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• W3136015095 abstract "HomeCirculation: Cardiovascular Quality and OutcomesVol. 14, No. 4Old Habits Die Hard Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBOld Habits Die HardDo Stable Patients With Non–ST-Segment–Elevation Myocardial Infarction Need an Intensive Care Unit? Andrea D. Thompson, MD, PhD and Thomas S. Valley, MD, MSc Andrea D. ThompsonAndrea D. Thompson https://orcid.org/0000-0001-8798-2024 Divison of Cardiovascular Medicine, Department of Internal Medicine (A.D.T.), University of Michigan, Ann Arbor. Search for more papers by this author and Thomas S. ValleyThomas S. Valley Thomas S. Valley, MD, MSc, University of Michigan, 2800 Plymouth Rd, Bldg 16-G028W, Ann Arbor, MI 48109. Email E-mail Address: [email protected] https://orcid.org/0000-0002-5766-4970 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine (T.S.V.), University of Michigan, Ann Arbor. Institute for Healthcare Policy and Innovation (T.S.V.), University of Michigan, Ann Arbor. Center for Bioethics and Social Sciences in Medicine (T.S.V.), University of Michigan, Ann Arbor. Search for more papers by this author Originally published24 Mar 2021https://doi.org/10.1161/CIRCOUTCOMES.120.007700Circulation: Cardiovascular Quality and Outcomes. 2021;14:e007700This article is a commentary on the followingElectronic Health Record Integration of Predictive Analytics to Select High-Risk Stable Patients With Non–ST-Segment–Elevation Myocardial Infarction for Intensive Care Unit AdmissionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 24, 2021: Ahead of Print See Article by Kansal et alThe inspirational speaker Jim Rohn would say, “Motivation is what gets you started. Habit is what keeps you going.” This maxim rings true for many of the daily routines we perform in medicine. For instance, when new locations of care are introduced within a hospital, their use is often motivated by the needs of their stakeholders. Chest pain units, for example, proliferated because they benefited patients (providing additional time and monitoring within the hospital to ensure they remain low risk for complications from chest pain), clinicians (freeing up emergency department space that was previously occupied for 6–12 hours for routine monitoring), and health care systems (care in these units may improve outcomes and reduce costs).1Yet, sometimes, these habits persist despite mounting evidence that suggests a need for change. For example, as health care transforms and certain locations of care become less important or even unnecessary, how do hospitals and health care systems demotivate their use? It is within this context that Kansal et al2 sought to change their hospital’s habit of intensive care use for patients with non–ST-segment–elevation myocardial infarction (NSTEMI) in this issue of Circulation: Cardiovascular Quality and Outcomes.Modern cardiac intensive care units (ICUs) trace their origins to high rates of arrhythmias after myocardial infarctions. As a result, cardiologists in the 1960s introduced continuous inpatient electrocardiographic monitoring.3 However, these devices were massive and required patients to be in close geographic proximity.4 Sixty years later, through the expansion of telemetry units, most NSTEMI patients no longer require ICU-level care. Modern ICU care is ideally targeted to patients who require close clinical supervision, such as those with shock or respiratory failure. Fortunately, early percutaneous intervention, highly trained clinicians, and widespread availability of telemetry have dramatically reduced the incidence of postmyocardial infarction complications, and most patients with NSTEMI are at low risk of mortality. In one large study of US patients with NSTEMI,5 most NSTEMI patients had a predicted mortality of <4%.Current evidence suggests that ICU care is not associated with improved clinical outcomes for NSTEMI patients.5,6 Yet, nearly half of NSTEMI patients continue to receive ICU care5 despite ICU care for NSTEMI being associated with a ≈$3000 increase in cost per hospitalization, independent of baseline factors, procedural variables, and complications.7For these reasons, Kansal et al integrated an algorithm into their hospital’s electronic health record to help emergency department clinicians identify NSTEMI patients at high risk of deterioration. Their hope was that in identifying high-risk patients, all others might be admitted to non-ICU locations, thereby decreasing the proportion of NSTEMI patients admitted to their ICU, from a historical average of about 40%. The authors described in detail the implementation of a best practice alert (BPA)–embedded risk score calculator Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU to support clinician decision-making.8 The ACTION-ICU score predicts the risk of developing the need for ICU care (defined as cardiac arrest, shock, high-grade atrioventricular block, respiratory failure, stroke, or death) by highlighting clinical features (signs or symptoms of heart failure, initial creatinine, heart rate, blood pressure), patient