Hospitalization required for r/o ACS?

[xaelia]

No, I'm not actually putting this into practice....

But, in theory, if >90% of our first-set-negative r/o ACS folks end up without a diagnosis of ACS...

And articles like this one:
Predicting freedom from clinical events in non-ST-elevation acute coronary syndromes: the Global Registry of Acute Coronary Events
http://www.ncbi.nlm.nih.gov/pubmed/19246481

...talk about <20% risk of in-house event after NSTEMI - and they can even risk-stratify into people at lower risk for in-house event...

You almost wonder if it's reasonable to have the low-risk chest pain go home and follow-up in 24 hours for a repeat EKG and troponin, since they're unlikely to have an in-house event on-monitor.

This obviously doesn't work in a no-miss litigation society, but in a bankrupt healthcare system trying to find lower-cost solutions....

Just using the crazy part of my brain this morning.

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[WilcoWorld]

I agree that our current approach to working up ACS is economically low-yield and possibly unsustainable. However, I'm not going to start practicing a new approach unilaterally. Public opinion and standard of care need to change first.

 

[pratik7]

20% events for " myocardial infarction, arrhythmia, congestive heart failure or shock, major bleeding, stroke or death" is really badness. If you look at the TIMI calculator 5% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization IF YOU HAVE NO RISK FACTORS!!!!

Granted, i dont like admiting them and some hospitalist dont want them. But, I am not gonna stop cause it my booty when feculent matter hits the fan.

 

[The White Coat Investor]

We have a pretty good group of cardiologists and it is easy to get a same day or next day stress test most of the time. So we frequently do a couple of EKGs, a couple of sets of enzymes, discuss it with cards, and send them out. But even with that approach, stuff can be missed. We had a LAD MI/V-fib arrest in the ED in a patient that had been seen in another ED in town, had two sets and a stress test lined up for the next day. Thankfully, we got him back and he walked out of the hospital a couple days later fully intact. But geez.....no guarantees in this business.

 

[Tiger26]

This is why having an observation unit is a practice gamechanger. With low risk chest-painers, I'll put them in our obs unit to rule out after one negative trop and can get one of eight different stress tests that day until about 7PM or early the next morning. It's awesome and it saves the hospital a fortune.

 

[EMFreakz]

i agree with looking ways to lower waste of resources. but i'm just curious, you mention saving the hospital money... doesn't r/o ACS actually make money for the hospital (assuming they're insured of course)? charge for 23hrs obs stay, cardiac monitoring, +/-, stress test, etc... and don't the hospitalists get physician fees as well? easy admit for them as well.

 

[WilcoWorld]

That assumes that your patients (or their insurers) pay their bills. Most of the patients at my shop do not.

What is more important to me than whether or not my hospital gets paid is whether we can continue to provide medical care in the current paradigm without bankrupting the country. I think that the answer is no, and that "rule out ACS" admissions are a representative example of the problems with our current approach (unreasonable expectations for miss rates, high ratio of cost of screening to benefit, strong medicolegal incentive to perform tests that the clinician is confident will be negative).

 

[EMFreakz]

wilco, definitely agree with you (and I like wilco and uncle tupelo as well). our patient population is well over >50% insured. but yes, agree with you otherwise... not just for ACS r/os, but a whole lot of other things I wish could change to not just make our jobs better, but provide care that makes more sense and not bankrupting our country.

 

[deleted6669]

This is why having an observation unit is a practice gamechanger. With no risk chest-painers, I'll put them in our obs unit to rule out after one negative trop and can get one of eight different stress tests that day until about 7PM or early the next morning. It's awesome and it saves the hospital a fortune.

we do the same thing. we have a 24 hr ed obs unit that takes atypical cp, tia's, cellulitis, asthma, trauma obs, etc
we staff it with em pa's and have docs round in the unit twice daily(and they are always available for calls). all the pa's have been trained to perform and interpret exercise stress tests which we get over read by one of the ed docs before the pt goes home. probably 90% of our treadmills are negative but we still pick up some significant dz every now and then and do send some pts directly from the treadmill room to the cath lab.

 

[McGillGrad]

This is why having an observation unit is a practice gamechanger. With no risk chest-painers, I'll put them in our obs unit to rule out after one negative trop and can get one of eight different stress tests that day until about 7PM or early the next morning. It's awesome and it saves the hospital a fortune.

I don't understand why there isn't a short-term assessment unit in every hospital. All you need is 30-40 beds and you could cut down on inpatient admissions and reduce ED overcrowding.

 

[Arcan57]

Making money on CP r/o depends not just on payor mix but also length of stay. The average LOS for CP r/o ACS observation patients at my hospital is 2-3 days. Which means we lose money hand over fist on these patients.

 

[deleted6669]

Making money on CP r/o depends not just on payor mix but also length of stay. The average LOS for CP r/o ACS observation patients at my hospital is 2-3 days. Which means we lose money hand over fist on these patients.

Our avg stay for r/o acs(for those going home) is less than 12 hrs.
we have a 12 bed unit and it is seldom full as turnover is fairly rapid. on the rare occasions that it is full we "borrow" beds on adjacent units.

 

[Arcan57]

Our avg stay for r/o acs(for those going home) is less than 12 hrs.
we have a 12 bed unit and it is seldom full as turnover is fairly rapid. on the rare occasions that it is full we "borrow" beds on adjacent units.

Is this with provocative testing? If so, do the ED docs read the stress tests or did you bribe cardiology to do them in real-time?

 

[deleted6669]

Is this with provocative testing? If so, do the ED docs read the stress tests or did you bribe cardiology to do them in real-time?

The em pa's do the basic exercise treadmills and the initial read and get an over read done by the ed docs minutes later. for the obviously positive tests we skip an ed doc over read and go right to the on call cardiologist to get the ball rolling.
all the em docs and pa's went through a training process with the dept of cardiology a few yrs ago to get credentialed to do/interpret basic treadmills. we do treadmills from 7am to 10 pm so a pt admitted later in the day will probably spend the night to get their second set of enzymes and ekg and then do a treadmill 1st thing in the morning.
for the dip/thals we have an assigned cardiologist every day who reads them.

 

[shookwell]

Just discharge everyone. Even in the original Pope paper there was no significant difference in mortality between the missed MIs and the people admitted for MIs. If the troponin is negative they should go home.

The only difference between admitting to telemetry and sending them home is that for the few unfortunate people who have a malignant disrhythmia, the ones who were admitted die on a recorded line.

 

[Old_Mil]

Ths obviously doesn't work in a no-miss litigation society, but in a bankrupt healthcare system trying to find lower-cost solutions....

Fix the no-miss litigation part of the equation, and I will worry about finding lower cost solutions.

In the meantime, my license isn't going to be the tool CMS uses to balance its budget.

 

[Birdstrike]

To me, EM is about risk reduction, as is most of Medicine, really. You're not going to make every diagnosis every time, and rarely have all the data needed to do so. You're playing a game of odds and risk reduction. And yes, the "no miss litigation society" isn't going away any time soon. In a country where our government is comfortable running debts in the trillions of dollars, talk of "cost savings" is no more than laughable lip service to me. When they're running debts like that, but want me to increase my and my patients' risk, to save a few inconsequential dollars, they must think they're selling to drooling idiots. I ain't buyin'.