Reduced admission rates and resource utilization for chest pain patients using an electronic health record-embedded clinical pathway in the emergency department

Jasmeet S Dhaliwal; Foster Goss; Melanie D Whittington; Kelly Bookman; P Michael Ho; Richard Zane; Jennifer Wiler

doi:10.1002/emp2.12308

Reduced admission rates and resource utilization for chest pain patients using an electronic health record-embedded clinical pathway in the emergency department

J Am Coll Emerg Physicians Open. 2020 Nov 17;1(6):1602-1613. doi: 10.1002/emp2.12308. eCollection 2020 Dec.

Authors

Jasmeet S Dhaliwal¹, Foster Goss¹, Melanie D Whittington^{2

3}, Kelly Bookman¹, P Michael Ho^{3

4}, Richard Zane^{1

5}, Jennifer Wiler^{1

5}

Affiliations

¹ Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA.
² Skaggs School of Pharmacy and Pharmaceutical Sciences University of Colorado Anschutz Medical Campus Aurora Colorado USA.
³ Data Science to Patient Value Program University of Colorado School of Medicine Aurora Colorado USA.
⁴ Division of Cardiology Department of Medicine University of Colorado School of Medicine Aurora Colorado USA.
⁵ UCHealth CARE Innovation Center Aurora Colorado USA.

Abstract

Objectives: Assess the impact of an electronic health record (EHR)-embedded clinical pathway (ePATH) as compared to a paper-based clinical decision support tool on outcomes for patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS).

Methods: A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications to evaluate the impact of an EHR-embedded clinical pathway between April 2013 and July 2017. The intervention was implemented in February 2016 at a large academic tertiary hospital and compared to a local community hospital without the intervention. Eligible patients included adults (>18 years) presenting to the ED with chest pain who had a troponin ordered within 2 hours of arrival and a chest pain-related diagnosis. Patients with initial evidence of acute myocardial infarction were excluded. Primary outcomes included rates of admission and stress testing, hospital length of stay, and occurrence of major adverse cardiac events.

Results: On average, there were 170 chest pain visits per month at the intervention site. The frequency of hospital admission (unadjusted 28.2% to 20.9%, P < 0.001) and stress testing (unadjusted 15.8% to 12.7%, P < 0.001) significantly declined after ePATH implementation. After comparison with the comparator site, ePATH was still associated with a significant reduction in hospital admissions (-10.79%, P < 0.001) and stress testing (-6.05%, P < 0.001). Hospital length of stay and rates of major adverse cardiac events did not significantly change.

Conclusions: Implementation of ePATH for patients presenting to the ED with chest pain was associated with safe reductions in hospital admission and stress testing. ePATH appears to be an effective tool for implementing evidence-based guidelines for ED patients with chest pain.

Keywords: acute coronary syndrome; chest pain; clinical; critical pathways; decision support systems; electronic health record; exercise test; myocardial infarction.