Table of Contents
The
Impact of Heart Disease
According
to the American Journal of Cardiology (Vol. 76, Nov. 15, 1995), acute myocardial
infarction (AMI) is the leading cause of death in the adult population in
the United States. Each year, more than five million Americans enter the
hospital with chest pain. Of those, 1.25 million will present cardiac distress
symptoms and 600,000 will die of heart disease.
Recent
advancements in the treatment of AMI have greatly reduced its mortality
and morbidity, but successful treatments are time dependent and necessitate
rapid initiation. For good outcome, the patient must quickly recognize the
signs and symptoms of an AMI and the physician must quickly diagnose the
AMI and initiate treatment. Preferably, the physician can identify patients
with an AMI having atypical signs and symptoms.
Delay
of Heart Problem Recognition and Treatment
Historically, patients
have waited too long after the onset of symptoms of acute myocardial infarction
(AMI) before seeking medical care. On average, a patient arrives in the
emergency department (ED) more than 2 hours after first noticing symptoms.
In fact, a small number of people wait more than 24 hours before seeking
medical attention.
If a patient with an
AMI is treated within 70 minutes, damage to the heart can be minimized (and
mortality decreased) by aborting the infarct. After delay, substantial heart
damage can occur, minimizing the impact of medical interventions.
Studies also indicate
that significant delays can occur between the time that the patient arrives
in the emergency department (ED) and when the physician makes the diagnosis
of AMI and initiates treatment. Many factors contribute to the failure to
provide prompt therapy: delays in obtaining an electrocardiogram, delays
in decision-making on instituting thrombolytic drugs, delays in preparing
and obtaining medication, and asking for consultation in patients with clear
evidence of AMI. Delays may also be due to gender biases, staff perception
of a patient's pain as noncardiac, or a lack of rapidly available serum
markers for AMI.
Incorrect
Diagnosis
Chest
pain is one of the most common complaints of patients presenting to the
ED. Yet, only 10% to 15% of patients with chest pain have an AMI. Most patients
with chest pain do not have significant disease.
Of
these AMI patients, 4% to 13% are released from the ED with false reassurance
that coronary artery disease is not the cause of their symptoms. Many of
these patients have complications from their AMI, with 11% to 25% dying.
The
Cost of Failure
It
is not surprising that missed AMI is the most expensive cause of malpractice
litigation against emergency physicians, constituting 20% of all dollars
paid. This has caused many EDs to establish Chest Pain Centers (CPCs)with
designated resources of personnel, protocol, space, and equipment for the
patient presenting with chest pain.
Various
names have been given to these programs: "Chest Pain ER," "Chest
Pain Center," "Chest Pain Evaluation Unit," "Short-Stay
ED Coronary Care Unit," and "ED Monitored Observation Bed."
The
History of Chest Pain Centers
The
concept of Chest Pain Centers in community hospitals was presented in the
late 1980s as a strategy to significantly reduce heart attack deaths through
the rapid treatment of patients with acute myocardial infarction. Since
then, they have evolved to include safe, cost-effective management of low
risk patients presenting with acute chest pain.
The
number of CPCs has grown continuously; it is estimated that there are now
as many as 1,500 Chest Pain Centers in the United States. That number continues
to grow as the value of such a center is proved in lives saved.
Goals
of a Chest Pain Center
One
of the goals of a Chest Pain Center is to significantly reduce the time
it takes for a patient experiencing symptoms of a possible heart attack
to see a physician, thus reducing the time to treatment during the critical
early stages, when treatments are most effective. Another is to provide
a specialized observation setting in which physicians are better able to
monitor patients when it is not clear whether they are having a coronary
event. Such observation helps ensure that a patient is neither sent home
too early nor needlessly occupying a CCU bed.
The
growth of Chest Pain Centers has also led to efforts to educate the community
about the risks of heart disease and the importance of seeking help early,
immediately upon feeling the symptoms of a possible heart attack.
Most
heart attacks present identifiable symptoms prior to serious damage to the
heart. However, patients often do not feel that their symptoms are significant
enough to seek professional help. By waiting, patients unfortunately put
themselves at a much greater risk of injury or death.
