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Shared Decision Making Using the HEART Score and
a Visual Aid in Patients Presenting to the Emergency
Department with Chest Pain
Gregory Gafni-Pappas, DO, Susanne Demeester, MD, Michael Boyd,
MD, Arun Ganti, MD
Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.
Times Are Changing
Many low-risk chest pain patients can be discharged.
The Goal
• Decrease unnecessary
hospitalization and testing
• Increase patient understanding and
satisfaction with their ED course.
The Baseline Practice
Accelerated Diagnostic Pathway, ADP
Accelerated Diagnostic Pathway
Background
Step 2: The HEART Score
• Prospectively and externally validated
–Utilizes 5 components:
• History
• EKG
• Age
• Risk factors
• Troponin
The Heart Score
• Backus, et al, 2008
Risk Level End Point Percentage Reached
Endpoint
Low 1/39 2.5%
Moderate 12/59 20.3%
High 16/22 72.7%
Neth Heart J. 2008 Jun;16(6):191-6.
Validation
• Backus, et. al 2013
– 2,440 Patients
– Low HEART Score
• MACE 6 weeks
– 1.7%
• Mahler, et. al 2011
– 1070 patients
– Low HEART Score
• MACE at 30 days
– 0.6%
Int J Cardiol. 2013 Oct 3;168(3):2153-8. Crit Pathw Cardiol. 2011
Sep;10(3):128-33
The Heart Score
• 30 days MACE is <1% in patients with a low HEART score
and two sets of troponins.
Background
x
22
x
55
Step 3: Visual Aid
• A visual tool is used to explain ED course, diagnosis,
and true risk.
Step 3: Visual Aid
• Educational
• Shared decision making
• Documents understanding
Shared Decision Making
• The visual aid is chosen based on the
patient’s calculated HEART score and
risk.
Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.
Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.
Implementation
1. HEART score calculated for patients with chest
pain and concern for ACS
2. 2 hour NSTEMI rule-out begins
3. Patient given corresponding visual aid (low,
moderate, high) after first troponin result
4. Patient and providers sign the visual aid.
Patient keeps a copy of the visual aid
5. Forms are scanned into chart
Results
2014 Pilot Phase
# Patients p/w
Chest Pain
4791 132
Admitted
Inpatient
148 (3.1%) 0
Direct to Cath 153 (3.2%) 0
EOC (Observation) 2716 (56.6%) 34 (25.7%)
Discharge 1927 (40.2%) 98 (74.24%)
Background
2014 Pilot Phase
# Patients p/w
Chest Pain
4643
(excludes Admit
and Cath)
132
Admitted Inpatient 148 (3.1%) 0
Direct to Cath 153 (3.2%) 0
EOC (Observation) 2716 (58.4%) 34 (25.7%)
Discharge 1927 (41.5%) 98 (74.24%)
Results
32.7% Reduction
in EOC Admissions
Fischer’s Exact Test
P < .0001
Key Points
• Chest pain is common
• Low-risk chest pain patients can safely
be discharged home provided they
understand their risk and have a plan for
follow-up.
Conclusions
• The HEART Score is a tool that can be
used to determine risk for 30 day
MACE.
• Visual aids improve provider and
patient understanding.
• All discharged patients still need time-
sensitive follow-up instructions.
References
1. Hess E. The chest pain choice decision aid: a randomized trial.Circ
Cardiovasc Qual Outcomes. 2012 May;5(3):251-9.
2. Six A et al. The HEART score for the assessment of patients with chest
pain in the emergency department: a multinational validation study. Crit
Pathw Cardiol. 2013 Sep;12(3):121-6.
3. Backus BE1, A prospective validation of the HEART score for chest pain
patients at the emergency department. Int J Cardiol. 2013 Oct
3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7.
4. Mahler SA et al. The HEART Pathway Randomized Trial: Identifying
Emergency Department Patients With Acute Chest Pain for Early
Discharge. Circ Cardiovasc Qual Outcomes. 2015 Mar;8(2):195-203. doi:
10.1161/CIRCOUTCOMES.114.001384. Epub 2015 Mar 3.
5. Flynn D et al. Engaging patients in health care decisions in the
emergency department through shared decision-making: a systematic
review. Acad Emerg Med. 2012 Aug;19(8):959-67.
