Acute coronary syndrome (ACS) remains a major healthcare challenge. Currently, the majority of patients with ACS have nonST‐segment (ST, part of an electrocardiogram between the QRS complex and the T wave) elevation myocardial infarction (MI) and unstable angina.1 Nevertheless, ST‐segment elevation MI is also an important cause of morbidity and mortality. In recent years, our understanding of ACS has improved as a result of several major advances based on results from multiple randomized clinical trials and registry analyses. The results of these analyses have influenced guidelines issued by professional societies and in some cases have become performance metrics. Therefore, it is particularly important for physicians involved in the care of patients with ACS to be aware of evolving treatment patterns (Table 1).

Case Study

A 64‐year‐old man presents to the emergency department with the chief complaint of chest pressure for the past 2 hours. His chest pressure began after he moved furniture in his home. He initially believed that a pulled muscle was the cause of the pain, but when the discomfort did not improve with rest and continued to worsen, he thought it best that his wife drive him to the emergency department, where he continues to have chest pressure. He has never had this symptom before. His past medical history is notable only for mild hypertension for which he takes hydrochlorothiazide 25 mg daily. Otherwise, he has been healthy.

Clinical Presentation and Risk Assessment

The clinical presentation of ACS is not always straightforward. Although physicians frequently inquire about chest pain, the pain often manifests as chest heaviness or chest pressure. Additionally, some patients have a more atypical presentation, where the predominant symptom of acute coronary ischemia is dyspnea or extreme fatigue. These atypical presentations are believed to be somewhat more common in women and in the elderly, but it is important to realize that they can occur in any patient. Nausea, vomiting, or diaphoresis may accompany these symptoms or occur in isolation. Chest discomfort radiating to the jaw, neck, or left arm may be present, but is not necessary to the diagnosis. Thus, we see a variety of symptoms presenting in a patient with ACS.

This varied presentation makes objective assessment of ACS particularly important. To inform assessment, biomarkers have emerged as a quick and effective tool to help with the diagnosis of ACS. In particular, troponin measurement is important and serial troponin measurement is useful to exclude myonecrosis. It should be noted that the initial troponin level may be normal during the early stages of ACS. A bedside troponin measurement can be useful for rapid identification of myocardial damage. Quantitative troponin measurement also adds value, as higher levels of troponin are associated with progressively worse outcomes, including mortality (Figure 1). Although a number of biomarkers are available, the most important commonly used at present is troponin.0, 0, 0, 0

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

In addition to biomarkers, the electrocardiogram (ECG) remains extremely important in diagnosis and risk stratification. In a moderate‐level emergency department, the triage nurse should obtain a 12‐lead ECG for a patient with a history that is suspicious for coronary ischemia, and ask the attending physician to review the ECG immediately. If there is ST‐segment elevation or any new or presumed new left bundle‐branch block, the patient should be triaged to the ST‐segment elevation MI pathway of care. If there is ST‐segment depression or marked T‐wave inversion, this greatly raises the suspicion for nonST‐segment elevation MI or unstable angina. The presence of any of these features on the ECG places the patient at markedly elevated risk of short‐term ischemic complications.

A protocol should be in place for rapid treatment of patients with ST‐segment elevation MI.2 If the hospital has 24/7 percutaneous coronary intervention (PCI) capability, the catheterization lab should be immediately activated and the patient should proceed to primary PCI. The goal door‐to‐balloon time is 90 minutes or less. A patient who presents to a hospital without primary PCI capability should receive either fibrinolysis or be transferred to a center that can perform primary PCI. If fibrinolytic therapy is planned, it is essential that the patient not have any absolute contraindications to fibrinolytic therapy. Fibrinolysis should be administered within 30 minutes of patient contact. If transfer for primary PCI is planned, it is important that systems to support the transfer are in place so that the time from first medical contact to PCI does not exceed 90 minutes. As a practical point, it can be difficult to achieve these short transfer times in many geographic regions of the United States. However, with organized systems of care, it is certainly possible to have effective transfer systems and to achieve a short door‐to‐balloon time.3

If the patient does not have ST‐segment elevation MI, the next step depends on the patient's level of risk, where risk stratification is particularly important. As mentioned above, troponin measurement and the ECG are both essential aspects of risk stratification, but they alone are not sufficient to establish risk. It is recommended that an objective risk tool also be used. This is especially important because the patient can be initially troponin‐negative and have a normal ECG but still be at high risk for ischemic complications. The TIMI risk score (Table 2) is 1 of a number of resources that can help determine whether patients are at high risk for short‐term ischemic complications using means more objective than the eyeball test (Table 3).

Table 2.Components of TIMI Risk Score for UA/NSTEMI

Related data were reported by Antman et al.28 Abbreviations: ASA, acetylsalicylic acid; CAD, coronary artery disease; ST, part of an electrocardiogram between the QRS complex and the T wave; TIMI, Thrombolysis in Myocardial Infarction; UA/NSTEMI, unstable angina/nonST‐segment elevation myocardial infarction.
Historical
Age 65 year
3 CAD risk factors
Family history, hypertension, hypercholesterolemia, diabetes, active smoker
Known CAD (stenosis 50%)
ASA use in past 7 days
At presentation
Recent (24 hours) severe angina
Elevated cardiac markers
ST deviation 0.5 mm
Risk score = total points, range: 07

Table 3.Risk of Cardiac Events by 14 Days in TIMI 11B

Risk Score	Death or MI (%)	Death, MI, or Urgent Revascularization (%)
NOTE: Entry criteria: MI or NSTEMI defined as ischemic pain at rest within past 24 hours, with evidence of CAD (ST‐segment deviation or positive marker). Related data were reported by Antman et al.28 Abbreviations: CAD, coronary artery disease; MI, myocardial infarction; NSTEMI, nonST‐segment elevation myocardial infarction; ST, part of an electrocardiogram between the QRS complex and the T wave; TIMI, Thrombolysis in Myocardial Infarction.
0/1	3	5
2	3	8
3	5	13
4	7	20
5	12	26
6/7	19	41

Delineation of the coronary anatomy in the catheterization lab is warranted for patients judged to be at high risk on the basis of the TIMI risk score, which would include most patients with elevated troponin or ST‐segment deviation. Many patients will undergo PCI on the basis of those test results and a smaller percentage might undergo coronary artery bypass grafting (CABG). Additionally, a sizeable minority of patients will be managed medically. This latter group is challenging because it consists of patients who have either trivial coronary artery disease or extensive coronary artery disease not amenable to revascularization and who have either a very low or very high risk of ischemic complications.

Even though catheterization may not be necessary, further evaluation is warranted in patients with ACS deemed to be at low risk. Typically, some form of functional assessment is indicated. In patients who are able to exercise, this would consist of exercise stress testing, often with an imaging modality. If the stress test is abnormal, cardiac catheterization is often the next step.

Discussion

Patients with ACS present several challenges in management. Risk stratification is particularly important for nonST‐segment elevation ACS and requires thoughtful evaluation by the physician. Additionally, the large amount of new data and guideline updates create a rapidly evolving field, making it difficult to keep abreast of new developments. Physicians of patients with ACS need to be aware of these key developments so that they can provide optimal care to their patients with potentially life‐threatening ACS.

Acute coronary syndrome (ACS) remains a major healthcare challenge. Currently, the majority of patients with ACS have nonST‐segment (ST, part of an electrocardiogram between the QRS complex and the T wave) elevation myocardial infarction (MI) and unstable angina.1 Nevertheless, ST‐segment elevation MI is also an important cause of morbidity and mortality. In recent years, our understanding of ACS has improved as a result of several major advances based on results from multiple randomized clinical trials and registry analyses. The results of these analyses have influenced guidelines issued by professional societies and in some cases have become performance metrics. Therefore, it is particularly important for physicians involved in the care of patients with ACS to be aware of evolving treatment patterns (Table 1).

Case Study

A 64‐year‐old man presents to the emergency department with the chief complaint of chest pressure for the past 2 hours. His chest pressure began after he moved furniture in his home. He initially believed that a pulled muscle was the cause of the pain, but when the discomfort did not improve with rest and continued to worsen, he thought it best that his wife drive him to the emergency department, where he continues to have chest pressure. He has never had this symptom before. His past medical history is notable only for mild hypertension for which he takes hydrochlorothiazide 25 mg daily. Otherwise, he has been healthy.

Clinical Presentation and Risk Assessment

The clinical presentation of ACS is not always straightforward. Although physicians frequently inquire about chest pain, the pain often manifests as chest heaviness or chest pressure. Additionally, some patients have a more atypical presentation, where the predominant symptom of acute coronary ischemia is dyspnea or extreme fatigue. These atypical presentations are believed to be somewhat more common in women and in the elderly, but it is important to realize that they can occur in any patient. Nausea, vomiting, or diaphoresis may accompany these symptoms or occur in isolation. Chest discomfort radiating to the jaw, neck, or left arm may be present, but is not necessary to the diagnosis. Thus, we see a variety of symptoms presenting in a patient with ACS.

This varied presentation makes objective assessment of ACS particularly important. To inform assessment, biomarkers have emerged as a quick and effective tool to help with the diagnosis of ACS. In particular, troponin measurement is important and serial troponin measurement is useful to exclude myonecrosis. It should be noted that the initial troponin level may be normal during the early stages of ACS. A bedside troponin measurement can be useful for rapid identification of myocardial damage. Quantitative troponin measurement also adds value, as higher levels of troponin are associated with progressively worse outcomes, including mortality (Figure 1). Although a number of biomarkers are available, the most important commonly used at present is troponin.0, 0, 0, 0

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

In addition to biomarkers, the electrocardiogram (ECG) remains extremely important in diagnosis and risk stratification. In a moderate‐level emergency department, the triage nurse should obtain a 12‐lead ECG for a patient with a history that is suspicious for coronary ischemia, and ask the attending physician to review the ECG immediately. If there is ST‐segment elevation or any new or presumed new left bundle‐branch block, the patient should be triaged to the ST‐segment elevation MI pathway of care. If there is ST‐segment depression or marked T‐wave inversion, this greatly raises the suspicion for nonST‐segment elevation MI or unstable angina. The presence of any of these features on the ECG places the patient at markedly elevated risk of short‐term ischemic complications.

A protocol should be in place for rapid treatment of patients with ST‐segment elevation MI.2 If the hospital has 24/7 percutaneous coronary intervention (PCI) capability, the catheterization lab should be immediately activated and the patient should proceed to primary PCI. The goal door‐to‐balloon time is 90 minutes or less. A patient who presents to a hospital without primary PCI capability should receive either fibrinolysis or be transferred to a center that can perform primary PCI. If fibrinolytic therapy is planned, it is essential that the patient not have any absolute contraindications to fibrinolytic therapy. Fibrinolysis should be administered within 30 minutes of patient contact. If transfer for primary PCI is planned, it is important that systems to support the transfer are in place so that the time from first medical contact to PCI does not exceed 90 minutes. As a practical point, it can be difficult to achieve these short transfer times in many geographic regions of the United States. However, with organized systems of care, it is certainly possible to have effective transfer systems and to achieve a short door‐to‐balloon time.3

If the patient does not have ST‐segment elevation MI, the next step depends on the patient's level of risk, where risk stratification is particularly important. As mentioned above, troponin measurement and the ECG are both essential aspects of risk stratification, but they alone are not sufficient to establish risk. It is recommended that an objective risk tool also be used. This is especially important because the patient can be initially troponin‐negative and have a normal ECG but still be at high risk for ischemic complications. The TIMI risk score (Table 2) is 1 of a number of resources that can help determine whether patients are at high risk for short‐term ischemic complications using means more objective than the eyeball test (Table 3).

