Post on 15-Apr-2017
Shared Decision Making Using the HEART Score and a Visual Aid in Patients Presenting to the Emergency
Department with Chest Pain
Gregory Gafni-Pappas, DO, Susanne Demeester, MD, Michael Boyd, MD, Arun Ganti, MD
Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.
The Goal
• Decrease unnecessary hospitalization and testing
• Increase patient understanding and satisfaction with their ED course.
Step 2: The HEART Score
• Prospectively and externally validated
–Utilizes 5 components:• History• EKG• Age• Risk factors• Troponin
The Heart Score
• Backus, et al, 2008
Risk Level End Point Percentage Reached Endpoint
Low 1/39 2.5%
Moderate 12/59 20.3%
High 16/22 72.7%
Neth Heart J. 2008 Jun;16(6):191-6.
Validation
• Backus, et. al 2013– 2,440 Patients
– Low HEART Score• MACE 6 weeks– 1.7%
• Mahler, et. al 2011– 1070 patients
– Low HEART Score• MACE at 30 days– 0.6%
Int J Cardiol. 2013 Oct 3;168(3):2153-8. Crit Pathw Cardiol. 2011 Sep;10(3):128-33
Shared Decision Making
• The visual aid is chosen based on the patient’s calculated HEART score and risk.
Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.
Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.
Implementation
1. HEART score calculated for patients with chest pain and concern for ACS
2. 2 hour NSTEMI rule-out begins3. Patient given corresponding visual aid (low,
moderate, high) after first troponin result4. Patient and providers sign the visual aid.
Patient keeps a copy of the visual aid5. Forms are scanned into chart
Results
2014 Pilot Phase
# Patients p/w Chest Pain
4791 132
Admitted Inpatient 148 (3.1%) 0
Direct to Cath 153 (3.2%) 0
EOC (Observation) 2716 (56.6%) 34 (25.7%)
Discharge 1927 (40.2%) 98 (74.24%)
Background
2014 Pilot Phase
# Patients p/w Chest Pain
4643(excludes Admit and Cath)
132
Admitted Inpatient 148 (3.1%) 0
Direct to Cath 153 (3.2%) 0
EOC (Observation) 2716 (58.4%) 34 (25.7%)
Discharge 1927 (41.5%) 98 (74.24%)
Key Points
• Chest pain is common • Low-risk chest pain patients can safely
be discharged home provided they understand their risk and have a plan for follow-up.
Conclusions
• The HEART Score is a tool that can be used to determine risk for 30 day MACE.
• Visual aids improve provider and patient understanding.
• All discharged patients still need time-sensitive follow-up instructions.
References
1. Hess E. The chest pain choice decision aid: a randomized trial.Circ Cardiovasc Qual Outcomes. 2012 May;5(3):251-9.
2. Six A et al. The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol. 2013 Sep;12(3):121-6.
3. 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. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7.
4. Mahler SA et al. The HEART Pathway Randomized Trial: Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circ Cardiovasc Qual Outcomes. 2015 Mar;8(2):195-203. doi: 10.1161/CIRCOUTCOMES.114.001384. Epub 2015 Mar 3.
5. 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.
6. 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