National Heart AttackAlert 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-to-drug, 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 MinutesNHAAP Ann Emerg Med 1994;23:311-29.

35

40

45

50

55

60

65

Minutes (median)

NRMI 1 & 2 Trends:NRMI 1 & 2 Trends: Door to Drug (t-PA) IntervalDoor to Drug (t-PA) Interval

All Hospitals, t-PA-treated Patients (N = 241,757)

W. Rogers, personal communication

0.6

0.8

1

1.2

1.4

0-30 31-60 61-90 >90

Door-to-Needle Time (minutes)

MV

Ad

just

ed

Od

ds

of

De

ath

Cannon CP ACC 2000

NRMI-2: Thrombolysis Door-to-Needle Time vs. Mortality

N=28,624 33,867 11,616 10,316

P=0.01P=0.0001

P=NS

1.03

1.11

1.23

BWH ED Checklist Orders for ACS

ST MI-Angioplasty ST MI- Thrombolysis 1 2

Clinical Acute MI Acute MIEKG ST elevation/New LBBB ST elevation/New LBBB

Goals 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

Treat and Admit

Positive

Negative

Discharge with followup

6-hour CPC evaluation• Serial cardiac markers 0, 3, 6 hours• ST-segment trend monitoring

Consider rest nuclear imaging in patients able to be injected during pain

ECG exercise stress test

Discharge

ECG changes of AMI or UA Nondiagnostic ECG

Symptoms suspicious for ACS

Negative

Univ. Cincinnati “Heart ER”

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

• Educate “high-risk” patients on timely presentation

NHAAP: Phone: 301-592-8573 http://www.nhlbi.nih.gov

0.2

0.6

1

1.4

1.8

2.2

0-60 61-90 91-120 121-150 151-180 >180

Door-to-Balloon Time (minutes)

MV

Ad

just

ed

Od

ds

of

De

ath P=0.01 P=0.0007 P=0.0003P=NSP=NS

1.14 1.15

1.41

1.62 1.61

N=2,230 5,734 6,616 4,461 2,627 5,412

NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality

Cannon CP, et al Circulation 1999;100:I-360.