Risk-score Based ICU Triage
| Status: | Recruiting |
|---|---|
| Conditions: | Cardiology |
| Therapuetic Areas: | Cardiology / Vascular Diseases |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 2/17/2019 |
| Start Date: | February 14, 2018 |
| End Date: | May 1, 2019 |
| Contact: | Alexander C Fanaroff, MD |
| Email: | alexander.fanaroff@dm.duke.edu |
| Phone: | 919-668-8815 |
Rational Coronary Care Unit Triage for Stable Patients With NSTEMI: Evaluating the Safety and Costs of a Risk Score-based Triaging System
The investigators have created a new risk score that predicts whether initially stable
patients with myocardial infarctions (heart attacks) will require intensive care while they
are in the hospital. To evaluate how well this risk score works, the investigators plan to
calculate this risk score for every patient that comes to the hospital with a heart attack,
provide the risk score to the emergency room doctor treating the patient, and determine
whether each patient required intensive care while they were in the hospital. The
investigators will then evaluate whether giving emergency room doctors access to this risk
score reduced costs of taking care of heart attack patients compared with previous years.
patients with myocardial infarctions (heart attacks) will require intensive care while they
are in the hospital. To evaluate how well this risk score works, the investigators plan to
calculate this risk score for every patient that comes to the hospital with a heart attack,
provide the risk score to the emergency room doctor treating the patient, and determine
whether each patient required intensive care while they were in the hospital. The
investigators will then evaluate whether giving emergency room doctors access to this risk
score reduced costs of taking care of heart attack patients compared with previous years.
Multiple recent studies have demonstrated considerable between-hospital variability in ICU
utilization for stable patients with NSTEMI and a lack of association between higher
hospital-level ICU utilization and short-term mortality. Moreover, severity of illness, as
measured by a traditional in-hospital mortality risk score, has only a trivial correlation
with ICU utilization. A minority of initially stable patients with NSTEMI (~15%) deteriorates
clinically while hospitalized and requires ICU care for management of cardiac arrest, shock,
arrhythmias requiring pacing, stroke, or respiratory failure. Across a variety of conditions
outcomes are better when patients are admitted directly to the ICU from the emergency
department (ED) rather than transferred in after admission. However, the cost of caring for
patients in the ICU is substantially more than the cost of caring for these patients in a
non-ICU environment. Furthermore, treating patients that do not require intensive care in the
ICU exposes them to unnecessary risks of ICU care, including medication errors, adverse
procedural outcomes, delirium, and excessive noise. Reducing ICU utilization for stable
patients with NSTEMI may reduce costs and improve patient satisfaction.
Using data from a nationally-representative registry enrolling patients with acute MI, the
investigators developed the ACTION ICU risk score. Incorporating demographic, clinical, and
laboratory data obtained routinely in the ED work-up of patients with suspected acute MI, the
ACTION ICU risk score calculates the risk of in-hospital complications mandating ICU care for
initially stable patients with NSTEMI. Complications mandating ICU care were defined as
death, shock (cardiogenic or otherwise), cardiac arrest, high degree heart block requiring
pacemaker placement, respiratory failure, or stroke. The risk score's c-statistic was 0.72,
indicating good discrimination. Importantly, it identified > 50% of patients as being at <
10% risk of in-hospital complications mandating ICU care.
However, the clinical and financial implications of using this score to guide ICU triage in
routine clinical practice are unknown, and the risk score has not been prospectively
validated.
The investigators will create a calculator for the electronic health record that
automatically calculates the ACTION ICU risk score for all patients with NSTEMI, as
identified by their initial troponin value. Once the score is calculated, it will provide the
score, and the patient's risk of clinical deterioration to the ED physician, along with a
recommendation for where patients at that risk should be treated. The ED physician, working
with the cardiologist on call, will then decide where the patient should be treated.
After one year, each patient for whom the score was calculated will be identified by a query
of the electronic medical record. From the electronic medical record, the investigators will
identify whether the patient was initially admitted to the ICU or to a non-ICU unit, whether
the patient was transferred to the ICU during their hospital course, and whether the patient
had clinical complications mandating ICU care (death, shock, cardiac arrest, heart block
requiring pacemaker, stroke, or respiratory failure). The investigators will also compare
total hospital costs for caring for NSTEMI patients before and after roll-out of the ACTION
ICU score electronic medical record plug-in. Study completion will be defined by the last
date of data extracted from the medical records for these patients.
utilization for stable patients with NSTEMI and a lack of association between higher
hospital-level ICU utilization and short-term mortality. Moreover, severity of illness, as
measured by a traditional in-hospital mortality risk score, has only a trivial correlation
with ICU utilization. A minority of initially stable patients with NSTEMI (~15%) deteriorates
clinically while hospitalized and requires ICU care for management of cardiac arrest, shock,
arrhythmias requiring pacing, stroke, or respiratory failure. Across a variety of conditions
outcomes are better when patients are admitted directly to the ICU from the emergency
department (ED) rather than transferred in after admission. However, the cost of caring for
patients in the ICU is substantially more than the cost of caring for these patients in a
non-ICU environment. Furthermore, treating patients that do not require intensive care in the
ICU exposes them to unnecessary risks of ICU care, including medication errors, adverse
procedural outcomes, delirium, and excessive noise. Reducing ICU utilization for stable
patients with NSTEMI may reduce costs and improve patient satisfaction.
Using data from a nationally-representative registry enrolling patients with acute MI, the
investigators developed the ACTION ICU risk score. Incorporating demographic, clinical, and
laboratory data obtained routinely in the ED work-up of patients with suspected acute MI, the
ACTION ICU risk score calculates the risk of in-hospital complications mandating ICU care for
initially stable patients with NSTEMI. Complications mandating ICU care were defined as
death, shock (cardiogenic or otherwise), cardiac arrest, high degree heart block requiring
pacemaker placement, respiratory failure, or stroke. The risk score's c-statistic was 0.72,
indicating good discrimination. Importantly, it identified > 50% of patients as being at <
10% risk of in-hospital complications mandating ICU care.
However, the clinical and financial implications of using this score to guide ICU triage in
routine clinical practice are unknown, and the risk score has not been prospectively
validated.
The investigators will create a calculator for the electronic health record that
automatically calculates the ACTION ICU risk score for all patients with NSTEMI, as
identified by their initial troponin value. Once the score is calculated, it will provide the
score, and the patient's risk of clinical deterioration to the ED physician, along with a
recommendation for where patients at that risk should be treated. The ED physician, working
with the cardiologist on call, will then decide where the patient should be treated.
After one year, each patient for whom the score was calculated will be identified by a query
of the electronic medical record. From the electronic medical record, the investigators will
identify whether the patient was initially admitted to the ICU or to a non-ICU unit, whether
the patient was transferred to the ICU during their hospital course, and whether the patient
had clinical complications mandating ICU care (death, shock, cardiac arrest, heart block
requiring pacemaker, stroke, or respiratory failure). The investigators will also compare
total hospital costs for caring for NSTEMI patients before and after roll-out of the ACTION
ICU score electronic medical record plug-in. Study completion will be defined by the last
date of data extracted from the medical records for these patients.
Inclusion Criteria:
- Presents to DUMC with elevated cardiac troponin
- Identified by ED physician as having myocardial infarction
Exclusion Criteria:
- ST segment elevation myocardial infarction
- Hemodynamically unstable
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