Reasons
Behind the Growth
Although
high risk patients were the original focus of CPCs, improved management
of low risk patients, who comprise the majority of those presenting with
chest pain, has been the primary factor in the increase of CPCs.
The
primary aim is to decrease the unnecessary admissions of low risk patients
with chest pain, who comprise 75% of patients presenting to the ED with
possible heart problem symptoms. However, there is also a need to resolve
the dilemma presented by the inadvertent discharge of patients with acute
coronary syndromes, which still occurs in 2% of patients in this country
with high morbidity and mortality.
Typical
Chest Pain Center Form and Function
Chest
Pain Centers vary in form, from those that entail a distinct, structural
unit or area to those that are based more on process and coordination ("virtual
units") of skilled personnel (cardiologists, emergency physicians and
nurse specialists) and dedicated equipment. The majority of CPCs in this
country are in the latter category.
Fundamental
to the goals of the CPC is a protocol-driven, systematic approach to patient
management that promotes optimal application of current standards of care.
Guidelines, or critical care pathways, are commonly utilized. These strategies
1) afford rapid initiation of crucial therapy in patients with high risk
acute coronary syndromes and 2) stratification of clinically low risk patients
into those requiring admission and those who can be safely discharged and
managed as outpatients.
In
addition to a directed history, physical examination and administration
of aspirin, current recommendations include acquisition and interpretation
of an ECG in <10minutes to detect myocardial ischemia/injury and determine
the indication for coronary reperfusion and other anti-ischemic therapy,
which should be initiated within <30 minutes of presentation. These patients
are recognized as high risk and are admitted to the inpatient service. By
contrast, low risk patients with chest pain, characterized by stable clinical
status and a normal or near-normal ECG, have been increasingly managed by
a variety of accelerated diagnostic protocols. These have usually comprised
6-12 hours of monitoring and serial cardiac biomarkers. If this evaluation
does not reveal an acute coronary syndrome, exercise testing or other noninvasive
cardiac stress study is usually performed. If this test is negative, the
patient is discharged; a positive finding results in admission for further
evaluation.
Recent
data demonstrate that rapid coronary reperfusion therapy in high risk patients
is enhanced by a CPC strategy. It has also been amply demonstrated that
accelerated diagnostic protocols applied in CPCs, in patients identified
as low risk on the basis of the initial presentation, are safe and accurate.
Length of stay has been consistently reduced and subsequent risk in patients
with negative evaluations is low. Initial data indicate that this strategy,
as implemented in a CPC, is cost-effective.
Formation
of the Society of Chest Pain Centers
In
the 1960s, cardiologists began to recognize the importance of patient monitoring
and intervention when ventricular fibrillation occurred. This set the stage
for the creation of cardiac care units in hospitals. In 1981, in order to
further diminish response time, Raymond D. Bahr, MD established a location
of intervention closer to the point of patient presentation to the hospital,
creating the world's first Chest Pain Emergency Room at St. Agnes Hospital
in Baltimore, Maryland.
In
1987, St. Agnes received a grant to take the Chest Pain ER concept, and
the required programs to create awareness, nationwide. This message was
frequently presented at related national conferences to promote the understanding
and benefits from this Chest Pain ER strategy.
The
Advisory Board published "Hospital Cardiology: Major Business Strategies"
in 1990, which had a primary focus on marketing of
Chest Pain ERs. To return the focus to the patient, a group of concerned
physicians formed a consensus panel of the American College of Emergency
Physicians, chaired by Louis Graff, MD and Tony Joseph, MD. The outcome
of their panel was a report describing the six essential components of a
Chest Pain Center:
-
Outreach Program
- Attack
Program
- Observation
Program
- Unit
Design
- Unit
Staffing
- Unit
Management.
The
Society of Chest Pain Centers was conceived during a meeting in Dearborn,
Michigan in 1998, when it became evident that there needed to be an organization
that focused on and encouraged membership of cardiologists
and emergency physicians who were partnering in early ACS intervention.