Table 2.Components of TIMI Risk Score for UA/NSTEMI

Related data were reported by Antman et al.28 Abbreviations: ASA, acetylsalicylic acid; CAD, coronary artery disease; ST, part of an electrocardiogram between the QRS complex and the T wave; TIMI, Thrombolysis in Myocardial Infarction; UA/NSTEMI, unstable angina/nonST‐segment elevation myocardial infarction.
Historical
Age 65 year
3 CAD risk factors
Family history, hypertension, hypercholesterolemia, diabetes, active smoker
Known CAD (stenosis 50%)
ASA use in past 7 days
At presentation
Recent (24 hours) severe angina
Elevated cardiac markers
ST deviation 0.5 mm
Risk score = total points, range: 07

Table 3.Risk of Cardiac Events by 14 Days in TIMI 11B

Risk Score	Death or MI (%)	Death, MI, or Urgent Revascularization (%)
NOTE: Entry criteria: MI or NSTEMI defined as ischemic pain at rest within past 24 hours, with evidence of CAD (ST‐segment deviation or positive marker). Related data were reported by Antman et al.28 Abbreviations: CAD, coronary artery disease; MI, myocardial infarction; NSTEMI, nonST‐segment elevation myocardial infarction; ST, part of an electrocardiogram between the QRS complex and the T wave; TIMI, Thrombolysis in Myocardial Infarction.
0/1	3	5
2	3	8
3	5	13
4	7	20
5	12	26
6/7	19	41

Delineation of the coronary anatomy in the catheterization lab is warranted for patients judged to be at high risk on the basis of the TIMI risk score, which would include most patients with elevated troponin or ST‐segment deviation. Many patients will undergo PCI on the basis of those test results and a smaller percentage might undergo coronary artery bypass grafting (CABG). Additionally, a sizeable minority of patients will be managed medically. This latter group is challenging because it consists of patients who have either trivial coronary artery disease or extensive coronary artery disease not amenable to revascularization and who have either a very low or very high risk of ischemic complications.

Even though catheterization may not be necessary, further evaluation is warranted in patients with ACS deemed to be at low risk. Typically, some form of functional assessment is indicated. In patients who are able to exercise, this would consist of exercise stress testing, often with an imaging modality. If the stress test is abnormal, cardiac catheterization is often the next step.

Discussion

Patients with ACS present several challenges in management. Risk stratification is particularly important for nonST‐segment elevation ACS and requires thoughtful evaluation by the physician. Additionally, the large amount of new data and guideline updates create a rapidly evolving field, making it difficult to keep abreast of new developments. Physicians of patients with ACS need to be aware of these key developments so that they can provide optimal care to their patients with potentially life‐threatening ACS.

Acute coronary syndrome (ACS) remains a major healthcare challenge. Currently, the majority of patients with ACS have nonST‐segment (ST, part of an electrocardiogram between the QRS complex and the T wave) elevation myocardial infarction (MI) and unstable angina.1 Nevertheless, ST‐segment elevation MI is also an important cause of morbidity and mortality. In recent years, our understanding of ACS has improved as a result of several major advances based on results from multiple randomized clinical trials and registry analyses. The results of these analyses have influenced guidelines issued by professional societies and in some cases have become performance metrics. Therefore, it is particularly important for physicians involved in the care of patients with ACS to be aware of evolving treatment patterns (Table 1).

Case Study

A 64‐year‐old man presents to the emergency department with the chief complaint of chest pressure for the past 2 hours. His chest pressure began after he moved furniture in his home. He initially believed that a pulled muscle was the cause of the pain, but when the discomfort did not improve with rest and continued to worsen, he thought it best that his wife drive him to the emergency department, where he continues to have chest pressure. He has never had this symptom before. His past medical history is notable only for mild hypertension for which he takes hydrochlorothiazide 25 mg daily. Otherwise, he has been healthy.

Clinical Presentation and Risk Assessment

The clinical presentation of ACS is not always straightforward. Although physicians frequently inquire about chest pain, the pain often manifests as chest heaviness or chest pressure. Additionally, some patients have a more atypical presentation, where the predominant symptom of acute coronary ischemia is dyspnea or extreme fatigue. These atypical presentations are believed to be somewhat more common in women and in the elderly, but it is important to realize that they can occur in any patient. Nausea, vomiting, or diaphoresis may accompany these symptoms or occur in isolation. Chest discomfort radiating to the jaw, neck, or left arm may be present, but is not necessary to the diagnosis. Thus, we see a variety of symptoms presenting in a patient with ACS.

This varied presentation makes objective assessment of ACS particularly important. To inform assessment, biomarkers have emerged as a quick and effective tool to help with the diagnosis of ACS. In particular, troponin measurement is important and serial troponin measurement is useful to exclude myonecrosis. It should be noted that the initial troponin level may be normal during the early stages of ACS. A bedside troponin measurement can be useful for rapid identification of myocardial damage. Quantitative troponin measurement also adds value, as higher levels of troponin are associated with progressively worse outcomes, including mortality (Figure 1). Although a number of biomarkers are available, the most important commonly used at present is troponin.0, 0, 0, 0

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

In addition to biomarkers, the electrocardiogram (ECG) remains extremely important in diagnosis and risk stratification. In a moderate‐level emergency department, the triage nurse should obtain a 12‐lead ECG for a patient with a history that is suspicious for coronary ischemia, and ask the attending physician to review the ECG immediately. If there is ST‐segment elevation or any new or presumed new left bundle‐branch block, the patient should be triaged to the ST‐segment elevation MI pathway of care. If there is ST‐segment depression or marked T‐wave inversion, this greatly raises the suspicion for nonST‐segment elevation MI or unstable angina. The presence of any of these features on the ECG places the patient at markedly elevated risk of short‐term ischemic complications.

A protocol should be in place for rapid treatment of patients with ST‐segment elevation MI.2 If the hospital has 24/7 percutaneous coronary intervention (PCI) capability, the catheterization lab should be immediately activated and the patient should proceed to primary PCI. The goal door‐to‐balloon time is 90 minutes or less. A patient who presents to a hospital without primary PCI capability should receive either fibrinolysis or be transferred to a center that can perform primary PCI. If fibrinolytic therapy is planned, it is essential that the patient not have any absolute contraindications to fibrinolytic therapy. Fibrinolysis should be administered within 30 minutes of patient contact. If transfer for primary PCI is planned, it is important that systems to support the transfer are in place so that the time from first medical contact to PCI does not exceed 90 minutes. As a practical point, it can be difficult to achieve these short transfer times in many geographic regions of the United States. However, with organized systems of care, it is certainly possible to have effective transfer systems and to achieve a short door‐to‐balloon time.3

If the patient does not have ST‐segment elevation MI, the next step depends on the patient's level of risk, where risk stratification is particularly important. As mentioned above, troponin measurement and the ECG are both essential aspects of risk stratification, but they alone are not sufficient to establish risk. It is recommended that an objective risk tool also be used. This is especially important because the patient can be initially troponin‐negative and have a normal ECG but still be at high risk for ischemic complications. The TIMI risk score (Table 2) is 1 of a number of resources that can help determine whether patients are at high risk for short‐term ischemic complications using means more objective than the eyeball test (Table 3).

Table 2.Components of TIMI Risk Score for UA/NSTEMI

Related data were reported by Antman et al.28 Abbreviations: ASA, acetylsalicylic acid; CAD, coronary artery disease; ST, part of an electrocardiogram between the QRS complex and the T wave; TIMI, Thrombolysis in Myocardial Infarction; UA/NSTEMI, unstable angina/nonST‐segment elevation myocardial infarction.
Historical
Age 65 year
3 CAD risk factors
Family history, hypertension, hypercholesterolemia, diabetes, active smoker
Known CAD (stenosis 50%)
ASA use in past 7 days
At presentation
Recent (24 hours) severe angina
Elevated cardiac markers
ST deviation 0.5 mm
Risk score = total points, range: 07

Table 3.Risk of Cardiac Events by 14 Days in TIMI 11B

Risk Score	Death or MI (%)	Death, MI, or Urgent Revascularization (%)
NOTE: Entry criteria: MI or NSTEMI defined as ischemic pain at rest within past 24 hours, with evidence of CAD (ST‐segment deviation or positive marker). Related data were reported by Antman et al.28 Abbreviations: CAD, coronary artery disease; MI, myocardial infarction; NSTEMI, nonST‐segment elevation myocardial infarction; ST, part of an electrocardiogram between the QRS complex and the T wave; TIMI, Thrombolysis in Myocardial Infarction.
0/1	3	5
2	3	8
3	5	13
4	7	20
5	12	26
6/7	19	41

Delineation of the coronary anatomy in the catheterization lab is warranted for patients judged to be at high risk on the basis of the TIMI risk score, which would include most patients with elevated troponin or ST‐segment deviation. Many patients will undergo PCI on the basis of those test results and a smaller percentage might undergo coronary artery bypass grafting (CABG). Additionally, a sizeable minority of patients will be managed medically. This latter group is challenging because it consists of patients who have either trivial coronary artery disease or extensive coronary artery disease not amenable to revascularization and who have either a very low or very high risk of ischemic complications.

Even though catheterization may not be necessary, further evaluation is warranted in patients with ACS deemed to be at low risk. Typically, some form of functional assessment is indicated. In patients who are able to exercise, this would consist of exercise stress testing, often with an imaging modality. If the stress test is abnormal, cardiac catheterization is often the next step.

Discussion

Patients with ACS present several challenges in management. Risk stratification is particularly important for nonST‐segment elevation ACS and requires thoughtful evaluation by the physician. Additionally, the large amount of new data and guideline updates create a rapidly evolving field, making it difficult to keep abreast of new developments. Physicians of patients with ACS need to be aware of these key developments so that they can provide optimal care to their patients with potentially life‐threatening ACS.

Addressing quality improvement (QI) for the management of acute coronary syndrome (ACS) at the institutional level is essential for supporting hospitalists and other clinicians as they manage patients with ACS and achieve desired institutional outcomes. This systems approach may identify institution‐specific barriers to quality care, including those that affect the complex management of ACS. Having a firsthand view of patient care puts the hospitalist in a good position to assess the viability of existing processes and protocols that support care. Indeed, the hospitalist has a vested interest in improving systems of care as these systems directly affect the hospitalist's practice. This unique perspective gives the hospitalist an opportunity to facilitate systems change within the institution and to become an integral participant or leader in QI initiatives.

An increasing number of hospitalists are providing critical care at secondary and tertiary care facilities, driven by a shortage of intensivists in the United States. In a 20052006 survey about 75% of hospitalists reported they provide critical care services as part of their practice,1 and this would include care of patients with ACS. The Society of Hospital Medicine (SHM) has developed core competencies that recognize the important role of hospitalists in leading or participating in QI teams for ACS.2 Hospitalists must also be able to apply evidenced‐based outcomes data to support these initiatives.3 Hospitalist competencies for ACS include protocol development that supports the timely diagnosis and treatment of ACS, evaluation of resource utilization, staff education of secondary prevention measures, and implementation of measures to ensure institutional compliance with national quality standards (Table 1).2 Most hospital medicine groups will be expected to contribute to systems improvement, an area where hospitalists have already shown leadership for QI protocols related to glycemic control and venous thromboembolism prophylaxis. Hospitalists were prominent in targeting QI in these areas even though these QI initiatives could easily have been spearheaded by specialists.46

QI Basics

QI at the institutional level addresses systems of care rather than individual performance, targeting both institutional performance and use of resources.3 QI is a continuous process in which practices and procedures related to patient management are regularly assessed to ascertain whether a quality gap exists. This in turn may lead to new processes, protocols, and algorithms that help the institution and clinicians meet benchmarks of quality care.

QI starts when an existing gap is recognizedthe gap between the scientific understanding of optimal care and actual patient care. The goal is to narrow or close this gap so that each patient receives optimal care. Underlying any QI initiative are 2 essential concepts. First, improvement requires systems changeany system will produce exactly what it is designed to produce. For example, if procedures are not in place to educate patients about smoking cessation while they are hospitalized, it is unlikely that the majority will routinely receive this counseling before they are discharged. Second, less is moreproductivity is not destroyed but often is enhanced by initiating simple and practical change. If a patient arrives in the emergency department (ED) with chest pain, instituting an order set that reminds clinicians to start antiplatelet therapy or a beta blocker can lessen the chance that these medications will be overlooked, especially when the patient transitions between providers or services within the hospital.

