The Changing Paradigm in Emergency Medicine:
Bridging the Gap Between Cardiology and the Emergency Department

Sandra Sieck, RN, RBA
Director of Cardiovascular Development
Providence Hospital
6801 Airport Blvd.
Mobile, AL 36608

Integrating the Goals of Healthcare Organizations and Providers

Although chest pain units and EDs have elements in common for evaluation and treatment of patients with suspected ACS, there are no universally accepted treatment or diagnostic algorithms. The recent ACC/AHA guidelines provide detailed recommendations regarding diagnostic and treatment approaches in patients with ACS," but these guidelines have not yet been translated -into algorithms. This is partly because few therapeutic areas are. as dynamic as cardiology. An equally important factor is that numerous regulatory and professional organizations have become more involved in all aspects of patient care, In addition, hospital staff must strive for a delicate balance between complying with specific orders, standing orders, and critical pathways, while staying within the bounds of evidence-based medicine. One of the goals of establishing a specialized chest pain unit is to facilitate this process and establish a partnership between ED physicians and cardiologists. Until recently, the importance of this partnership was under appreciated. Now, with the bewildering array of diagnostic tools and treatment options for patients with ACS, this partnership has become crucial.

Figure 2 The goals of healthcare organizations and providers include improving the quality of care, reducing lengths of hospital stay and cost of care, and increasing revenue. Hospital staff must balance specific orders issued by the treating physician, standing orders of the department, and critical pathways, while staying within the bounds of evidence-based medicine and adhering to the most recent ACC/AHA guidelines. Healthcare providers also must strive to satisfy the often competing demands of agencies involved in regulating different aspects of healthcare provision such as HCFA, JCAHO, AHRQ, NCQA, each of which has different priorities.

The goals of healthcare organizations and providers include improving the quality of care, reducing lengths of hospital stay and cost of care and increasing revenue (Fig 2). While attempting to meet these goals, healthcare providers must strive to satisfy the often-competing demands of healthcare regulatory agencies, which may have different priorities (Fig 2).

The Health Care Financing Administration (HCFA), one of five major healthcare regulatory agencies in the US, administers Medicare, Medicaid- and the State Children's Health Insurance Program and also regulates laboratory testing, develops coverage policies and maintains oversight of the survey and certification of nursing homes and continuing care providers. HCFA is primarily interested in the financial aspects of health care, The Joint Commission on Accreditation, of Healthcare Organizations (JCAHO), an independent, nonprofit organization, accredits, sets standards for and evaluates compliance with established benchmarks for healthcare organizations. Its primary concern is monitoring and maintaining acceptable clinical outcomes within healthcare organizations, The Agency for Healthcare Research and Quality (ABRQ), formerly the Agency for Health Care Policy and Research (AHCPR), is involved in developing treatment standards that are consistent with evidence-based medicine. The National Committee for Quality Assurance (NCQA) is an independent, nonprofit organization that evaluates and reports on the quality of managed care organizations. One of its primary focuses is to insure medications are being used within their approved indications and in compliance with benchmarks. The National Institutes of Health (NIH) consists of 25 separate institutes and centers that conduct, fund, and monitor publicly funded biomedical research in the US. Despite a billion dollar budget for research, the NIF1 has not had the effect on healthcare delivery it had expected. For example, whereas mortality rates in well controlled clinical trials of AINU have been reduced approximately 30% morality in clinical practice remains unacceptably high.

Formerly, ED physicians focused on managing the acute disease state. Now they must focus on implementing guidelines that include detailed recommendations on diagnosis and treatment, Indeed, in today's environment of integrated care, all clinicians involved in treating patients with chest pain need to be aware of these guidelines. With this paradigm shift in healthcare delivery, we must explore ways to implement these guidelines starting at the "front door," that is, In the ED, and continuing through to cardiology and primary care. Although there is no single solution to ensuring a seamless transition from the ED to cardiology, specialized chest pain centers appear to be uniquely positioned to facilitate this process.