On
October 11, 1999 in Las Vegas, the original 48 founding members elected
a Board of Trustees, Raymond D. Bahr, MD, President; Louis Graff, MD, Vice
President; and Anthony Joseph, MD, Treasurer. Brian Gibler, MD and Joseph
Ornato, MD were appointed Special Advisors, and liaison officers were appointed
to key cardiovascular associations.
The
initial infrastructure for the Society was maintained under Dr. Raymond
D. Bahr in Baltimore, Maryland. The Board of Trustees initiated a search
for executive director and in 2001, hired Robert Weisenburger Lipetz, moving
the offices to Columbus, Ohio. Presently, the mission of the Society is
being executed through an array of initiatives that include accreditation,
international programs, and education.
The
Focus of the Society
The
Society of Chest Pain Centers is a patient-centered professional society
with a focus on heart disease and a mission of educating the public and
healthcare professionals on the importance of rapid diagnosis and treatment
for those experiencing chest pain.
The
Society promotes evidence-based medicine, delivered through a Chest Pain
Center model, that addresses the diagnosis
and treatment of acute coronary syndromes.
Society
Members
In
1999, the 50 healthcare professionals, including MDs, PhDs, and RNs, founded
the Society of Chest Pain Centers and elected a board of directors. Since
then, membership has grown significantly.
The Society of Chest Pain Centers now counts among it's members cardiologists,
emergency physicians, nurses, and other healthcare providers, such as hospital
chief executives, operating, financial, and nursing officers, medical directors,
cardiovascular directors and others associated with the development and
implementation of Chest Pain Centers, such as architects and marketing strategists.
The
Society's Mission
The reason behind the
establishment of the Society of Chest Pain Centers can be found in its mission
statement:
"A
society without walls whose primary purpose is to significantly reduce heart
attack deaths."
"Without walls"
implies no turfs or constraints, just an esprit de corps among the
cardiologists, emergency physicians, critical care nurses, and others who
are working to side-by-side, and in concert with the general public, to
reduce heart attack deaths.
The Society hopes to
create a curve of progress similar to that which occurred in the 1960s with
the development and universal application of the coronary care unit. It
recognizes that science-based medicine is at the very heart of this effort,
but also understands that more is needed if modern treatment is to be applied
optimally to the population at large.
Educational
Goals
The Society brings together
diverse medical specialties, such as emergency medicine and cardiology,
clinicians, administrators, and other healthcare professionals, in order
to promote its educational mission - using community outreach programs to
help the general public recognize the early symptoms
of acute coronary syndrome.
The
Society also educates clinicians and hospital administrators, so they can
help healthcare providers better manage the early treatment of acute coronary
disease in a manner that optimizes quality patient care and positive hospital
outcomes.
In
addition to these educational missions, the Society provides expert opinion
to legislative work with various governing bodies and accredits Chest Pain
Centers.
Recommendations for Improving Chest Pain Centers
The Society of Chest
Pain Centers has compiled a list of recommendations that are designed to
improve the overall efficiency and effectiveness of the typical Chest Pain
Center:
- Recreate and expand
the CCU so that it includes the entire emergency department (Chest Pain
Center).
- Prepare the emergency
department by implementing a comprehensive, systematic triage system for
patients presenting with chest pain.
- Develop critical
pathways to quality care that is both cost effective and appropriate.
- Use the CQI process
to develop chest pain providers who will champion the cause.
- Integrate the Chest
Pain Center in the emergency department with the coronary care system,
and unite the emergency physicians, cardiologists, and critical care nurses
in early heart attack care in order to shift the paradigm of heart attack
care from emergency care to preventive care.
- Promote recognition
of early heart attack symptoms to the public through hospital outreach
and rehab programs, community educators, instructors in the workplace,
CPR instructors, EMS personnel, and so on.
- Better understand
the implications and benefits of recognizing a heart attack through the
prodromal symptom information obtained through focus interviews with patients,
cardiologists, and the public.