features (chronic lung disease, age, and prior revascularization), and features of ischemia (new ST-segment depression and initial troponin).8They theorized that integrating the ACTION-ICU score into the electronic health record would reduce ICU use. Yet, after implementation, the BPA was not associated with a change in ICU utilization. The intervention also did not affect clinical outcomes, including in-hospital mortality, ICU transfer, ICU length of stay, and hospital length of stay.Despite the negative outcome, this study yields several important findings. Key strengths of this work include its novelty and its real-world evaluation of an electronic health record–integrated predictive analytic. While many risk scores have been developed to influence ICU use, few have been implemented into routine practice. This study lays a foundation onto which future studies seeking to optimize ICU use can build.Yet, perhaps the most intriguing aspects of this study are in speculating about key decision points within the implementation of a BPA, learning from the author’s experience, and considering potential avenues for improvement going forward. Most clearly in this case, the intervention was limited by the low use of the BPA by emergency department clinicians. There may be several reasons for this, related to the BPA itself and to the clinicians using it.First, one might consider the ideal tradeoff between sensitivity and specificity at which to trigger a BPA. The investigators chose a seemingly sensitive trigger, a single positive troponin value within the emergency department, which led to a BPA in ≈1000 patients. Yet, only about 14% of these events were actually associated with a diagnosis of NSTEMI. Certainly, in the era of BPA fatigue, this decision may have diminished its use. Future studies might consider such tradeoffs, perhaps by studying a BPA triggered with an admission order for patients with a diagnosis of NSTEMI, which could improve specificity and thereby potentially improve utilization.Second, one might consider how the BPA was integrated into the habits of the end user—in this case, the emergency department clinician. The success of a BPA depends upon the end user’s motivation to incorporate the BPA into their daily practice and trust the BPA enough for it to influence their decision-making. In this instance, the investigators ran into several issues. First, the design of the BPA was such that clinicians often encountered it before seeing the patient. While the BPA could be snoozed until the next time the chart was opened, one wonders how this disruption of the natural workflow might have influenced its ongoing use. Tailoring the BPA to the natural decision-making workflow, such as an admission order, may also negate the need to allow providers to hide or cancel the BPA. Second, while all clinicians want to ensure the safety of their patients, clinicians may have differing motivations when it comes to ICU use. For example, an emergency department clinician may prioritize stabilization and efficient emergency department throughput while an intensive care clinician may prioritize stabilization, recovery, and efficient ICU bed allocation. The extent to which differences in these motivations might influence use of a BPA that may prioritize bed allocation over throughput is unclear. There is a clear need to better understand these motivations of ICU use. Studying a BPA tool across institutions which also collects feedback from physicians regarding why they chose to admit an NSTEMI patient to an ICU may help to uncover previously unanticipated medical needs and site-specific considerations that influence ICU utilization in NSTEMI patients.Finally, one might consider the level of risk clinicians are willing to accept when deciding whether to use ICU care. Kansal et al selected a fairly conservative approach when incorporating the risk score ACTION-ICU to guide triage decision-making. Since the ACTION-ICU does not provide a natural cutoff for which patients should receive ICU care, the authors relied on institutional consensus to establish a cutoff score of >5. This selection closely reflected the decision-making practices at their institution before implementation of the intervention, where the median ACTION-ICU score among patients admitted to an ICU was 7 (interquartile range, 4–9). Recently, Guimarães et al9 independently evaluated the ACTION-ICU score at another institution and found that a score of <8 had a negative predictive value of 90% for the development of complications requiring ICU care. Thus, selecting a higher cutoff could have been more likely to change clinical practice, albeit at the expense of potentially missing some NSTEMI patients at moderate risk.In a world where ICU care for NSTEMI, on average, provides no added benefit at increased cost,5–7 a central question remains—is there any role for ICU care in cardiac patients who do not have a current indication for ICU care? In other words, could an alternative study design avoided a risk score altogether and instead simply reminded emergency department clinicians