Standardized Chest Pain Pathway Improved Outcomes

ORLANDO — A standardized pathway for assessing and managing patients who come to the emergency department with chest pain led to a “remarkable” reduction in patient deaths and readmissions during the first 4 years of use, based on a review of about 3,000 patients.

In an emergency department that has hundreds of residents on the staff, the standardized assessment, stratification, and treatment tool used at St. Luke's-Roosevelt Hospital Center in New York makes patient management uniform and helps every physician provide the same high level of care, Emid F. Aziz, D.O., said while presenting a poster at the annual meeting of the American College of Cardiology.

The Priority, Advanced, Intermediate, or Negative (PAIN) risk stratification and treatment pathway, introduced in 2004, provides a step-by-step plan for assessing and treating patients who arrive at the emergency department with chest pain, said Dr. Aziz, coordinator of the advanced cardiac admission program. The pathway features a series of decision trees that guide physicians through risk stratification with a simple algorithm. The pathway also involves detailed, preprinted chart and order forms that leave little room for deviating from the best-practice treatment course.

During June 2005-March 2008, 3,041 chest pain patients who were admitted to the St. Luke's emergency department were stratified into one of four categories. In 2005, 8% of these patients died following their hospital discharge, a rate that steadily dropped during subsequent years and reached 2% during the first 3 months of 2008. The readmission rate was 37% in 2005, and then steadily fell to a 15% rate in early 2008. (See box.)

Concurrent with these improved outcomes has been broader use of evidence-based medical treatments. By early 2008, 96% of patients were prescribed an antiplatelet drug, 87% were on a beta-blocker, 79% were on an angiotensin-converting enzyme inhibitor, and 75% were on a statin. These levels of drug use were far above the 2005 rates, and also exceeded contemporary U.S. averages, Dr. Aziz and his associates reported.

The therapeutic steps designated for each category follow what is considered current standard of care. Patients identified with an ST elevation myocardial infarction, for example, are slated for treatment with nitroglycerin, oxygen, clopidogrel, aspirin, an intravenous beta-blocker, a high-dose statin, and heparin, and quickly go to coronary catheterization and revascularization. Other pathway options take patients who don't qualify for immediate revascularization to thrombolytic therapy, and those who have a more equivocal presentation go to the coronary care unit for additional assessment.

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