SHM has identified 7 essential elements of any QI initiative, and these are applicable to the care of the ACS patient (Table 2).7 These elements highlight the need for institutional support and teamwork that support standardized measures and tools specific to issues in ACS management. These issues include: (1) rapidly identifying a patient with ACS and initiating a care plan when the patient is admitted; (2) encouraging good communication between providers; (3) symptom management; (4) medication safety, polypharmacy, and medication reconciliation; (5) patient and caregiver education; (6) safe discharge and transitions in care; and (7) meeting Centers for Medicare and Medicaid Services (CMS) core measures.

Tools such as process flow mapping and run charts can reveal quality gaps and indicate if process improvements are leading to stated objectives. Process flow mapping makes it possible to identify and visualize quality gaps that might otherwise be hidden and to identify their source or cause. Process mapping documents discrete steps within the flow and usually requires input from multiple disciplines; this information can guide a multidisciplinary QI team when formulating interventions for process improvement.7 Figure 1 shows process flow mapping for the early identification of ST‐segment elevation myocardial infarction (STEMI) when hospitalists have open access to activate the catheterization laboratory (cath lab). The time from door‐to‐balloon is a critical factor in reducing STEMI‐related morbidity8; processes that overcome delays to percutaneous coronary intervention (PCI) and improve communication can have a direct benefit on patient outcomes.

Figure 1

A run chart is a commonly used tool which graphically depicts progress in attaining a goal over time, before and after an intervention. Figure 2a is a run chart that shows the average time to PCI following implementation of an order set designed to support the use of a risk stratification tool for the early diagnosis of STEMI. In this case, the average time to PCI is observed to decrease over time, but still lags behind the desired goal of less than 90 minutes. This run chart indicates that further work is needed to improve the process of identifying patients with STEMI. Figure 2b shows the number of eligible STEMI patients who received aspirin at discharge following implementation of a discharge order set; here, the hospital has clearly made progress toward meeting this CMS core measure.

Figure 2

The following is a case study that illustrates how the implementation of standardized measures and tools can help hospitalists and other clinicians achieve quality measures in the care of a patient with ACS.

Measuring Performance Relative to ACS

Two agencies promulgating quality measures for hospital inpatient care are The Joint Commission (TJC) and the CMS. TJC and CMS jointly established core measures for patients with acute myocardial infarction (AMI) and these are considered key indicators of quality, evidence‐based care. As outlined in Table 3, the TJC/CMS recommendations promote, unless contraindicated, a minimum standard of care for patients with AMI.9, 10 Public reporting of institutional core measure performance has led to an intense focus on improving these metrics.

On a national level, TJC documented performance improvement from 2002 to 2008 for each of the core measures. Compliance with smoking cessation counseling improved the most, rising from 67% to almost 99%. In 2008, a combined measure of all individual core measures indicated that, overall, care of heart attack patients is of high quality. Hospitals delivered evidenced‐based care in 96.7% of the opportunities they had to provide this care. Compliance related to oral medications was also good (95%); however, a closer look at other individual measures shows that improvement is needed to reduce the time to fibrinolysis (52.4% compliance rate for 30 minutes or less) and time to primary PCI (81.6% compliance rate for 90 minutes or less).11

Financial incentives are tied to QI measures including those from CMS. At present, this system is in the pay‐for‐reporting phase, in which institutions are penalized for not reporting quality metrics for the CMS core measures. It is likely that, to further incentivize institutions to meet quality benchmarks, this will be expanded to a pay‐for‐performance system (eg, differential payments for readmissions or different payment scales based on prior performance). Public disclosure of institutional performance relative to ACS and other medical conditions is available through the HHS.gov website (www.hospitalcompare.hhs.gov), which compares performance between hospitals and provides a clear business motivation for institutions to improve and provide high quality care.

Two other reporting systems should be noted. The CMS Physician Quality Reporting Initiative (PQRI) includes physician‐related quality measures specific to ACS12 that overlap with institution‐level CMS core measures with regard to prescribing ACS medications. Payments associated with the PQRI are currently a small financial factor for hospitalists, but will likely grow as quality initiatives develop overall. The Hospital Care Quality Information From the Consumer Perspective (HCAHPS) initiative, also from CMS, strives to capture patients' perspectives on hospital care through a standardized survey. The goals are to collect data that can be used to compare hospital performance, create an incentive for QI through public disclosure of results, and increase transparency regarding the quality of hospital care.13 However, the focus is not ACS‐specific. Patients are queried about communication with hospital staff, communication about medications, and information about discharge, all areas of concern for the hospitalist in general that have been identified as areas for improvement relative to ACS.

Special QI Issues in ACS Management for the Hospitalist

Coordination is especially important for patients with ACS because their care is so complex. Seamless transitions promote safe care as the patient moves from the ED, cath lab, recovery unit, medical floor, and discharge through the transition to primary care. Poor communication between clinicians during these transitions may result in delayed or overlooked treatment and other medical errors. Implementing an institutional system of care may overcome communication barriers and help ensure the institution meets its quality benchmarks, such as the CMS core measures. Standard order sets and protocols identify the steps and components needed to manage ACS. At admission, these measures promote early assessment of patient risk, triage to early intervention, medication reconciliation, and communication between stakeholders such as the hospitalist, cardiologist, and the cath lab.15, 16 During hospitalization, they help assure ongoing risk assessment and early consideration of discharge planning, culminating in discharge and the transition back to primary care.

A recent guideline update8 focused attention on the coordination of care between institutions and the critical importance of rapid triage for patients who need primary PCI and transfer from a non‐PCI to a PCI‐capable institution. The decision to transfer rests on multiple factors and requires rapid decision making on the part of clinicians. Time to reperfusion is shown to have a direct effect on patient outcomes. Established protocols within a non‐PCI facility can support timely transfer to a PCI‐capable facility if indicated. Factors such as the patient's mortality risk, the risk of bleeding from fibrinolytic therapy, duration of symptoms, and the time for transport to a PCI facility all must be considered. It is recognized that a regional system of STEMI care best supports collaborative efforts between institutions and community resources that support QI efforts.

Transitions in care, and particularly discharge, are areas with identified gaps in quality care17, 18 for which improvement has been pursued on an institutional level. Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) seeks to improve the care of patients during the transition from inpatient to outpatient care, and focuses on elderly patients identified to be at high‐risk for adverse events during this transition.19 The goal is to improve outcomes related to 30‐day readmission rates, patient satisfaction, communication between inpatient and outpatient providers, identification of high‐risk patients who need intervention to reduce risk, and patient education about their risk for an adverse event. BOOST addresses these outcomes at an institutional level by offering resources related to project management, data collection, tools for clinicians and patients, and participating mentor institutions. These resources help an institution assess its readiness for change, identify quality gaps, promote teamwork, and guide the implementation and subsequent evaluation of process improvements. Specific tools for clinicians also support institutional goals for teamwork and communication, creating an environment for safe transitions. Both BOOST19 and the adaptable Transitions Tool from the SHM20 provide a framework for understanding processes that involve multiple departments and stakeholders, breaking complex processes into discrete parts for which quality gaps can be identified and change instituted to improve care. A checklist can also be a useful tool for ensuring specific issues are addressed during transitions in care. SHM developed a checklist for hospitalist use that lists elements of a discharge summary for patients with ACS (Table 4).21

Staff and patient education is also an area that can benefit from evaluation. Clinicians from multiple disciplines are stakeholders in QI and they should receive education about its purpose and goals. Usually institutions will have a QI methodology in place, and this should be conveyed to the members of the ACS team. Staff education about ACS should be tailored to each specialty, be institution‐specific, current, and comprehensive, and include methods for assessing the learner. Education should be easily available (eg, on the Internet or via an electronic format), interactive, case‐based, and mandatory. For patients, education should be available in languages other than English and identify community resources and opportunities for additional outpatient education. The value of any educational program should be assessed to measure learner participation, satisfaction, and comprehension.

Gathering metrics and generating objective evidence of change is critical to QI; quantifying improvement (or lack thereof) must be done to determine whether the changes implemented improve care and ultimately whether desired outcomes are met. Metrics should be meaningful, associated with standards of care (eg, CMS core measures), and carefully chosen to reflect current practice. CMS core measures are a good target for collecting metrics to assess an institution's performance relative to ACS (Table 3). The Specifications Manual for National and Hospital Inpatient Quality Measures10 from TJC and CMS identifies the data elements needed for reporting. Other metrics not specified as core measures are worthy of measurement because they are considered the standard of care for patients with ACS (Table 5). The metrics shown in Tables 3 and 5 assume that all patients are eligible for core‐measure or standard‐of‐care medications and procedures. Because some measures are contraindicated in some patients, it is more meaningful to measure the percentage of patients without a contraindication who receive the measure. If a measure is contraindicated, the patient's medical record must include supporting documentation indicating why a core measure was not met. To be objective and reduce bias regarding the effectiveness of QI measures, data collection is best done prospectively. If necessary, periodic assessments against performance measures (institutional, government, professional association) should be made to support timely intervention. Run charts can be particularly useful here, measuring change over time to identify trends or an intervention that supported, did not affect, or was a barrier to the desired change.

Conclusion

Each hospitalist can have an impact on ACS care systemwide. Hospitalists are on the front line of care and have a unique perspective on patients as they are transitioned through the hospital stay and on how an institution handles patient care overall. They experience firsthand the challenges presented by poor communication between providers, patients, and their families. They can offer breadth of experience and perspective when assessing processes linked to patient care and can be instrumental in ensuring each patient experiences safe transitions during the hospital stay. Hospitalists should participate in QI initiatives for ACS and should consider opportunities to take the lead on these initiatives within their institutions.

Addressing quality improvement (QI) for the management of acute coronary syndrome (ACS) at the institutional level is essential for supporting hospitalists and other clinicians as they manage patients with ACS and achieve desired institutional outcomes. This systems approach may identify institution‐specific barriers to quality care, including those that affect the complex management of ACS. Having a firsthand view of patient care puts the hospitalist in a good position to assess the viability of existing processes and protocols that support care. Indeed, the hospitalist has a vested interest in improving systems of care as these systems directly affect the hospitalist's practice. This unique perspective gives the hospitalist an opportunity to facilitate systems change within the institution and to become an integral participant or leader in QI initiatives.

An increasing number of hospitalists are providing critical care at secondary and tertiary care facilities, driven by a shortage of intensivists in the United States. In a 20052006 survey about 75% of hospitalists reported they provide critical care services as part of their practice,1 and this would include care of patients with ACS. The Society of Hospital Medicine (SHM) has developed core competencies that recognize the important role of hospitalists in leading or participating in QI teams for ACS.2 Hospitalists must also be able to apply evidenced‐based outcomes data to support these initiatives.3 Hospitalist competencies for ACS include protocol development that supports the timely diagnosis and treatment of ACS, evaluation of resource utilization, staff education of secondary prevention measures, and implementation of measures to ensure institutional compliance with national quality standards (Table 1).2 Most hospital medicine groups will be expected to contribute to systems improvement, an area where hospitalists have already shown leadership for QI protocols related to glycemic control and venous thromboembolism prophylaxis. Hospitalists were prominent in targeting QI in these areas even though these QI initiatives could easily have been spearheaded by specialists.46

QI Basics

QI at the institutional level addresses systems of care rather than individual performance, targeting both institutional performance and use of resources.3 QI is a continuous process in which practices and procedures related to patient management are regularly assessed to ascertain whether a quality gap exists. This in turn may lead to new processes, protocols, and algorithms that help the institution and clinicians meet benchmarks of quality care.