6. Neumar RW et al. Part 1: Executive Summary: 2015 American Heart
Association Guidelines Update for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl
2):S315-67

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Shared Decision Making Using the HEART Score and a Visual Aid in Patients Presenting to the Emergency Department with Chest Pain by Michael Boyd

  • 1. Shared Decision Making Using the HEART Score and a Visual Aid in Patients Presenting to the Emergency Department with Chest Pain Gregory Gafni-Pappas, DO, Susanne Demeester, MD, Michael Boyd, MD, Arun Ganti, MD
  • 2. Background • Chest pain = 5 to 8% of ED volume • Classically, these patients have been admitted or observed.
  • 3. Times Are Changing Many low-risk chest pain patients can be discharged.
  • 4. The Goal • Decrease unnecessary hospitalization and testing • Increase patient understanding and satisfaction with their ED course.
  • 5. The Baseline Practice Accelerated Diagnostic Pathway, ADP
  • 8. Step 2: The HEART Score • Prospectively and externally validated –Utilizes 5 components: • History • EKG • Age • Risk factors • Troponin
  • 9.
  • 10. The Heart Score • Backus, et al, 2008 Risk Level End Point Percentage Reached Endpoint Low 1/39 2.5% Moderate 12/59 20.3% High 16/22 72.7% Neth Heart J. 2008 Jun;16(6):191-6.
  • 11. Validation • Backus, et. al 2013 – 2,440 Patients – Low HEART Score • MACE 6 weeks – 1.7% • Mahler, et. al 2011 – 1070 patients – Low HEART Score • MACE at 30 days – 0.6% Int J Cardiol. 2013 Oct 3;168(3):2153-8. Crit Pathw Cardiol. 2011 Sep;10(3):128-33
  • 12. The Heart Score • 30 days MACE is <1% in patients with a low HEART score and two sets of troponins.
  • 14. x 55
  • 15. Step 3: Visual Aid • A visual tool is used to explain ED course, diagnosis, and true risk.
  • 16. Step 3: Visual Aid • Educational • Shared decision making • Documents understanding
  • 17. Shared Decision Making • The visual aid is chosen based on the patient’s calculated HEART score and risk.
  • 18.
  • 19. Background • Chest pain = 5 to 8% of ED volume • Classically, these patients have been admitted or observed.
  • 20. Background • Chest pain = 5 to 8% of ED volume • Classically, these patients have been admitted or observed.
  • 21. Implementation 1. HEART score calculated for patients with chest pain and concern for ACS 2. 2 hour NSTEMI rule-out begins 3. Patient given corresponding visual aid (low, moderate, high) after first troponin result 4. Patient and providers sign the visual aid. Patient keeps a copy of the visual aid 5. Forms are scanned into chart
  • 22. Results 2014 Pilot Phase # Patients p/w Chest Pain 4791 132 Admitted Inpatient 148 (3.1%) 0 Direct to Cath 153 (3.2%) 0 EOC (Observation) 2716 (56.6%) 34 (25.7%) Discharge 1927 (40.2%) 98 (74.24%)
  • 23. Background 2014 Pilot Phase # Patients p/w Chest Pain 4643 (excludes Admit and Cath) 132 Admitted Inpatient 148 (3.1%) 0 Direct to Cath 153 (3.2%) 0 EOC (Observation) 2716 (58.4%) 34 (25.7%) Discharge 1927 (41.5%) 98 (74.24%)
  • 24. Results 32.7% Reduction in EOC Admissions Fischer’s Exact Test P < .0001
  • 25. Key Points • Chest pain is common • Low-risk chest pain patients can safely be discharged home provided they understand their risk and have a plan for follow-up.
  • 26. Conclusions • The HEART Score is a tool that can be used to determine risk for 30 day MACE. • Visual aids improve provider and patient understanding. • All discharged patients still need time- sensitive follow-up instructions.
  • 27. References 1. Hess E. The chest pain choice decision aid: a randomized trial.Circ Cardiovasc Qual Outcomes. 2012 May;5(3):251-9. 2. Six A et al. The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol. 2013 Sep;12(3):121-6. 3. Backus BE1, A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7. 4. Mahler SA et al. The HEART Pathway Randomized Trial: Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circ Cardiovasc Qual Outcomes. 2015 Mar;8(2):195-203. doi: 10.1161/CIRCOUTCOMES.114.001384. Epub 2015 Mar 3. 5. Flynn D et al. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med. 2012 Aug;19(8):959-67. 6. Neumar RW et al. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl 2):S315-67