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