QI starts when an existing gap is recognizedthe gap between the scientific understanding of optimal care and actual patient care. The goal is to narrow or close this gap so that each patient receives optimal care. Underlying any QI initiative are 2 essential concepts. First, improvement requires systems changeany system will produce exactly what it is designed to produce. For example, if procedures are not in place to educate patients about smoking cessation while they are hospitalized, it is unlikely that the majority will routinely receive this counseling before they are discharged. Second, less is moreproductivity is not destroyed but often is enhanced by initiating simple and practical change. If a patient arrives in the emergency department (ED) with chest pain, instituting an order set that reminds clinicians to start antiplatelet therapy or a beta blocker can lessen the chance that these medications will be overlooked, especially when the patient transitions between providers or services within the hospital.

SHM has identified 7 essential elements of any QI initiative, and these are applicable to the care of the ACS patient (Table 2).7 These elements highlight the need for institutional support and teamwork that support standardized measures and tools specific to issues in ACS management. These issues include: (1) rapidly identifying a patient with ACS and initiating a care plan when the patient is admitted; (2) encouraging good communication between providers; (3) symptom management; (4) medication safety, polypharmacy, and medication reconciliation; (5) patient and caregiver education; (6) safe discharge and transitions in care; and (7) meeting Centers for Medicare and Medicaid Services (CMS) core measures.

Tools such as process flow mapping and run charts can reveal quality gaps and indicate if process improvements are leading to stated objectives. Process flow mapping makes it possible to identify and visualize quality gaps that might otherwise be hidden and to identify their source or cause. Process mapping documents discrete steps within the flow and usually requires input from multiple disciplines; this information can guide a multidisciplinary QI team when formulating interventions for process improvement.7 Figure 1 shows process flow mapping for the early identification of ST‐segment elevation myocardial infarction (STEMI) when hospitalists have open access to activate the catheterization laboratory (cath lab). The time from door‐to‐balloon is a critical factor in reducing STEMI‐related morbidity8; processes that overcome delays to percutaneous coronary intervention (PCI) and improve communication can have a direct benefit on patient outcomes.

Figure 1

A run chart is a commonly used tool which graphically depicts progress in attaining a goal over time, before and after an intervention. Figure 2a is a run chart that shows the average time to PCI following implementation of an order set designed to support the use of a risk stratification tool for the early diagnosis of STEMI. In this case, the average time to PCI is observed to decrease over time, but still lags behind the desired goal of less than 90 minutes. This run chart indicates that further work is needed to improve the process of identifying patients with STEMI. Figure 2b shows the number of eligible STEMI patients who received aspirin at discharge following implementation of a discharge order set; here, the hospital has clearly made progress toward meeting this CMS core measure.

Figure 2

The following is a case study that illustrates how the implementation of standardized measures and tools can help hospitalists and other clinicians achieve quality measures in the care of a patient with ACS.

Measuring Performance Relative to ACS

Two agencies promulgating quality measures for hospital inpatient care are The Joint Commission (TJC) and the CMS. TJC and CMS jointly established core measures for patients with acute myocardial infarction (AMI) and these are considered key indicators of quality, evidence‐based care. As outlined in Table 3, the TJC/CMS recommendations promote, unless contraindicated, a minimum standard of care for patients with AMI.9, 10 Public reporting of institutional core measure performance has led to an intense focus on improving these metrics.

On a national level, TJC documented performance improvement from 2002 to 2008 for each of the core measures. Compliance with smoking cessation counseling improved the most, rising from 67% to almost 99%. In 2008, a combined measure of all individual core measures indicated that, overall, care of heart attack patients is of high quality. Hospitals delivered evidenced‐based care in 96.7% of the opportunities they had to provide this care. Compliance related to oral medications was also good (95%); however, a closer look at other individual measures shows that improvement is needed to reduce the time to fibrinolysis (52.4% compliance rate for 30 minutes or less) and time to primary PCI (81.6% compliance rate for 90 minutes or less).11

Financial incentives are tied to QI measures including those from CMS. At present, this system is in the pay‐for‐reporting phase, in which institutions are penalized for not reporting quality metrics for the CMS core measures. It is likely that, to further incentivize institutions to meet quality benchmarks, this will be expanded to a pay‐for‐performance system (eg, differential payments for readmissions or different payment scales based on prior performance). Public disclosure of institutional performance relative to ACS and other medical conditions is available through the HHS.gov website (www.hospitalcompare.hhs.gov), which compares performance between hospitals and provides a clear business motivation for institutions to improve and provide high quality care.

Two other reporting systems should be noted. The CMS Physician Quality Reporting Initiative (PQRI) includes physician‐related quality measures specific to ACS12 that overlap with institution‐level CMS core measures with regard to prescribing ACS medications. Payments associated with the PQRI are currently a small financial factor for hospitalists, but will likely grow as quality initiatives develop overall. The Hospital Care Quality Information From the Consumer Perspective (HCAHPS) initiative, also from CMS, strives to capture patients' perspectives on hospital care through a standardized survey. The goals are to collect data that can be used to compare hospital performance, create an incentive for QI through public disclosure of results, and increase transparency regarding the quality of hospital care.13 However, the focus is not ACS‐specific. Patients are queried about communication with hospital staff, communication about medications, and information about discharge, all areas of concern for the hospitalist in general that have been identified as areas for improvement relative to ACS.

Special QI Issues in ACS Management for the Hospitalist

Coordination is especially important for patients with ACS because their care is so complex. Seamless transitions promote safe care as the patient moves from the ED, cath lab, recovery unit, medical floor, and discharge through the transition to primary care. Poor communication between clinicians during these transitions may result in delayed or overlooked treatment and other medical errors. Implementing an institutional system of care may overcome communication barriers and help ensure the institution meets its quality benchmarks, such as the CMS core measures. Standard order sets and protocols identify the steps and components needed to manage ACS. At admission, these measures promote early assessment of patient risk, triage to early intervention, medication reconciliation, and communication between stakeholders such as the hospitalist, cardiologist, and the cath lab.15, 16 During hospitalization, they help assure ongoing risk assessment and early consideration of discharge planning, culminating in discharge and the transition back to primary care.

A recent guideline update8 focused attention on the coordination of care between institutions and the critical importance of rapid triage for patients who need primary PCI and transfer from a non‐PCI to a PCI‐capable institution. The decision to transfer rests on multiple factors and requires rapid decision making on the part of clinicians. Time to reperfusion is shown to have a direct effect on patient outcomes. Established protocols within a non‐PCI facility can support timely transfer to a PCI‐capable facility if indicated. Factors such as the patient's mortality risk, the risk of bleeding from fibrinolytic therapy, duration of symptoms, and the time for transport to a PCI facility all must be considered. It is recognized that a regional system of STEMI care best supports collaborative efforts between institutions and community resources that support QI efforts.

Transitions in care, and particularly discharge, are areas with identified gaps in quality care17, 18 for which improvement has been pursued on an institutional level. Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) seeks to improve the care of patients during the transition from inpatient to outpatient care, and focuses on elderly patients identified to be at high‐risk for adverse events during this transition.19 The goal is to improve outcomes related to 30‐day readmission rates, patient satisfaction, communication between inpatient and outpatient providers, identification of high‐risk patients who need intervention to reduce risk, and patient education about their risk for an adverse event. BOOST addresses these outcomes at an institutional level by offering resources related to project management, data collection, tools for clinicians and patients, and participating mentor institutions. These resources help an institution assess its readiness for change, identify quality gaps, promote teamwork, and guide the implementation and subsequent evaluation of process improvements. Specific tools for clinicians also support institutional goals for teamwork and communication, creating an environment for safe transitions. Both BOOST19 and the adaptable Transitions Tool from the SHM20 provide a framework for understanding processes that involve multiple departments and stakeholders, breaking complex processes into discrete parts for which quality gaps can be identified and change instituted to improve care. A checklist can also be a useful tool for ensuring specific issues are addressed during transitions in care. SHM developed a checklist for hospitalist use that lists elements of a discharge summary for patients with ACS (Table 4).21

Staff and patient education is also an area that can benefit from evaluation. Clinicians from multiple disciplines are stakeholders in QI and they should receive education about its purpose and goals. Usually institutions will have a QI methodology in place, and this should be conveyed to the members of the ACS team. Staff education about ACS should be tailored to each specialty, be institution‐specific, current, and comprehensive, and include methods for assessing the learner. Education should be easily available (eg, on the Internet or via an electronic format), interactive, case‐based, and mandatory. For patients, education should be available in languages other than English and identify community resources and opportunities for additional outpatient education. The value of any educational program should be assessed to measure learner participation, satisfaction, and comprehension.

Gathering metrics and generating objective evidence of change is critical to QI; quantifying improvement (or lack thereof) must be done to determine whether the changes implemented improve care and ultimately whether desired outcomes are met. Metrics should be meaningful, associated with standards of care (eg, CMS core measures), and carefully chosen to reflect current practice. CMS core measures are a good target for collecting metrics to assess an institution's performance relative to ACS (Table 3). The Specifications Manual for National and Hospital Inpatient Quality Measures10 from TJC and CMS identifies the data elements needed for reporting. Other metrics not specified as core measures are worthy of measurement because they are considered the standard of care for patients with ACS (Table 5). The metrics shown in Tables 3 and 5 assume that all patients are eligible for core‐measure or standard‐of‐care medications and procedures. Because some measures are contraindicated in some patients, it is more meaningful to measure the percentage of patients without a contraindication who receive the measure. If a measure is contraindicated, the patient's medical record must include supporting documentation indicating why a core measure was not met. To be objective and reduce bias regarding the effectiveness of QI measures, data collection is best done prospectively. If necessary, periodic assessments against performance measures (institutional, government, professional association) should be made to support timely intervention. Run charts can be particularly useful here, measuring change over time to identify trends or an intervention that supported, did not affect, or was a barrier to the desired change.

Conclusion

Each hospitalist can have an impact on ACS care systemwide. Hospitalists are on the front line of care and have a unique perspective on patients as they are transitioned through the hospital stay and on how an institution handles patient care overall. They experience firsthand the challenges presented by poor communication between providers, patients, and their families. They can offer breadth of experience and perspective when assessing processes linked to patient care and can be instrumental in ensuring each patient experiences safe transitions during the hospital stay. Hospitalists should participate in QI initiatives for ACS and should consider opportunities to take the lead on these initiatives within their institutions.

Addressing quality improvement (QI) for the management of acute coronary syndrome (ACS) at the institutional level is essential for supporting hospitalists and other clinicians as they manage patients with ACS and achieve desired institutional outcomes. This systems approach may identify institution‐specific barriers to quality care, including those that affect the complex management of ACS. Having a firsthand view of patient care puts the hospitalist in a good position to assess the viability of existing processes and protocols that support care. Indeed, the hospitalist has a vested interest in improving systems of care as these systems directly affect the hospitalist's practice. This unique perspective gives the hospitalist an opportunity to facilitate systems change within the institution and to become an integral participant or leader in QI initiatives.

An increasing number of hospitalists are providing critical care at secondary and tertiary care facilities, driven by a shortage of intensivists in the United States. In a 20052006 survey about 75% of hospitalists reported they provide critical care services as part of their practice,1 and this would include care of patients with ACS. The Society of Hospital Medicine (SHM) has developed core competencies that recognize the important role of hospitalists in leading or participating in QI teams for ACS.2 Hospitalists must also be able to apply evidenced‐based outcomes data to support these initiatives.3 Hospitalist competencies for ACS include protocol development that supports the timely diagnosis and treatment of ACS, evaluation of resource utilization, staff education of secondary prevention measures, and implementation of measures to ensure institutional compliance with national quality standards (Table 1).2 Most hospital medicine groups will be expected to contribute to systems improvement, an area where hospitalists have already shown leadership for QI protocols related to glycemic control and venous thromboembolism prophylaxis. Hospitalists were prominent in targeting QI in these areas even though these QI initiatives could easily have been spearheaded by specialists.46

QI Basics

QI at the institutional level addresses systems of care rather than individual performance, targeting both institutional performance and use of resources.3 QI is a continuous process in which practices and procedures related to patient management are regularly assessed to ascertain whether a quality gap exists. This in turn may lead to new processes, protocols, and algorithms that help the institution and clinicians meet benchmarks of quality care.

