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Network Success Story

Impact of a Chest Pain Pathway on Hospitalization Rates

The University of Vermont Health Network Emergency Medicine Specialty Council, in conjunction with the Department of Pathology and the Cardiovascular Service Line, developed and implemented a network-wide evidence-based clinical chest pain pathway from 2015-2019. Implementing a standardized pathway in all Emergency Departments across the network reduces provider variability.

Key Drivers

  1. Chest pain is a common presenting complaint in University of Vermont Health Network Emergency Departments but patients with Acute Coronary Syndrome (ACS) and Acute Myocardial Infarction (AMI) represent a minority of these patients.
  2. Many of these patients have undifferentiated chest pain and are considered low risk by established risk stratification tools.
  3. Improvement in the sensitivity in the Troponin assay that is used for the ACS workup has potential to better evaluate patients.
  4. Research shows that routine stress testing to rule out ACS does not reduce 30 day morbidity and mortality and actually leads to increased incidence of invasive testing.
  5. In the year prior to starting the new pathway, 32% of chest pain patients were admitted after an ED evaluation and the majority of them were discharged without intervention after 36 hours.

Traditional Pathways

  1. EKG

  2. Troponin and other LAB testing

  3. Chest X-Ray

  4. Cardiology Consultation

  5. Probable Admission

  6. Stress Testing During Admission

Traditional Pathways

  1. EKG

  2. Troponin

  3. Repeat Troponin in 3 Hours

  4. If Low-Risk Patient with Non-ischemic EKG and 2 Negative

  5. Troponin, Discharge to Home

  6. Chest Pain Follow-Up Order Pathway for Outpatient Follow-Up

  7. Stress Test at Discretion of Follow-Up Provider

Outcomes

$

65% reduction of troponin negative admissions

(20% to 7%)

$

50% reduction of overall hospital admission rates

(32% to 15%)

$

Reduced utilization of laboratory services and cardiology resources

$

Identified variation in provider behavior

Next Steps

Z

Identify areas of opportunity across the health network in which new pathway research and development processes can be applied in the development of other pathways.

Z

Study ED length of stay impact

Z

Study the impact of the pathway, including de-identification of provider-specific data, on provider variability