bee
Zimetbaum P, Reynolds MR, Ho KKL et al (2003) Impact of a practice guideline for patients with atrial fibrillation on medical resource utilization and costs. Am J Cardiol 92:677–681. https://doi.org/10.1016/j.accreview.2003.10.020
Smulowitz PB, Honigman L, Landon BE (2013) A novel approach to identifying targets for cost reduction in the emergency department. Ann Emerg Med 61:293–300. https://doi.org/10.1016/j.annemergmed.2012.05.042
Shelton R (2009) The emergency severity index 5-level triage system. Dimens Crit Care Nurs 28:9–12. https://doi.org/10.1097/01.DCC.0000325106.28851.89
Prasad V, Cheung M, Cifu A (2012) Chest pain in the emergency department: the case against our current practice of routine noninvasive testing. Arch Intern Med 172:1506–1509. https://doi.org/10.1001/archinternmed.2012.4037
Landon BE, Hicks LS, O’Malley AJ et al (2007) Improving the management of chronic disease at community health centers. N Engl J Med 356:921–934. https://doi.org/10.1056/NEJMsa062860
Levitan EB, Yang AZ, Wolk A, Mittleman MA (2009) Adiposity and incidence of heart failure hospitalization and mortality: a population-based prospective study. Circul Heart Fail 2:202–208. https://doi.org/10.1161/circheartfailure.108.794099
Schafer JL (1997) Analysis of incomplete multivariate data. CRC Press, Boca Raton
Amsterdam EA, Kirk JD, Bluemke DA et al (2010) Testing of low-risk patients presenting to the emergency Department with chest pain: a scientific statement from the American Heart Association. Circulation 122:1756–1776. https://doi.org/10.1161/CIR.0b013e3181ec61df
Penumetsa SC, Mallidi J, Friderici JL et al (2012) Outcomes of patients admitted for observation of chest pain. Arch Intern Med 172:873–877. https://doi.org/10.1001/archinternmed.2012.940
Meyer MC, Mooney RP, Sekera AK (2006) 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 47:427–435. https://doi.org/10.1016/j.annemergmed.2005.10.010
Storrow AB, Collins SP, Lyons MS et al (2005) Emergency department observation of heart failure: preliminary analysis of safety and cost. Congest Heart Fail 11:68–72
Storrow AB, Jenkins CA, Self WH et al (2014) The burden of acute heart failure on U.S. emergency departments. JACC Heart Fail 2:269–277. https://doi.org/10.1016/j.jchf.2014.01.006
Collins SP, Pang PS (2019) ACUTE heart failure risk stratification. Circulation 139:1157–1161. https://doi.org/10.1161/CIRCULATIONAHA.118.038472
Lee DS, Lee JS, Schull MJ et al (2019) Prospective validation of the emergency heart failure mortality risk grade for acute heart failure. Circulation 139:1146–1156. https://doi.org/10.1161/CIRCULATIONAHA.118.035509
Feng Z, Wright B, Mor V (2012) Sharp rise in medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood) 31:1251–1259. https://doi.org/10.1377/hlthaff.2012.0129
United States Centers for Medicare & Medicaid Services (2018) Medicare fee for service recovery audit program. https://www.cms.gov/Research-statistics-data-and-systems/monitoring-programs/medicare-FFS-compliance-programs/recovery-audit-program/index.html. Accessed 22 Mar 2019
(2010) Patient Protection and Affordable care act of 2010 (PPACA). 1–906
Acknowledgements
This work was conducted with support from Harvard Catalyst| The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic healthcare centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The author(s) declare that they have no conflict of interest.
Statement of human and animal rights
All procedures performed were in accordance and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards and ethical approval was obtained from the Beth Israel Deaconess Medical Center Institutional Review Board.
Informed consent
Informed consent for this retrospective study was waived by the Beth Israel Deaconess Medical Center Institutional review board given no more than minimal risk to the privacy of individuals given protection of health information identifiers.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Gavin, M., Landon, B., Lu, J. et al. A combined care model using early access to specialists off-hours to reduce cardiac admissions. Intern Emerg Med 14, 973–979 (2019). https://doi.org/10.1007/s11739-019-02076-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11739-019-02076-6