QI starts when an existing gap is recognizedthe gap between the scientific understanding of optimal care and actual patient care. The goal is to narrow or close this gap so that each patient receives optimal care. Underlying any QI initiative are 2 essential concepts. First, improvement requires systems changeany system will produce exactly what it is designed to produce. For example, if procedures are not in place to educate patients about smoking cessation while they are hospitalized, it is unlikely that the majority will routinely receive this counseling before they are discharged. Second, less is moreproductivity is not destroyed but often is enhanced by initiating simple and practical change. If a patient arrives in the emergency department (ED) with chest pain, instituting an order set that reminds clinicians to start antiplatelet therapy or a beta blocker can lessen the chance that these medications will be overlooked, especially when the patient transitions between providers or services within the hospital.

SHM has identified 7 essential elements of any QI initiative, and these are applicable to the care of the ACS patient (Table 2).7 These elements highlight the need for institutional support and teamwork that support standardized measures and tools specific to issues in ACS management. These issues include: (1) rapidly identifying a patient with ACS and initiating a care plan when the patient is admitted; (2) encouraging good communication between providers; (3) symptom management; (4) medication safety, polypharmacy, and medication reconciliation; (5) patient and caregiver education; (6) safe discharge and transitions in care; and (7) meeting Centers for Medicare and Medicaid Services (CMS) core measures.

Tools such as process flow mapping and run charts can reveal quality gaps and indicate if process improvements are leading to stated objectives. Process flow mapping makes it possible to identify and visualize quality gaps that might otherwise be hidden and to identify their source or cause. Process mapping documents discrete steps within the flow and usually requires input from multiple disciplines; this information can guide a multidisciplinary QI team when formulating interventions for process improvement.7 Figure 1 shows process flow mapping for the early identification of ST‐segment elevation myocardial infarction (STEMI) when hospitalists have open access to activate the catheterization laboratory (cath lab). The time from door‐to‐balloon is a critical factor in reducing STEMI‐related morbidity8; processes that overcome delays to percutaneous coronary intervention (PCI) and improve communication can have a direct benefit on patient outcomes.

Figure 1

A run chart is a commonly used tool which graphically depicts progress in attaining a goal over time, before and after an intervention. Figure 2a is a run chart that shows the average time to PCI following implementation of an order set designed to support the use of a risk stratification tool for the early diagnosis of STEMI. In this case, the average time to PCI is observed to decrease over time, but still lags behind the desired goal of less than 90 minutes. This run chart indicates that further work is needed to improve the process of identifying patients with STEMI. Figure 2b shows the number of eligible STEMI patients who received aspirin at discharge following implementation of a discharge order set; here, the hospital has clearly made progress toward meeting this CMS core measure.

Figure 2

The following is a case study that illustrates how the implementation of standardized measures and tools can help hospitalists and other clinicians achieve quality measures in the care of a patient with ACS.

Measuring Performance Relative to ACS

Two agencies promulgating quality measures for hospital inpatient care are The Joint Commission (TJC) and the CMS. TJC and CMS jointly established core measures for patients with acute myocardial infarction (AMI) and these are considered key indicators of quality, evidence‐based care. As outlined in Table 3, the TJC/CMS recommendations promote, unless contraindicated, a minimum standard of care for patients with AMI.9, 10 Public reporting of institutional core measure performance has led to an intense focus on improving these metrics.

On a national level, TJC documented performance improvement from 2002 to 2008 for each of the core measures. Compliance with smoking cessation counseling improved the most, rising from 67% to almost 99%. In 2008, a combined measure of all individual core measures indicated that, overall, care of heart attack patients is of high quality. Hospitals delivered evidenced‐based care in 96.7% of the opportunities they had to provide this care. Compliance related to oral medications was also good (95%); however, a closer look at other individual measures shows that improvement is needed to reduce the time to fibrinolysis (52.4% compliance rate for 30 minutes or less) and time to primary PCI (81.6% compliance rate for 90 minutes or less).11

Financial incentives are tied to QI measures including those from CMS. At present, this system is in the pay‐for‐reporting phase, in which institutions are penalized for not reporting quality metrics for the CMS core measures. It is likely that, to further incentivize institutions to meet quality benchmarks, this will be expanded to a pay‐for‐performance system (eg, differential payments for readmissions or different payment scales based on prior performance). Public disclosure of institutional performance relative to ACS and other medical conditions is available through the HHS.gov website (www.hospitalcompare.hhs.gov), which compares performance between hospitals and provides a clear business motivation for institutions to improve and provide high quality care.

Two other reporting systems should be noted. The CMS Physician Quality Reporting Initiative (PQRI) includes physician‐related quality measures specific to ACS12 that overlap with institution‐level CMS core measures with regard to prescribing ACS medications. Payments associated with the PQRI are currently a small financial factor for hospitalists, but will likely grow as quality initiatives develop overall. The Hospital Care Quality Information From the Consumer Perspective (HCAHPS) initiative, also from CMS, strives to capture patients' perspectives on hospital care through a standardized survey. The goals are to collect data that can be used to compare hospital performance, create an incentive for QI through public disclosure of results, and increase transparency regarding the quality of hospital care.13 However, the focus is not ACS‐specific. Patients are queried about communication with hospital staff, communication about medications, and information about discharge, all areas of concern for the hospitalist in general that have been identified as areas for improvement relative to ACS.

Special QI Issues in ACS Management for the Hospitalist

Coordination is especially important for patients with ACS because their care is so complex. Seamless transitions promote safe care as the patient moves from the ED, cath lab, recovery unit, medical floor, and discharge through the transition to primary care. Poor communication between clinicians during these transitions may result in delayed or overlooked treatment and other medical errors. Implementing an institutional system of care may overcome communication barriers and help ensure the institution meets its quality benchmarks, such as the CMS core measures. Standard order sets and protocols identify the steps and components needed to manage ACS. At admission, these measures promote early assessment of patient risk, triage to early intervention, medication reconciliation, and communication between stakeholders such as the hospitalist, cardiologist, and the cath lab.15, 16 During hospitalization, they help assure ongoing risk assessment and early consideration of discharge planning, culminating in discharge and the transition back to primary care.

A recent guideline update8 focused attention on the coordination of care between institutions and the critical importance of rapid triage for patients who need primary PCI and transfer from a non‐PCI to a PCI‐capable institution. The decision to transfer rests on multiple factors and requires rapid decision making on the part of clinicians. Time to reperfusion is shown to have a direct effect on patient outcomes. Established protocols within a non‐PCI facility can support timely transfer to a PCI‐capable facility if indicated. Factors such as the patient's mortality risk, the risk of bleeding from fibrinolytic therapy, duration of symptoms, and the time for transport to a PCI facility all must be considered. It is recognized that a regional system of STEMI care best supports collaborative efforts between institutions and community resources that support QI efforts.

Transitions in care, and particularly discharge, are areas with identified gaps in quality care17, 18 for which improvement has been pursued on an institutional level. Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) seeks to improve the care of patients during the transition from inpatient to outpatient care, and focuses on elderly patients identified to be at high‐risk for adverse events during this transition.19 The goal is to improve outcomes related to 30‐day readmission rates, patient satisfaction, communication between inpatient and outpatient providers, identification of high‐risk patients who need intervention to reduce risk, and patient education about their risk for an adverse event. BOOST addresses these outcomes at an institutional level by offering resources related to project management, data collection, tools for clinicians and patients, and participating mentor institutions. These resources help an institution assess its readiness for change, identify quality gaps, promote teamwork, and guide the implementation and subsequent evaluation of process improvements. Specific tools for clinicians also support institutional goals for teamwork and communication, creating an environment for safe transitions. Both BOOST19 and the adaptable Transitions Tool from the SHM20 provide a framework for understanding processes that involve multiple departments and stakeholders, breaking complex processes into discrete parts for which quality gaps can be identified and change instituted to improve care. A checklist can also be a useful tool for ensuring specific issues are addressed during transitions in care. SHM developed a checklist for hospitalist use that lists elements of a discharge summary for patients with ACS (Table 4).21

Staff and patient education is also an area that can benefit from evaluation. Clinicians from multiple disciplines are stakeholders in QI and they should receive education about its purpose and goals. Usually institutions will have a QI methodology in place, and this should be conveyed to the members of the ACS team. Staff education about ACS should be tailored to each specialty, be institution‐specific, current, and comprehensive, and include methods for assessing the learner. Education should be easily available (eg, on the Internet or via an electronic format), interactive, case‐based, and mandatory. For patients, education should be available in languages other than English and identify community resources and opportunities for additional outpatient education. The value of any educational program should be assessed to measure learner participation, satisfaction, and comprehension.

Gathering metrics and generating objective evidence of change is critical to QI; quantifying improvement (or lack thereof) must be done to determine whether the changes implemented improve care and ultimately whether desired outcomes are met. Metrics should be meaningful, associated with standards of care (eg, CMS core measures), and carefully chosen to reflect current practice. CMS core measures are a good target for collecting metrics to assess an institution's performance relative to ACS (Table 3). The Specifications Manual for National and Hospital Inpatient Quality Measures10 from TJC and CMS identifies the data elements needed for reporting. Other metrics not specified as core measures are worthy of measurement because they are considered the standard of care for patients with ACS (Table 5). The metrics shown in Tables 3 and 5 assume that all patients are eligible for core‐measure or standard‐of‐care medications and procedures. Because some measures are contraindicated in some patients, it is more meaningful to measure the percentage of patients without a contraindication who receive the measure. If a measure is contraindicated, the patient's medical record must include supporting documentation indicating why a core measure was not met. To be objective and reduce bias regarding the effectiveness of QI measures, data collection is best done prospectively. If necessary, periodic assessments against performance measures (institutional, government, professional association) should be made to support timely intervention. Run charts can be particularly useful here, measuring change over time to identify trends or an intervention that supported, did not affect, or was a barrier to the desired change.

Conclusion

Each hospitalist can have an impact on ACS care systemwide. Hospitalists are on the front line of care and have a unique perspective on patients as they are transitioned through the hospital stay and on how an institution handles patient care overall. They experience firsthand the challenges presented by poor communication between providers, patients, and their families. They can offer breadth of experience and perspective when assessing processes linked to patient care and can be instrumental in ensuring each patient experiences safe transitions during the hospital stay. Hospitalists should participate in QI initiatives for ACS and should consider opportunities to take the lead on these initiatives within their institutions.

Patients with acute coronary syndrome (ACS) are a challenge for the hospitalist, as they require substantial coordination of care and support during hospitalization and in the transition back into primary care. ACS accounted for 733,000 discharge diagnoses in 2006 (inclusive of unstable angina or acute myocardial infarction [MI]), and the American Heart Association considers this a conservative estimate.1 Readmission of these patients occurs with some frequency and expends healthcare resources. A multiemployer claims database showed a 20% rehospitalization rate for patients with ischemic heart disease within 1 year of discharge after ACS.2

Implementation of evidenced‐based care for patients with ACS and an emphasis on preventive measures for coronary heart disease (CHD) have improved CHD‐related outcomes. A 2007 study revealed that almost one‐half of the 40% decrease in CHD‐related mortality between 1988 and 2000 was directly attributable to therapeutic interventions and prevention and treatment of recognized risk factors for CHD. However, this news was tempered by the effect of 2 risk factors, increased body mass index and diabetes, which accounted for additional CHD‐related deaths in 2000.3

The Society of Hospital Medicine (SHM) has established core competencies for hospitalists who manage patients with ACS, defining the scope of interactions between the hospitalist, patient, and other clinicians such as specialists and primary care providers (PCP).4, 5 Several competencies focus on ACS and transitions in care, requiring the hospitalist to demonstrate the skills and attitudes outlined in Table 1. Of concern is the risk for adverse events associated with medication errors and lack of follow‐up related to diagnostic tests during the postdischarge period, which in turn raises the risk of readmission.6 The hospitalist is in a unique position to have a positive impact on the transition from inpatient to primary care by proactively addressing patient‐specific issues through careful planning and coordination with the patient, the PCP, and other stakeholders. The hospitalist cannot be accountable for all elements of the transition process, but can be proactive, working with hospital leadership and allied health professionals to promote systems that support safe transitions in care.

