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FROM THE PRESIDENT EMERITUS |
CONTINUOUS QUALITY IMPROVEMENT (CQI)
IN THE CHEST PAIN CENTER DEVELOPMENT
Perhaps one of the most effective mechanism for improving patient care has been the acceptance in medicine of the continuous quality improvement strategy (CQI). Nowhere is this more helpful than in the Emergency Room setting. This involves tackling a problem with a process of analysis, planning, putting the strategy into place and periodically examining the derived data for feedback action. It brings together the players involved in the problem through a process of identifying barriers needing to be overcome. The strategy is aimed at addressing the top 20% barriers to the problem in that this approach has been proven to have an 80% outcome impact. Hospitals may differ in their approach based on expertise, technology available and existing geographic problems but still can improve their performance with this continuous quality improvement exercise.
The Chest Pain Center strategy is such a CQI approach and fulfills a need for the hospital to prepare better for heart attack patients within its community. Focusing on chest pain presentations becomes a way to get to the heart attack patient. This involves putting together a comprehensive triage plan for all patients presenting with chest pain so as to pick out the patients who are infarcting from the patients who have unstable angina (active ischemia) and last but not least patients with non cardiac chest pain. Chest Pain Centers have now developed a strategy for dealing with patients who have a low probability of having ischemic heart disease that has proven to be cost effective. This then allows the hospital the "machinery" to sort out patients with mild chest pain symptoms, thereby reducing inappropriate admissions to the hospital while at the same time reducing missed MIÕs being sent home. This strategy opens the door to the community and begs for awareness messages that can be given to the public and focuses on patients with prodromal symptoms that are known to exist in approximately 50% of acute MI patients. This then becomes the focus of a targeted community awareness program aimed at properly educating the public. In our experience the following four features of prodromal unstable angina are the barriers that need to be properly addressed:
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| 1. |
The central chest discomfort is described as a fullness, an ache,
a burning, a dullness or most frequently as chest pressure.
Patients deny that this is chest pain......... that is
why they do not come in. |
| 2. |
The chest discomfort has a tendency to come and go rather than be persistent. This also contributes to the time delay in that patients are hoping it will go away. |
| 3. |
The chest discomfort is usually not recognizable by a person in the midst of the patient because the patient does not look sick. These patients can actually quiet down their symptoms by doing very little and thus not giving it away. Even when patients tell someone it is easy for the bystander to leave and attribute it to something else other than the heart because "business of the days activities" take on more importance than checking out these early symptoms. |
| 4. |
Since the chest symptoms are mild, it becomes rather difficult to call 911 and get the sirens from the ambulances and the hook and ladder from the fire engines. Patients literally wait until the discomfort becomes painful enough and
reaches a threshold to call 911. Its almost as if the chest pain
has to stop one dead in oneีs track and this is actually what
happens.
This why 600,000 Americans each year lose their
lives....... and half of these are clearly preventable. The EHAC
Awareness message teaches about the chest pressure before the chest pain and allows intervention to bring about prevention which is the best form of medicine.
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If we can modify the behavorial response using the CQI approach correcting these delays, we may be able to make a major impact on reducing heart attack deaths within the United States. This targeted awareness program has been called EHAC (Early Heart Attack Care) and is now being driven by the Chest Pain Center Strategy. As low probability patients can now be safely ruled out and sent home, the door is now open for making the community more fully aware of the reasons that prevent patients with early ischemic heart disease from entering at the time when they can be most helped. The EHAC Awareness Program is a targeted program and differs from the REACT Awareness Program that is more wide in scope.
The Chest Pain Center Strategy represents a paradigm shift in attempting to reduce time to treatment in patients with acute unstable angina especially in those patients with prodromal unstable angina as described above.
Thus, the Chest Pain Center Strategy appears to be taking us in the direction of early heart attack care through the perfection of the low probability of ischemic disease work up and a shift to reduce the time to treatment in patients with acute unstable angina. This process solving of the heart attack problem at the local hospital level as well as on a global level can best be accomplished by utilizing the Continuous Quality Improvement approach.
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