Emergency Care Partnerships: It Takes Two to Triage

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 - Emergency staff at the UMHS
Emergency staff at the University of Michigan Health System in Ann Arbor are empowered to activate the cath lab, but if they have doubts they now call a cardiology fellow beforehand.

By teaming together, cardiologists and emergency care physicians are finding ways to improve efficiencies and patient care. But like many budding relationships, they may make missteps and need to recalibrate along the way.

Getting in sync on afib

After repeated late night phone calls from the emergency department (ED), Darryl Elmouchi, MD, and his team thought they had a solution. Elmouchi, medical director of cardiac electrophysiology (EP) at the Frederick Meijer Heart & Vascular Institute in Grand Rapids, Mich., often served as the point person for emergency personnel at Spectrum Health Butterworth Hospital when a patient presented with atrial fibrillation. The reason for the calls, the physicians determined, was lack of a standardized protocol for treating atrial fibrillation in the acute setting.

Partnering on Heart Failured

Emergency physicians and heart failure patients are no strangers. The American Heart Association reported almost 700,000 emergency department (ED) visits for heart failure in 2010. As many as half of those patients may be low to moderate risk, and swift and appropriate care may help avoid a costly hospitalization and improve outcomes. Sean P. Collins, MD, an emergency medicine professor at Vanderbilt University in Nashville, Tenn., has collaborated with cardiologists on an ED observational unit approach designed to evaluate and treat low- to moderate-risk heart failure patients. In a pilot study, they compared outcomes in suspected heart failure patients admitted directly to an inpatient setting to patients sent to an observation unit (Congest Heart Fail 2005;11:68-72). Physicians determined that six of the 28 patients in the observation unit should be admitted. Thirty-day outcomes in both groups were similar but observation patients had shorter length of stay and less charges for a cost savings of $3,600 per each observation unit patient. Based on that and other research, the team is now making a case for a randomized clinical trial to compare standard care with observation unit management (J Am Coll Cardiol 2013;61-121-126). The strong working relationships built by emergency and cardiology physicians for chest pain and STEMI care are beginning to take shape in heart failure, too, Collins says. "We don't have something quite as time sensitive as STEMI and MI but I think more people realize [collaborating] makes sense from a clinical care and research perspective. You can't do these things in isolation and silos. Synergy is great and benefits everybody."

That prompted a meeting of minds in 2010, with representatives from EP, general cardiology, internal medicine and the emergency departments designing an evidence-based protocol to use in the emergency room. The protocol offered two detailed pathways for care, depending on duration of atrial fibrillation that was more or less than 48 hours.

“The pathways both had similar goals: to exclude any other serious condition that might require further evaluation or hospital admission,” Elmouchi says. They wanted to get the patient safely home, on proper medications if needed, and avoid unnecessary admissions.

Problem solved, right? Without a secure and timely handoff and follow-up, they discovered, emergency physicians balked at releasing patients. ”These were patients who were given a potentially serious diagnosis, being placed on new medications—including blood thinners—without a home to take care of them once they left the ED. That was a problem,” he recognizes in hindsight. 

To address the gap in care, they created that home: a cardiology-run atrial fibrillation clinic that guarantees a patient referred through the ED will be seen within 72 business hours. An EP supervises the clinic, with staffing from EP-trained mid-level providers. The clinic identifies comorbidities that may have prompted or exacerbated the patient’s atrial fibrillation, starts or re-evaluates anticoagulation therapy, educates the patient and his or her family about the condition, handles near-term treatment and sets up follow-up with a general cardiologist or EP.

“That has been a smashing success,” Elmouchi says. The number of patients seen at the clinic grew from 334 in 2011 to 484 in 2012. Referrals now also come internally from cardiology as well as from primary care physicians, putting 2013 on target to total between 700 and 800 patients.

Elmouchi and his colleagues are assessing outcomes such as readmission, stroke and medication adherence in a study of 100 patients seen in the ED and referred to the clinic. He describes the results, which have been submitted for publication, as “very positive.”

Stopping false starts

The mantra “time is muscle” drives home the importance of rapid reperfusion of patients presenting with STEMI. Based on evidence that delays lead to poorer outcomes, hospitals have implemented various strategies to meet or beat the benchmark of 90-minute door-to-balloon (D2B) time when PCI is used. The University of Michigan Health System (UMHS) in Ann Arbor, like many hospitals, developed a system designed to trim off minutes in the race between first medical contact and PCI. Its cardiologists and ED physicians worked out a protocol that allowed emergency medical service (EMS) staff and ED doctors to activate the cardiac catheterization laboratory before consulting with a cardiologist.

“The purpose was to not miss patients,” says Geoffrey D. Barnes, MD, a UMHS cardiology fellow. “We succeeded in that, but we found that it was a double-edged sword.  By offering ourselves very readily and easily, we received calls for things that didn’t fit.”

One study that evaluated activation rates of cath labs at 14 primary PCI hospitals reported 15 percent of activations by EMS technicians or ED physicians between 2008 and 2009 were canceled because the activation was inappropriate (Circulation online Dec. 6, 2011). Reinterpretation of the electrocardiogram accounted for 72 percent of the false activations and inappropriateness, such as patients being older than 90 years, terminal illness, refusal of treatment or other reasons, made up the remainder. 

False activation carries a price. An analysis of one healthcare system’s false activations between 2009 and 2010 placed the cost of crying wolf after hours at $700 (Circ Cardiovasc Qual Outcomes 2012;5:62-69). False activations also put a strain on cath lab staff and can disrupt lab scheduling.

At UMHS, Barnes and his cardiology and ED colleagues decided to examine trends in their facility after they began to detect what might be a false-activation creep. Reviewing data on STEMI patients who presented in the ED between 2007 and 2011, they found a steady increase in the rate of false activations, growing from 15 percent in 2007 to 40 percent in 2011. The mean door-to-balloon time dropped from 67 minutes to 55 minutes over that period.

Evidence in hand, the two departments revisited the process to identify ways to reduce the burden that false activations placed on the cath lab and patients without compromising the gains made in patient care. Their solution was to emphasize to ED personnel the availability of interventional fellows to review ambiguous cases. “They were always the first point of contact, but now the emergency department has been encouraged that if unsure, contact that person directly,” he says, rather than alert the whole team.

The new protocol required procedural but not staffing changes. Preliminary review suggests that D2B time has remained stable while false activations have “dropped pretty dramatically” with ED frequently contacting the cardiologist on call.

And like Elmouchi’s experience, the Michigan team found that “take two” gave them greater insights about their partners. “There has been an educational component,” Barnes says, based on sharing and harmonizing priorities to “find a solution that fits both [departments’] needs while maintaining good patient care.”