Case Study

Jose is a 66‐year‐old retiree recovering on the medical floor after diagnosis of an ST‐segment elevation myocardial infarction (STEMI) and implantation of a drug‐eluting stent (DES). Jose and his family were poor historians on admission and it is unclear whether his medical and medication history are accurate. Jose is anxious to get out of here and thinks this is no big deal. Upon admission Jose was hypertensive and mildly obese. He denies smoking and exercises once in awhile by working in his yard. His lipid profile on admission indicated elevated low‐density lipoprotein (LDL) and total cholesterol.

You decide to address several issues during Jose's hospital stay. These include contacting Jose's PCP to obtain a complete medical and medication history, and educating Jose about his cardiac disease, his risk of future events, and strategies for risk reduction.

Conclusion

Timely and accurate communication between the hospitalist and the PCP is a vital component of a safe transition from inpatient to primary care. This communication directly impacts the continuity of care, patient outcomes, patient and caregiver satisfaction, and use of healthcare resources. The role of the hospitalist is still evolving. Hospitalists will continue to have a pivotal role in transitions of care, and have a direct impact on the quality of the transition at discharge and patient outcomes after ACS. Hospitalists should be cognizant of gaps in care related to how information is generated, recorded, and shared between the inpatient setting and primary care, and should be proactive in identifying barriers and facilitating solutions. The hospitalist's responsibility for the patient does not end at the time of discharge but extends until the PCP assumes responsibility for patient care following hospitalization. We must make every reasonable effort to assure that our patients and their outpatient providers and caregivers are given all the tools necessary to complete and maintain the patient's therapy.

Patients with acute coronary syndrome (ACS) are a challenge for the hospitalist, as they require substantial coordination of care and support during hospitalization and in the transition back into primary care. ACS accounted for 733,000 discharge diagnoses in 2006 (inclusive of unstable angina or acute myocardial infarction [MI]), and the American Heart Association considers this a conservative estimate.1 Readmission of these patients occurs with some frequency and expends healthcare resources. A multiemployer claims database showed a 20% rehospitalization rate for patients with ischemic heart disease within 1 year of discharge after ACS.2

Implementation of evidenced‐based care for patients with ACS and an emphasis on preventive measures for coronary heart disease (CHD) have improved CHD‐related outcomes. A 2007 study revealed that almost one‐half of the 40% decrease in CHD‐related mortality between 1988 and 2000 was directly attributable to therapeutic interventions and prevention and treatment of recognized risk factors for CHD. However, this news was tempered by the effect of 2 risk factors, increased body mass index and diabetes, which accounted for additional CHD‐related deaths in 2000.3

The Society of Hospital Medicine (SHM) has established core competencies for hospitalists who manage patients with ACS, defining the scope of interactions between the hospitalist, patient, and other clinicians such as specialists and primary care providers (PCP).4, 5 Several competencies focus on ACS and transitions in care, requiring the hospitalist to demonstrate the skills and attitudes outlined in Table 1. Of concern is the risk for adverse events associated with medication errors and lack of follow‐up related to diagnostic tests during the postdischarge period, which in turn raises the risk of readmission.6 The hospitalist is in a unique position to have a positive impact on the transition from inpatient to primary care by proactively addressing patient‐specific issues through careful planning and coordination with the patient, the PCP, and other stakeholders. The hospitalist cannot be accountable for all elements of the transition process, but can be proactive, working with hospital leadership and allied health professionals to promote systems that support safe transitions in care.

Case Study

Jose is a 66‐year‐old retiree recovering on the medical floor after diagnosis of an ST‐segment elevation myocardial infarction (STEMI) and implantation of a drug‐eluting stent (DES). Jose and his family were poor historians on admission and it is unclear whether his medical and medication history are accurate. Jose is anxious to get out of here and thinks this is no big deal. Upon admission Jose was hypertensive and mildly obese. He denies smoking and exercises once in awhile by working in his yard. His lipid profile on admission indicated elevated low‐density lipoprotein (LDL) and total cholesterol.

You decide to address several issues during Jose's hospital stay. These include contacting Jose's PCP to obtain a complete medical and medication history, and educating Jose about his cardiac disease, his risk of future events, and strategies for risk reduction.

Conclusion

Timely and accurate communication between the hospitalist and the PCP is a vital component of a safe transition from inpatient to primary care. This communication directly impacts the continuity of care, patient outcomes, patient and caregiver satisfaction, and use of healthcare resources. The role of the hospitalist is still evolving. Hospitalists will continue to have a pivotal role in transitions of care, and have a direct impact on the quality of the transition at discharge and patient outcomes after ACS. Hospitalists should be cognizant of gaps in care related to how information is generated, recorded, and shared between the inpatient setting and primary care, and should be proactive in identifying barriers and facilitating solutions. The hospitalist's responsibility for the patient does not end at the time of discharge but extends until the PCP assumes responsibility for patient care following hospitalization. We must make every reasonable effort to assure that our patients and their outpatient providers and caregivers are given all the tools necessary to complete and maintain the patient's therapy.

Patients with acute coronary syndrome (ACS) are a challenge for the hospitalist, as they require substantial coordination of care and support during hospitalization and in the transition back into primary care. ACS accounted for 733,000 discharge diagnoses in 2006 (inclusive of unstable angina or acute myocardial infarction [MI]), and the American Heart Association considers this a conservative estimate.1 Readmission of these patients occurs with some frequency and expends healthcare resources. A multiemployer claims database showed a 20% rehospitalization rate for patients with ischemic heart disease within 1 year of discharge after ACS.2

Implementation of evidenced‐based care for patients with ACS and an emphasis on preventive measures for coronary heart disease (CHD) have improved CHD‐related outcomes. A 2007 study revealed that almost one‐half of the 40% decrease in CHD‐related mortality between 1988 and 2000 was directly attributable to therapeutic interventions and prevention and treatment of recognized risk factors for CHD. However, this news was tempered by the effect of 2 risk factors, increased body mass index and diabetes, which accounted for additional CHD‐related deaths in 2000.3

The Society of Hospital Medicine (SHM) has established core competencies for hospitalists who manage patients with ACS, defining the scope of interactions between the hospitalist, patient, and other clinicians such as specialists and primary care providers (PCP).4, 5 Several competencies focus on ACS and transitions in care, requiring the hospitalist to demonstrate the skills and attitudes outlined in Table 1. Of concern is the risk for adverse events associated with medication errors and lack of follow‐up related to diagnostic tests during the postdischarge period, which in turn raises the risk of readmission.6 The hospitalist is in a unique position to have a positive impact on the transition from inpatient to primary care by proactively addressing patient‐specific issues through careful planning and coordination with the patient, the PCP, and other stakeholders. The hospitalist cannot be accountable for all elements of the transition process, but can be proactive, working with hospital leadership and allied health professionals to promote systems that support safe transitions in care.

Case Study

Jose is a 66‐year‐old retiree recovering on the medical floor after diagnosis of an ST‐segment elevation myocardial infarction (STEMI) and implantation of a drug‐eluting stent (DES). Jose and his family were poor historians on admission and it is unclear whether his medical and medication history are accurate. Jose is anxious to get out of here and thinks this is no big deal. Upon admission Jose was hypertensive and mildly obese. He denies smoking and exercises once in awhile by working in his yard. His lipid profile on admission indicated elevated low‐density lipoprotein (LDL) and total cholesterol.

You decide to address several issues during Jose's hospital stay. These include contacting Jose's PCP to obtain a complete medical and medication history, and educating Jose about his cardiac disease, his risk of future events, and strategies for risk reduction.

Conclusion

Timely and accurate communication between the hospitalist and the PCP is a vital component of a safe transition from inpatient to primary care. This communication directly impacts the continuity of care, patient outcomes, patient and caregiver satisfaction, and use of healthcare resources. The role of the hospitalist is still evolving. Hospitalists will continue to have a pivotal role in transitions of care, and have a direct impact on the quality of the transition at discharge and patient outcomes after ACS. Hospitalists should be cognizant of gaps in care related to how information is generated, recorded, and shared between the inpatient setting and primary care, and should be proactive in identifying barriers and facilitating solutions. The hospitalist's responsibility for the patient does not end at the time of discharge but extends until the PCP assumes responsibility for patient care following hospitalization. We must make every reasonable effort to assure that our patients and their outpatient providers and caregivers are given all the tools necessary to complete and maintain the patient's therapy.

Two national surveys indicate that 14% to 28% of patients admitted to intensive care units (ICU's) are unplanned transfers (i.e., moving a patient to the ICU from other areas in the hospital providing lower intensity care due to an unanticipated change in the patient's clinical status), and that the most common reason for unplanned transfers is respiratory insufficiency/failure.1, 2 Patients suffering adverse events during a hospitalization are more likely to have an unplanned ICU transfer and patients requiring unplanned transfers have a higher mortality.35 Accordingly, the Joint Commission has identified improved recognition and response to changes in a patient's condition as a national patient safety goal,6 and Rapid Response Teams (RRTs) have been advocated to deal with these changes,7 although recent studies question the effectiveness of RRTs.811

We sought to classify the causes of unplanned, in‐hospital transfers to a medical ICU (MICU) with the idea of identifying common problems in care that might be addressed by process improvement activities. We also sought to determine the fraction of patients requiring an unplanned MICU transfer that had evidence of clinical deterioration prior to the time of transfer and whether, in retrospect, different or earlier interventions might have prevented the transfer. Our hypotheses were that (1) most unplanned MICU transfers occurred as a result of errors in care, (2) most were preceded by clinical deterioration within 12 hours prior to the transfer, and (3) most were preventable.

Methods

We conducted a retrospective cohort study of patients transferring to the MICU from non‐ICU Medicine units at Denver Health, a university‐affiliated, public safety net hospital. All adult patients between 18 to 89 years of age, who were admitted to the Medicine service between June, 2005 and May, 2006 were included in the study. Exclusion criteria included patients who (1) transferred from outside hospitals, (2) transferred from nonMedicine units within Denver Health, (3) were admitted directly to the MICU from the emergency department (ED), (4) were prisoners, (5) were readmitted to the MICU during the same hospitalization, (6) were known to be pregnant, or (7) were planned MICU transfers following invasive procedures (eg, elective cardiac catheterization, defibrillator placement, ablations). Patients readmitted to the MICU were excluded because of the difficulty distinguishing between premature transfer from the MICU or potential problems in care that might have occurred prior to the time of transfer from those occurring during follow‐up care on the Medicine floor services.

Computerized medical records of eligible patients were searched for demographic information and for admitting and transfer diagnoses (with the latter being categorized using a taxonomy we developed for classifying unplanned transfers, Table 1). Three independent observers (all of whom were board certified in Internal Medicine and had been practicing as Hospitalists at our institution for a minimum of three years) retrospectively reviewed each patient's hospital record to determine the cause of the unplanned transfer using this taxonomy. All three also made a judgment as to whether deterioration was evident at any time within the 12 hours preceding the unplanned transfer on the basis of clinical criteria used as our hospital's rapid response triggers (Table 2). When clinical triggers were found, each of the reviewers independently judged whether the unplanned transfer might have been prevented had different or earlier interventions been instituted. Each reviewer was blinded to the results of the other two.

All analyses were done using SAS Enterprise Guide 4.1, SAS Institute, Cary, NC. Data are presented as mean (standard deviation [SD]). Interobserver agreement was measured by calculating a statistic. values were interpreted by using the guidelines suggested by Landis and colleagues.12 A chi‐square test was used to seek associations between baseline characteristics, reasons for MICU transfer and mortality. P < 0.05 was considered to be statistically significant. The Colorado Multiple Institutional Review Board approved the research protocol.

