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

2

x

5

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 begins3. Patient given corresponding visual aid (low,

moderate, high) after first troponin result4. Patient and providers sign the visual aid.

Patient keeps a copy of the visual aid5. 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 TestP < .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