University of Tennessee

Leading Change in Emergency Department Chest Pain Care

September 15, 2017

The following is the profile of an organizational action project conducted by Leon Adelman, a member of the Haslam Physician Executive MBA, Class of 2016.

CHALLENGE: Chest pain is a common reason people seek emergency medical care, resulting in about eight million emergency department (ED) visits in the United States each year. Many of those patients are hospitalized for comprehensive—and expensive—testing, even if they are at very low risk for life-threatening acute coronary syndrome (ACS) based on their history, electrocardiogram (ECG) findings, and cardiac biomarkers. Over-testing of ED patients with chest pain can lead to hospital crowding and inefficiency, while harming patient outcomes.

PROJECT: Leon Adelman, emergency medicine physician and director of clinical operations at the Inova Alexandria (Va.) Hospital (IAH) Emergency Department recognized that a standard, evidence-based approach to chest pain evaluation was needed to accurately determine whether a patient was at very low risk for acute coronary syndrome (and thus, safely could be discharged without further cardiac testing). Using the modeling tools learned in the PEMBA program—and the input and guidance of his UT PEMBA mentor and advisor Jody Crane—Adelman focused his Organizational Action Project on designing and implementing a ED Low Risk Chest Pain Initiative (LRCP) at IAH. He led an IAH LRCP team charged with improving the quality, consistency, and efficiency of the process for chest pain evaluation at the hospital.

PROCESS: The IAH LRCP team followed the model outlined in John Kotter’s popular “8-Step Process of Leading Change.” Here’s a quick overview of how the team employed Kotter’s approach to address the challenge and create a low-risk chest pain pathway.

1. Create a sense of urgency. Adelman and his team used existing research to illustrate how improvements in laboratory testing and clinical decision-making algorithms for chest pain have outpaced changes in practice, leading to excessive admission rates and variation. They also conducted a thorough review of journal articles, best practices currently used by leading medical institutions, and American Heart Association guidelines, as well as discussions with national chest pain experts, to make a compelling case for how consistently adhering to best-evidence practice can improve chest pain care quality, safety, and efficiency, while decreasing costs.

2. Build a guiding coalition. The LRCP initiative was incorporated into the Alexandria-Springfield Emergency Physicians (ASE) Clinical Operations Council, which provided key support to the project. Council member Darren Morris, emergency physician and assistant director of the Virginia Hospital Center in Arlington, Va., served as project co-leader with Adelman.

3. Form a strategic vision and initiatives. The LRCP team crafted a vision based on the premise that using an algorithmic approach to chest pain would help IAH clinicians better protect patients from missed myocardial infarctions, or heart attacks; help protect providers from litigation; increase efficiency; and decrease costs. After a literature and best practice review, the team created a new evidence-based ED chest pain pathway based on the HEART (history, electrocardiogram results, age, risk factors, and troponin) Score. The guidelines are designed as single-page graphic pathways to walk a provider through the steps of evaluation and treatment.

4. Enlist a Volunteer Army: Involving key stakeholders—such as IAH ED providers, cardiologists, administrators, hospitalists, and nurses—early in the process helped build buy-in. The team educated stakeholders about the issue, answered questions, and provided multiple avenues for feedback. In addition, the IAH ED providers and cardiologists participated in drafting the new evidence-based chest pain pathway.

5. Enable action by removing barriers. Educational tools—including pocket cards that providers can carry with them during a shift, mandatory online learning modules, informational posters in the ED, and staff meeting presentations—helped build the knowledge and consensus needed for full integration of the new pathway. In addition, cardiologists agreed to see all insured LRCP referrals within 3 days and a new 24/7 voicemail-based ED cardiology referral system was created.

6. Generate short term wins. When compared with the six months prior to the LRCP Initiative, the first three months’ post-pathway launch showed improvements in key metrics.

7. Sustain acceleration. The subsequent three-month period showed mixed results, likely due to incomplete integration of the pathway into provider workflow and challenges in obtaining process measures integral to driving continuous improvement.

8. Institute change. Based on the initial improvements, the team partnered with Inova’s Quality and Informatics Departments to better integrate the LRCP Pathway into ED clinician workflow via the Epic EMR (electronic medical record) system. Epic data will drive a continuous improvement process based on individualized transparent performance feedback.

RESULTS: The IAH ED LRCP Pathway was adopted in November 2016 by all EDs in the Inova Health System, a network of hospitals and other health care facilities located throughout Northern Virginia and the Washington, D.C. metro area. Patient data collected during the first several months of implementation clearly demonstrated that the new evidence-based ED chest pain pathway improved safety, quality, and efficiency of IAH ED chest pain evaluations. From Sept. 2016 to June 2017, for example, the percentage of Inova patients presenting with chest pain who received a HEART score increased from 1.1 percent to 32.4 percent. During that same period, the percentage of patients with a primary diagnosis of chest pain who returned to the emergency department within 30 days decreased from 9.1 percent to 4.4 percent. Next steps include EMR optimization, implementing data-driven improvement strategies, and application of the LRCP model to other common ED conditions.

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