Results

Over the period of the study the Medicine floor services had 4468 admissions of which 152 met the inclusion criteria for having an unplanned MICU transfer (Table 3). The most common admitting diagnoses were heart failure (12%) and community acquired pneumonia (9%). The most common diagnoses to which the unplanned MICU transfers were attributed were respiratory failure (27%) and sepsis (9%) (Table 4). Seven cardiopulmonary arrests were successfully resuscitated and transferred to the MICU. Throughout the period of the study, no patients were admitted to non‐MICU units because the MICU was at full capacity. Additionally the investigators did not find any inordinate delays in transfer to the ICU while waiting for a bed.

A total of 51 patients (34%) were transferred within the first 24 hours of admission. The most common diagnoses resulting in transfer in this group were respiratory failure, hypertensive emergency, hypotension, gastrointestinal bleed, and acute coronary syndrome. The remaining 101 patients (66%) were transferred from two to 15 days following admission for a variety of problems but respiratory failure was most common (34 patients, 22%).

Worsening of the problem for which the patients were initially admitted accounted for the unplanned transfers of 73 patients (48%) (Table 5). Development of a new problem unrelated to the admitting diagnosis accounted for the transfer in 59 patients (39%). Five patients were transferred to the ICU for a critical laboratory value that required a closer monitoring of the patient or needed more frequent lab draws that could not be achieved on the floor.

Errors in care were thought to be present in 29 patients (19% of the unplanned transfers). For 15 of these (52%) the error involved incorrect triage from the ED as 14 of the 15 patients met MICU admission criteria at the time they were triaged to non‐MICU units (Table 6). The remaining patient had a dissecting aortic aneurysm that was not considered while he was being evaluated for acute chest pain. All these patients were transferred to the ICU within 24 hours of their admission and the reviewers agreed that all could have been prevented if existing diagnostic and admission algorithms were followed.

Of the remaining 14 patients thought to have errors in care, nine were classified as the development of a new, iatrogenic problem (ie, opiate or benzodiazepine overdose occurring during treatment for pain and/or anxiety in 3, volume overload in 2, insulin‐induced hypoglycemia, antibiotic associated reaction, ‐blocker overdose and acute renal failure from over‐diuresis in one each) and five occurred because the patient's admitting problem worsened because treatment was thought to be either delayed, incorrect, or inadequate (Table 5). The reviewers all agreed that the unplanned transfers could have been prevented in eight of the 14 patients who developed iatrogenic problems if existing algorithms were followed or if an earlier or different intervention had occurred. The reviewers did not agree about whether the unplanned transfer could have been prevented in one patient who developed an iatrogenic problem and in all five patients whose underlying condition worsened. Accordingly, in sum, the reviewers felt that 23 of the 152 unplanned transfers (15%) could have been prevented.

In addition to trying to determine how many of the unplanned MICU transfers could have been prevented, we also investigated the utility of rapid response triggers in alerting the physicians and nurses of impending deteriorations in status and whether earlier recognition of this deterioration might have prevented the transfers. Of the 152 unplanned transfers, 106 (70%) had one or more rapid response triggers within the preceding 12 hours. All three reviewers agreed and concluded that in 94 (89%) of these, the unplanned transfer could not have been prevented, even with different or earlier interventions. For five patients (5% of the 106) all reviewers agreed and concluded that earlier intervention might have averted the subsequent transfer. For the other seven patients (6%), no consensus was reached. If we assume that, for all of these latter seven, earlier or different intervention might have averted the unplanned transfer, a maximum of 12 unplanned transfers (11% of the 106) might have been prevented by having a system of care that employed regularly assessing rapid response triggers and acting on them when recognized.

The interobserver reliability for the three reviewers was moderate to almost perfect with = 0.60, 95% confidence interval (CI) (0.31, 0.88); = 0.90, 95% CI (0.71, 1); = 0.55, 95% CI (0.26, 0.84).

A total of 27 (18%) of the patients with unplanned transfers died in the MICU. During this same time period 91 of 1511 patients (6%) admitted directly from the ED to the MICU died (P < 0.05). Mortality was lower for patients transferred within 24 hours of admission compared to those transferred > 24 hours after admission (4% vs. 22% mortality, respectively, P < 0.05; 95% CI, 0.09‐0.89). We found no difference in mortality as a function of time of admission or time of transfer implying that differences in staffing, or the availability of various services, did not contribute to the unplanned transfers.

Discussion

The important findings of this study were that (1) 19% of unplanned, in‐hospital transfers from Medicine floor services to the MICU seemed to result from apparent errors in care, (2) 15% of the unplanned transfers were potentially preventable, (3) the majority of the errors in care involved inappropriate triage of patients from the ED to the non‐MICU units, (4) 106 (70%) of the patients requiring unplanned transfers developed rapid response criteria within 12 hours prior to the transfer, but on review of these (5) the transfer was thought to be preventable in only a maximum of 12 (11%).

We designed our study in part to find specific errors that commonly resulted in unplanned MICU transfers with the idea that, if these could be identified, they might be corrected, thereby improving care. Contrary to our hypothesis we found that only 29 (19%) of the unplanned transfers seemed to result from errors in care. Of these, however, half were attributable to overlooking that patients met our own institution's MICU admission criteria at the time they were triaged to non‐MICU units. This result is consistent with Walter et al.13 finding that while 88% of MICUs in academic health centers had written MICU admission criteria, only 25% used these criteria on a regular basis. Hospital mortality is likely lower for patients meeting MICU admission criteria when they are appropriately and expeditiously triaged.1418 Accordingly, developing mechanisms by which patients are routinely screened for meeting MICU admission criteria could and should reduce this source of error and improve patient outcomes.

Nine of the remaining 14 errors in care resulted from what the chart reviewers concluded was overly aggressive treatment; either excess fluid resuscitation or excess treatment of pain or anxiety. It is not clear that these represent correctable errors in care, however, as hypotensive patients require fluid resuscitation, and patients with pain or anxiety should receive analgesics or anxiolytics and it is not reasonable to expect that these interventions will be appropriately titrated in every instance. Nonetheless, our reviewers all agreed that, in eight of these patients, different interventions could have prevented the unplanned transfer.

Since 41 (27%) of the unplanned transfers were for respiratory failure, we reviewed each of these patients' records seeking evidence suggesting that the problem might have resulted from excessive use of fluids, narcotics, or anxiolytics. By retrospective analysis only six such cases could be identified. Most were due to worsening of the problem for which the patient was admitted.

Consistent with our hypothesis the majority of patients requiring unplanned MICU transfers (106/152, 70%) developed rapid response clinical triggers within the 12 hours preceding transfer, as has been previously demonstrated by Hillman et al.7 and others.8‐10, 19 Our reviewers tried to determine whether earlier or different interventions might have prevented the deterioration and the resulting unplanned transfer. Interestingly, in the large majority (94/106, 89%) they concluded that nothing different could have been done and that the transfer could not have been avoided. While this observation contrasts with our hypothesis, it is consistent with two studies questioning the utility of RRTs in preventing unplanned ICU transfers.9, 10 In addition some patients may ultimately need an ICU transfer despite receiving appropriate interventions as it is impossible to prevent an ICU transfer in every patient. Conversely, just because a patient meets a rapid response criteria does not mean that the patient needs a higher level of care or an ICU transfer as some can be safely managed on the floor.

Our study has a number of potential limitations. The data came from a single teaching hospital and we only assessed patients admitted to General Internal Medicine units and transferred to a MICU. Accordingly, our results might not generalize to other hospitals (teaching or nonteaching), to other services or to other types of ICUs. We found, however, that (1) unplanned transfers accounted for 10% of the total admissions to our MICU, a similar fraction as reported by Angus et al.1 in 2006; (2) respiratory failure/emnsufficiency and sepsis were the most common diagnoses leading to unplanned transfers as previously reported by Groeger et al.2 and Hillman et al.5; (3) mortality was increased in patients requiring unplanned transfer, as noted by Escarce and Kelley3 and Hillman et al.5; and (4) patients who were transferred to the MICU within 24 hours of admission had better outcomes than those who were transferred later, as reported by Goldhill et al.4 Accordingly, our patient population seems quite similar to others in the literature.

Since we did not use objective criteria to assign patients to each of the categories itemized in Table 5 we could have misclassified patients with respect to the cause for their unplanned MICU transfer. Despite this shortcoming, however, the scores among our independent reviewers were moderate to almost perfect suggesting misclassification did not occur commonly.

Our retrospective study design may have underestimated the utility of RRTs as we had no way of knowing the outcomes of patients who met rapid response criteria and had interventions that prevented unplanned MICU transfers.

In summary, approximately 15% of unplanned MICU transfers seem to be preventable and approximately one‐fifth seem to result from errors in care, the majority of which are errors in triage from the ED. While the large majority of unplanned transfers were preceded by clinical deterioration within the preceding 12 hours, manifested by the presence of rapid response triggers, the large majority of these do not seem to be preventable. From these findings we suggest that unplanned transfers could be reduced by more closely screening patients for the presence of defined MICU admission criteria at the time of admission from the ED, by recognizing that fluid resuscitation and control of pain and/or anxiety can have adverse effects and by monitoring patients receiving these interventions more closely.

Two national surveys indicate that 14% to 28% of patients admitted to intensive care units (ICU's) are unplanned transfers (i.e., moving a patient to the ICU from other areas in the hospital providing lower intensity care due to an unanticipated change in the patient's clinical status), and that the most common reason for unplanned transfers is respiratory insufficiency/failure.1, 2 Patients suffering adverse events during a hospitalization are more likely to have an unplanned ICU transfer and patients requiring unplanned transfers have a higher mortality.35 Accordingly, the Joint Commission has identified improved recognition and response to changes in a patient's condition as a national patient safety goal,6 and Rapid Response Teams (RRTs) have been advocated to deal with these changes,7 although recent studies question the effectiveness of RRTs.811

We sought to classify the causes of unplanned, in‐hospital transfers to a medical ICU (MICU) with the idea of identifying common problems in care that might be addressed by process improvement activities. We also sought to determine the fraction of patients requiring an unplanned MICU transfer that had evidence of clinical deterioration prior to the time of transfer and whether, in retrospect, different or earlier interventions might have prevented the transfer. Our hypotheses were that (1) most unplanned MICU transfers occurred as a result of errors in care, (2) most were preceded by clinical deterioration within 12 hours prior to the transfer, and (3) most were preventable.

Methods

We conducted a retrospective cohort study of patients transferring to the MICU from non‐ICU Medicine units at Denver Health, a university‐affiliated, public safety net hospital. All adult patients between 18 to 89 years of age, who were admitted to the Medicine service between June, 2005 and May, 2006 were included in the study. Exclusion criteria included patients who (1) transferred from outside hospitals, (2) transferred from nonMedicine units within Denver Health, (3) were admitted directly to the MICU from the emergency department (ED), (4) were prisoners, (5) were readmitted to the MICU during the same hospitalization, (6) were known to be pregnant, or (7) were planned MICU transfers following invasive procedures (eg, elective cardiac catheterization, defibrillator placement, ablations). Patients readmitted to the MICU were excluded because of the difficulty distinguishing between premature transfer from the MICU or potential problems in care that might have occurred prior to the time of transfer from those occurring during follow‐up care on the Medicine floor services.

Computerized medical records of eligible patients were searched for demographic information and for admitting and transfer diagnoses (with the latter being categorized using a taxonomy we developed for classifying unplanned transfers, Table 1). Three independent observers (all of whom were board certified in Internal Medicine and had been practicing as Hospitalists at our institution for a minimum of three years) retrospectively reviewed each patient's hospital record to determine the cause of the unplanned transfer using this taxonomy. All three also made a judgment as to whether deterioration was evident at any time within the 12 hours preceding the unplanned transfer on the basis of clinical criteria used as our hospital's rapid response triggers (Table 2). When clinical triggers were found, each of the reviewers independently judged whether the unplanned transfer might have been prevented had different or earlier interventions been instituted. Each reviewer was blinded to the results of the other two.