- Promote community
action through the unified efforts of the hospital's Chest Pain Center
and community awareness programs.
- Perfect the low probability
ischemic disease work up so the emergency department has the tool it needs
to sort out patients with suspected early ischemic heart disease.
- Use the science-based
evidence supplied by the American Heart Association, ACC Guidelines and
AHCPR to develop optimal treatment of patients with ischemic heart disease.
- Utilize hospital
television educational channels to broadcast short videos with a simple
outreach message to patients, families, and visitors on how to proactively
use this early recognition knowledge.
- Promote and appreciate
acute prevention as the earliest form of secondary prevention, so pre-hospital
care becomes more important than post-hospital care.
The
Preferred Patient
Chest Pain Centers typically
have no problems treating patients with cardiac arrest, pulmonary edema,
cardiogenic shock, or even patients crashing with myocardial infarction.
However, the Society suggests that the "preferred" patient is the one
who is...
Seen early, when death
can be prevented---------> CPR not needed
Seen early, when damage
can be prevented---------> Heart damage prevented
Seen early, when the
vessel can be opened ---------> Ischemia prevented
Seen early, when the
Chest Pain Center experience can be used as a teaching opportunity to change
the patient's behavior and improve his/her lifestyle through primary risk
factor prevention
Accreditation
by the Society of Chest Pain Centers
The
Society of Chest Pain Centers inaugurated an accreditation process through
which they evaluate Chest Pain Centers across the country in order to ensure
that these centers meet or exceed quality-of-care measures in acute cardiac
medicine.
Unlike
the fear driven compliance certifications that most facilities have experienced,
the Society's accreditation review is designed as a collegial process improvement
initiative that provides reviewed facilities with a clear road map to improved
quality of care. It highlights needed resources to ease clinicians' budget
requests, creates cost controls, and assists managers with reimbursement.
Most importantly, it improves patient care.
Before
Accreditation guidelines were established by the Society, the designation
of "Chest Pain Center" was used by any facility that, in good faith, felt
that it had met the basic requirements of a Chest Pain Center, as published
by the 1994 Consensus Panel Report in the American Journal of Cardiology.
"Simply stated, a sign and a marketing plan are not good enough.
A facility needs to show ongoing effort and intent to improve to earn the
designation of Accredited Chest Pain Center," said Weisenburger Lipetz,
Executive Director of the Society.
If
you would like your hospital to develop a Chest Pain Center, the Society
of Chest Pain Centers can help by providing the educational material you
need to convince your organization of the importance of offering better
patient care to the community through the development and implementation
of an observation unit/Chest Pain Center within your Emergency Department.
If your hospital has already implemented a Chest Pain Center, the Society
can help you attain accreditation through the Accreditation Process established
in 2003.
The
Components of a Chest Pain Center
Virtually every hospital
in the United States now has a Coronary Care Unit or a Chest Pain Center,
which is designed to focus attention on patients with heart attacks. However,
these CPCs vary in form, coordination of skilled personnel, and dedicated
equipment.
By studying these CPCs,
the Society of Chest Pain Centers identified eight components common to
all:
- Emergency Department Integration with the Emergency Medical System:
A formal relationship
between the ED and the local EMS that links the care processes for patients
with symptoms of possible ACS.
- Emergency Assessment of Patients with Symptoms of ACS - Timely Diagnosis
and Treatment of ACS: an ED attack program to minimize delays in institution of therapy
for an AMI (thrombolytics, nitrates, heparin, aspirin, etc.).
- Patients with Low Risk for ACS and No Assignable Cause for their
Symptoms: ED or hospital observation program that
monitors and evaluates low-risk patients to avoid the inadvertent release
home of patients with AMI or unstable angina.
- Functional Facility Design: an ED CPU that has a functional design for chest pain evaluation
to accomplish optimal patient care. It includes appropriate cardiovascular
monitoring equipment.
- Personnel, Competencies, and Training: Physicians and nursing staff in contact
with patients with symptoms of ACS require certain core competencies and
training. Leadership and management
may require additional core competencies and training.
