Transcript Cardiac Troponin - Clinical Trial Results

National Heart Attack
Alert Program (NHAAP)
CRITICAL/CLINICAL PATHWAYS
FOR THE TREATMENT OF
PATIENTS WITH
ACUTE CORONARY SYNDROMES
Critical Pathways
• Standardized protocols for care
• Strict definition
– Full list of all tasks, tracks variances
• Broader definition
– Includes clinical protocols (NHAAP 4D’s)
• Diagnostic pathways - Chest Pain
Centers
• Treatment pathways - Thrombolysis
TABLE 1: Goals of Critical
Pathways
• Increase use of recommended medical therapies
(e.g., aspirin)
• Decrease use of unnecessary tests.
• Decrease hospital length of stay
• Increase participation in clinical research
• Improve patient care and decrease costs.
•
Need ad Rationale for
Critical Pathways
• Underutilization of recommended
medications (e.g. Aspirin)
• Overutilization of procedures
• Length of stay, # ICU days
• Quality of care measures (door-todrug, door-to-balloon times)
TABLE 2: Steps In The
Development And Implementation
Of Critical Pathways
• Identify problems ( practice variation)
• Identify working committee/task force to develop
path
• Distribute draft Critical Pathway to all personnel
and departments involved. Revise based on
approach.
• Implement pathway
• Collect and monitor data on pathway
performance.
• Modify the pathway as needed to further improve
performance.
Methods of Implementation
of Pathways
• Specific case manager for each Pt
– High compliance, high cost
• Standardized order sheets, Pocket
guides
• “Championing” - Grand rounds
• Recent study -> similar improvements
in care with either formal or simpler
pathways (Holmboe, ES et al. Am J Med
1999;107:324-31.)
Goal: < 30 Minutes
NHAAP
Ann Emerg Med
1994;23:311-29.
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(median)
65
60
55
50
45
40
90-b
91-a
91-b
92-a
92-b
93-a
93-b
94-a
94-b
95-a
95-b
96-a
96-b
97-a
97-b
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35
W. Rogers, personal communication
MV Adjusted Odds of Death
NRMI-2: Thrombolysis
Door-to-Needle Time vs. Mortality
P=0.0001
1.4
P=0.01
P=NS
1.2
1.23
1.11
1.03
1
0.8
N=28,624
33,867
11,616
10,316
0.6
0-30
Cannon CP ACC 2000
31-60
61-90
Door-to-Needle Tim e (m inutes)
>90
BWH ED Checklist Orders
for ACS
Clinical
EKG
Goals
ST  MI-Angioplasty ST  MI- Thrombolysis
1
2
Acute MI
Acute MI
ST elevation/New LBBB
ST elevation/New LBBB
Call Cath lab <20 min
Door to Needle <30 min
Leave ED <30 min
(Actual_ _ _)
Door to Balloon <90 min
(Actual_ _ _)
Tests
CBC, CMP, PT/PTT
CBC, CMP, PT/PTT
CK-MB
CPK/MB
Lipid profile
Lipid profile
Medications
ASA 325mg chew
ASA 325mg chew
Heparin IV
r-PA 10U & 10U in 30 min
IV dose: 60U/kg bolus, 12U/kg/hr infusion
Metoprolol IV
Heparin IV
Clopidogrel 300 mg PO
Metoprolol IV/PO
NTG PRN
NTG PRN
Univ. Cincinnati “Heart ER”
Symptoms suspicious for ACS
ECG changes of AMI or UA
Treat
and Admit
Nondiagnostic ECG
Positive
Consider rest nuclear imaging in patients
able to be injected during pain
Negative
6-hour CPC evaluation
• Serial cardiac markers 0, 3, 6 hours
• ST-segment trend monitoring
Negative
ECG exercise stress test
Discharge
Discharge with
followup
NHAAP Web site - Critical
Pathways
• NHAAP review paper
• Annotated literature review with
figures
• Example critical pathways
• Downloadable slides
• Possible links to other sites
Conclusions
• Critical pathways hold great promise to improve
the quality of care, clinical outcomes and the
cost-effectiveness
• Several levels of complexity
• Primary focus should be on improving the quality
of care
• Further research is needed to better define the
true worth of these tools.
• NHAAP web page examples of specific
pathways, to facilitate the use
Patient Advisory Form
What To Do If You Think You Are Having a Heart Attack:
• Recognize how you may feel
– List of symptoms
• Take medication as instructed
– Aspirin, nitroglycerin
• Act if symptoms continue for more than 15
minutes
• Call EMS phone number wherever you are
• Go to the location of the nearest full-service
ED
Dracup K,et al. Ann Intern Med 1997;126:645-651.
National Heart Attack Alert Program (NHAAP)
Recommendations: Summary
• Use standardized MI and ACS protocols
– Door-to-Drug time < 30 mins, door-to-balloon 90+30
mins
– ED/Chest Pain Centers appear effective
– Evaluate and Integrate new technologies in pathways
• Use CQI: Analyze processes of care to
eliminate delays and refine protocols
• Community Planning to establish “Chain of
Survival” for cardiac arrest/AMI; Expand use
of 9-1-1
NHAAP: Phone: 301-592-8573
•http://www.nhlbi.nih.gov
Educate “high-risk” patients on timely
MV Adjusted Odds of Death
NRMI-2: Primary PCI
Door-to-Balloon Time vs. Mortality
P=NS
2.2
P=NS
P=0.01 P=0.0007 P=0.0003
1.8
1.62
1.4
1.61
1.41
1.14
1.15
1
0.6
0.2
N=2,230
0-60
5,734
61-90
6,616
91-120
4,461
2,627
121-150 151-180
5,412
>180
Door-to-Balloon Tim e (m inutes)
Cannon CP, et al Circulation 1999;100:I-360.