of typical indications for ICU-level care? In the modern era of specialized cardiology and telemetry units, a total reevaluation of the types of patients admitted to ICU care may be necessary.Routine ICU care for NSTEMI patients is inconsistent with current evidence. It is associated with increased costs without improving outcomes. Still, the concerned clinician will worry about the risk of developing complications over the course of an NSTEMI admission that could result in the need for ICU care. Identifying the optimal timing and patient selection for ICU care in NSTEMI patients will require (1) an improved understanding of factors that currently influence medical decision-making across institutions and (2) the design of effective interventions. In this article, Kansal et al may have been unsuccessful at changing their local patterns of ICU use but still provide a detailed description of the type of quality improvement effort that is necessary to inform efforts to optimize ICU admission practices for NSTEMI patients. Our goal, as clinicians, must be to ensure that our motivations and habits align to guarantee patient safety while minimizing health care costs and allocating ICU beds thoughtfully.Disclosures Dr Thompson is supported by National Institutes of Health-National Heart, Lung, and Blood Institute (T32 HL007853) and the protein folding disease initiative and Michigan Biology of Cardiovascular Aging at the University of Michigan. Dr Thompson receives compensation as an editor for Merck Manuals. Dr Valley is supported by National Institutes of Health-National Heart, Lung, and Blood Institute (K23 HL140165) and Agency for Healthcare Research and Quality (R01 HS028038).FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Thomas S. Valley, MD, MSc, University of Michigan, 2800 Plymouth Rd, Bldg 16-G028W, Ann Arbor, MI 48109. Email [email protected]umich.eduReferences1. Goodacre S, Nicholl J, Dixon S, Cross E, Angelini K, Arnold J, Revill S, Locker T, Capewell SJ, Quinney D, et al.. Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care.BMJ. 2004; 328:254. doi: 10.1136/bmj.37956.664236.EECrossrefMedlineGoogle Scholar2. Kansal A, Green CL, Peterson ED, Newby LK, Wang TY, Sendak M, Balu S, Patel MR, Fanaroff AC. Electronic health record integration of predictive analytics to select high-risk stable patients with non–ST-segment–elevation myocardial infarction for intensive care unit admission.Circulation. 2020; 14:xxx–xxx. doi: 10.1161/CIRCOUTCOMES.120.007602Google Scholar3. Brown KW, Macmillan RL, Forbath N, Melgrano F, Scott JW. Coronary unit: an intensive-care centre for acute myocardial infarction.Lancet. 1963; 2:349–352. doi: 10.1016/s0140-6736(63)93011-3CrossrefMedlineGoogle Scholar4. Lown B, Fakhro AM, Hood WB, Thorn GW. The coronary care unit. New perspectives and directions.JAMA. 1967; 199:188–198.CrossrefMedlineGoogle Scholar5. Fanaroff AC, Peterson ED, Chen AY, Thomas L, Doll JA, Fordyce CB, Newby LK, Amsterdam EA, Kosiborod MN, de Lemos JA, et al.. Intensive care unit utilization and mortality among medicare patients hospitalized with non-ST-segment elevation myocardial infarction.JAMA Cardiol. 2017; 2:36–44. doi: 10.1001/jamacardio.2016.3855CrossrefMedlineGoogle Scholar6. Valley TS, Iwashyna TJ, Cooke CR, Sinha SS, Ryan AM, Yeh RW, Nallamothu BK. Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study.BMJ. 2019; 365:l1927. doi: 10.1136/bmj.l1927CrossrefMedlineGoogle Scholar7. Cowper PA, Knight JD, Davidson-Ray L, Peterson ED, Wang TY, Mark DB; TRANSLATE-ACS Investigators. Acute and 1-year hospitalization costs for acute myocardial infarction treated with percutaneous coronary intervention: results from the TRANSLATE-ACS registry.J Am Heart Assoc. 2019; 8:e011322. doi: 10.1161/JAHA.118.011322LinkGoogle Scholar8. Fanaroff AC, Chen AY, Thomas LE, Pieper KS, Garratt KN, Peterson ED, Newby LK, de Lemos JA, Kosiborod MN, Amsterdam EA, et al.. Risk score to predict need for intensive care in initially hemodynamically stable adults with non-ST-segment-elevation myocardial infarction.J Am Heart Assoc. 2018; 7:e008894. doi: 10.1161/JAHA.118.008894LinkGoogle Scholar9. Guimarães PO, Sampaio MC, Malafaia FL, Lopes RD, Fanaroff AC, de Barros E Silva PGM, Dos Santos TM, Okada MY, Mouallem ARE, Diniz MDS, et al.. Clinical outcomes and need for intensive care after non-ST-segment-elevation myocardial infarction.Eur J Intern Med. 2020; 76:58–63. doi: 10.1016/j.ejim.2020.02.008CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesElectronic Health Record Integration of Predictive Analytics to Select High-Risk Stable Patients With Non–ST-Segment–Elevation Myocardial Infarction for Intensive Care Unit AdmissionAman Kansal, et al. Circulation: Cardiovascular Quality and Outcomes. 2021;14 April 2021Vol 14, Issue 4Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.120.007700PMID: 33757308 Originally publishedMarch 24, 2021 Keywordsintensive care unitsEditorialschest painhospitalsPDF download Advertisement SubjectsHealth ServicesMyocardial InfarctionQuality and Outcomes" @default.
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