- Process Improvement Orientation: CPU management structure based on continuous
quality improvement program principles to ensure quality patient care
and proper utilization of ED resources.
- Organizational Structure and Commitment: The facility's administration, medical
staff, and multidisciplinary committee must make a commitment to the establishment
and support of a Chest Pain Center.
- Community Outreach Program: An ED- or hospital-based community outreach program that educates
the public to promptly seek medical care if they have symptoms of an AMI,
such as chest pain, chest discomfort, shortness of breath, diaphoresis,
syncope, and risk factors for coronary artery disease, particularly smoking.
The
Accreditation Process
The Chest Pain Center
accreditation process takes a process improvement approach, in contrast
to a traditional compliance driven QA. Two separate tracks are offered,
based upon the needs of the facility: the accreditation track and
the education track.
Accreditation
Track
This track is used by
facilities that are committed to providing quality cardiac care to patients
and currently have the resources available to do so. To earn accreditation
status, facilities must meet or exceed a wide set of stringent criteria
and then allow an on-site evaluation by a review team from the Society of
Chest Pain Centers.
The
eight areas in which a facility must demonstrate expertise include:
- Ability to integrate
effectively with the local Emergency Medical System
- Ability to assess,
diagnose, and treat patients quickly
- Effectively handle
patients with low risk for acute coronary syndromes (ACS) and no assignable
cause for their symptoms
- Functional facility
design
- Personnel competencies
and training
- Organizational structure
and commitment
- Process improvement
orientation
- Community outreach
Facilities that meet these criteria are assigned
one of three possible designations:
- Accredited
Chest Pain Center is the designation earned by a healthcare
facility that meets the requirements for full accreditation. Accreditation
is for three (3) years.
- Provisional
Accreditation is the designation given to a healthcare facility
that has met the minimum requirements, has successfully completed the
accreditation process, and has made a written commitment to implement
recommended changes within a 12-month timeframe.
- No Accreditation
Granted is given to a healthcare facility that has not met
the minimum requirements or has received Provisional Accreditation but
has not met its commitment to implement recommended changes within a 12-month
timeframe.
Education
Track
This
track is used primarily by facilities that want or need guidance in order
to achieve accreditation. The facility participates in the standard accreditation
process and receives a written site visit report that delineates areas of
needed improvement along with specific recommendations.
Initiating
the Accreditation or Education Process
Your
facility can request a copy of the Accreditation Manual by using the Accreditation
Manual request form on the Society of Chest Pain Centers' website at www.scpcp.org. The Accreditation
Manual contains an application, a detailed description of accreditation
review process, the accreditation booklet and detailed criteria for review.
Accreditation
Support Service
Healthcare
providers seeking to further educate themselves on the accreditation process
can do so through educational programs and workshops offered by The Society
of Chest Pain Centers.
Information
on Accreditation Manuals, Workshops and Teleworkshops can be found on the
Society's website at www.scpcp.org.
Hospitals
With Accredited Chest Pain Centers
Today,
the accreditation process established and administered by the Society of
Chest Pain Centers formalizes and standardizes this elite certification.
Accreditation is granted only to those facilities whose Chest Pain Center
meets the criteria established by a formal Accreditation Committee.
Chest
Pain Centers Within the Emergency Department - What it Says About Your Cardiovascular
Program
-
Communicates that the hospital has taken their heart program to a new level
of care
-
Communicates that the hospital's emergency department offers a full-spectrum
emergency cardiac care program; offering rapid diagnosis and fast track
treatment before a situation worsens, often preventing a severe heart attack
from occurring.
-
Positions the hospital as a leader in cardiovascular care in the community
- Positions
the hospital as an educator/preferred provider for cardiovascular care
- Fosters
cooperative relationships between cardiologists and emergency physicians
- Increases
ED productivity
- Standardized
care for those entering with Chest Pain results in more efficient use of
the ED, which reduces or eliminates bottle-necks in the emergency department
-
Decreases errors of omission
-
Decreases errors of delay
-
Decreases errors of treatment gap
-
Increases market share