All analyses were done using SAS Enterprise Guide 4.1, SAS Institute, Cary, NC. Data are presented as mean (standard deviation [SD]). Interobserver agreement was measured by calculating a statistic. values were interpreted by using the guidelines suggested by Landis and colleagues.12 A chi‐square test was used to seek associations between baseline characteristics, reasons for MICU transfer and mortality. P < 0.05 was considered to be statistically significant. The Colorado Multiple Institutional Review Board approved the research protocol.

Results

Over the period of the study the Medicine floor services had 4468 admissions of which 152 met the inclusion criteria for having an unplanned MICU transfer (Table 3). The most common admitting diagnoses were heart failure (12%) and community acquired pneumonia (9%). The most common diagnoses to which the unplanned MICU transfers were attributed were respiratory failure (27%) and sepsis (9%) (Table 4). Seven cardiopulmonary arrests were successfully resuscitated and transferred to the MICU. Throughout the period of the study, no patients were admitted to non‐MICU units because the MICU was at full capacity. Additionally the investigators did not find any inordinate delays in transfer to the ICU while waiting for a bed.

A total of 51 patients (34%) were transferred within the first 24 hours of admission. The most common diagnoses resulting in transfer in this group were respiratory failure, hypertensive emergency, hypotension, gastrointestinal bleed, and acute coronary syndrome. The remaining 101 patients (66%) were transferred from two to 15 days following admission for a variety of problems but respiratory failure was most common (34 patients, 22%).

Worsening of the problem for which the patients were initially admitted accounted for the unplanned transfers of 73 patients (48%) (Table 5). Development of a new problem unrelated to the admitting diagnosis accounted for the transfer in 59 patients (39%). Five patients were transferred to the ICU for a critical laboratory value that required a closer monitoring of the patient or needed more frequent lab draws that could not be achieved on the floor.

Errors in care were thought to be present in 29 patients (19% of the unplanned transfers). For 15 of these (52%) the error involved incorrect triage from the ED as 14 of the 15 patients met MICU admission criteria at the time they were triaged to non‐MICU units (Table 6). The remaining patient had a dissecting aortic aneurysm that was not considered while he was being evaluated for acute chest pain. All these patients were transferred to the ICU within 24 hours of their admission and the reviewers agreed that all could have been prevented if existing diagnostic and admission algorithms were followed.

Of the remaining 14 patients thought to have errors in care, nine were classified as the development of a new, iatrogenic problem (ie, opiate or benzodiazepine overdose occurring during treatment for pain and/or anxiety in 3, volume overload in 2, insulin‐induced hypoglycemia, antibiotic associated reaction, ‐blocker overdose and acute renal failure from over‐diuresis in one each) and five occurred because the patient's admitting problem worsened because treatment was thought to be either delayed, incorrect, or inadequate (Table 5). The reviewers all agreed that the unplanned transfers could have been prevented in eight of the 14 patients who developed iatrogenic problems if existing algorithms were followed or if an earlier or different intervention had occurred. The reviewers did not agree about whether the unplanned transfer could have been prevented in one patient who developed an iatrogenic problem and in all five patients whose underlying condition worsened. Accordingly, in sum, the reviewers felt that 23 of the 152 unplanned transfers (15%) could have been prevented.

In addition to trying to determine how many of the unplanned MICU transfers could have been prevented, we also investigated the utility of rapid response triggers in alerting the physicians and nurses of impending deteriorations in status and whether earlier recognition of this deterioration might have prevented the transfers. Of the 152 unplanned transfers, 106 (70%) had one or more rapid response triggers within the preceding 12 hours. All three reviewers agreed and concluded that in 94 (89%) of these, the unplanned transfer could not have been prevented, even with different or earlier interventions. For five patients (5% of the 106) all reviewers agreed and concluded that earlier intervention might have averted the subsequent transfer. For the other seven patients (6%), no consensus was reached. If we assume that, for all of these latter seven, earlier or different intervention might have averted the unplanned transfer, a maximum of 12 unplanned transfers (11% of the 106) might have been prevented by having a system of care that employed regularly assessing rapid response triggers and acting on them when recognized.

The interobserver reliability for the three reviewers was moderate to almost perfect with = 0.60, 95% confidence interval (CI) (0.31, 0.88); = 0.90, 95% CI (0.71, 1); = 0.55, 95% CI (0.26, 0.84).

A total of 27 (18%) of the patients with unplanned transfers died in the MICU. During this same time period 91 of 1511 patients (6%) admitted directly from the ED to the MICU died (P < 0.05). Mortality was lower for patients transferred within 24 hours of admission compared to those transferred > 24 hours after admission (4% vs. 22% mortality, respectively, P < 0.05; 95% CI, 0.09‐0.89). We found no difference in mortality as a function of time of admission or time of transfer implying that differences in staffing, or the availability of various services, did not contribute to the unplanned transfers.

Discussion

The important findings of this study were that (1) 19% of unplanned, in‐hospital transfers from Medicine floor services to the MICU seemed to result from apparent errors in care, (2) 15% of the unplanned transfers were potentially preventable, (3) the majority of the errors in care involved inappropriate triage of patients from the ED to the non‐MICU units, (4) 106 (70%) of the patients requiring unplanned transfers developed rapid response criteria within 12 hours prior to the transfer, but on review of these (5) the transfer was thought to be preventable in only a maximum of 12 (11%).

We designed our study in part to find specific errors that commonly resulted in unplanned MICU transfers with the idea that, if these could be identified, they might be corrected, thereby improving care. Contrary to our hypothesis we found that only 29 (19%) of the unplanned transfers seemed to result from errors in care. Of these, however, half were attributable to overlooking that patients met our own institution's MICU admission criteria at the time they were triaged to non‐MICU units. This result is consistent with Walter et al.13 finding that while 88% of MICUs in academic health centers had written MICU admission criteria, only 25% used these criteria on a regular basis. Hospital mortality is likely lower for patients meeting MICU admission criteria when they are appropriately and expeditiously triaged.1418 Accordingly, developing mechanisms by which patients are routinely screened for meeting MICU admission criteria could and should reduce this source of error and improve patient outcomes.

Nine of the remaining 14 errors in care resulted from what the chart reviewers concluded was overly aggressive treatment; either excess fluid resuscitation or excess treatment of pain or anxiety. It is not clear that these represent correctable errors in care, however, as hypotensive patients require fluid resuscitation, and patients with pain or anxiety should receive analgesics or anxiolytics and it is not reasonable to expect that these interventions will be appropriately titrated in every instance. Nonetheless, our reviewers all agreed that, in eight of these patients, different interventions could have prevented the unplanned transfer.

Since 41 (27%) of the unplanned transfers were for respiratory failure, we reviewed each of these patients' records seeking evidence suggesting that the problem might have resulted from excessive use of fluids, narcotics, or anxiolytics. By retrospective analysis only six such cases could be identified. Most were due to worsening of the problem for which the patient was admitted.

Consistent with our hypothesis the majority of patients requiring unplanned MICU transfers (106/152, 70%) developed rapid response clinical triggers within the 12 hours preceding transfer, as has been previously demonstrated by Hillman et al.7 and others.8‐10, 19 Our reviewers tried to determine whether earlier or different interventions might have prevented the deterioration and the resulting unplanned transfer. Interestingly, in the large majority (94/106, 89%) they concluded that nothing different could have been done and that the transfer could not have been avoided. While this observation contrasts with our hypothesis, it is consistent with two studies questioning the utility of RRTs in preventing unplanned ICU transfers.9, 10 In addition some patients may ultimately need an ICU transfer despite receiving appropriate interventions as it is impossible to prevent an ICU transfer in every patient. Conversely, just because a patient meets a rapid response criteria does not mean that the patient needs a higher level of care or an ICU transfer as some can be safely managed on the floor.

Our study has a number of potential limitations. The data came from a single teaching hospital and we only assessed patients admitted to General Internal Medicine units and transferred to a MICU. Accordingly, our results might not generalize to other hospitals (teaching or nonteaching), to other services or to other types of ICUs. We found, however, that (1) unplanned transfers accounted for 10% of the total admissions to our MICU, a similar fraction as reported by Angus et al.1 in 2006; (2) respiratory failure/emnsufficiency and sepsis were the most common diagnoses leading to unplanned transfers as previously reported by Groeger et al.2 and Hillman et al.5; (3) mortality was increased in patients requiring unplanned transfer, as noted by Escarce and Kelley3 and Hillman et al.5; and (4) patients who were transferred to the MICU within 24 hours of admission had better outcomes than those who were transferred later, as reported by Goldhill et al.4 Accordingly, our patient population seems quite similar to others in the literature.

Since we did not use objective criteria to assign patients to each of the categories itemized in Table 5 we could have misclassified patients with respect to the cause for their unplanned MICU transfer. Despite this shortcoming, however, the scores among our independent reviewers were moderate to almost perfect suggesting misclassification did not occur commonly.

Our retrospective study design may have underestimated the utility of RRTs as we had no way of knowing the outcomes of patients who met rapid response criteria and had interventions that prevented unplanned MICU transfers.

In summary, approximately 15% of unplanned MICU transfers seem to be preventable and approximately one‐fifth seem to result from errors in care, the majority of which are errors in triage from the ED. While the large majority of unplanned transfers were preceded by clinical deterioration within the preceding 12 hours, manifested by the presence of rapid response triggers, the large majority of these do not seem to be preventable. From these findings we suggest that unplanned transfers could be reduced by more closely screening patients for the presence of defined MICU admission criteria at the time of admission from the ED, by recognizing that fluid resuscitation and control of pain and/or anxiety can have adverse effects and by monitoring patients receiving these interventions more closely.

Two national surveys indicate that 14% to 28% of patients admitted to intensive care units (ICU's) are unplanned transfers (i.e., moving a patient to the ICU from other areas in the hospital providing lower intensity care due to an unanticipated change in the patient's clinical status), and that the most common reason for unplanned transfers is respiratory insufficiency/failure.1, 2 Patients suffering adverse events during a hospitalization are more likely to have an unplanned ICU transfer and patients requiring unplanned transfers have a higher mortality.35 Accordingly, the Joint Commission has identified improved recognition and response to changes in a patient's condition as a national patient safety goal,6 and Rapid Response Teams (RRTs) have been advocated to deal with these changes,7 although recent studies question the effectiveness of RRTs.811

We sought to classify the causes of unplanned, in‐hospital transfers to a medical ICU (MICU) with the idea of identifying common problems in care that might be addressed by process improvement activities. We also sought to determine the fraction of patients requiring an unplanned MICU transfer that had evidence of clinical deterioration prior to the time of transfer and whether, in retrospect, different or earlier interventions might have prevented the transfer. Our hypotheses were that (1) most unplanned MICU transfers occurred as a result of errors in care, (2) most were preceded by clinical deterioration within 12 hours prior to the transfer, and (3) most were preventable.

Methods

We conducted a retrospective cohort study of patients transferring to the MICU from non‐ICU Medicine units at Denver Health, a university‐affiliated, public safety net hospital. All adult patients between 18 to 89 years of age, who were admitted to the Medicine service between June, 2005 and May, 2006 were included in the study. Exclusion criteria included patients who (1) transferred from outside hospitals, (2) transferred from nonMedicine units within Denver Health, (3) were admitted directly to the MICU from the emergency department (ED), (4) were prisoners, (5) were readmitted to the MICU during the same hospitalization, (6) were known to be pregnant, or (7) were planned MICU transfers following invasive procedures (eg, elective cardiac catheterization, defibrillator placement, ablations). Patients readmitted to the MICU were excluded because of the difficulty distinguishing between premature transfer from the MICU or potential problems in care that might have occurred prior to the time of transfer from those occurring during follow‐up care on the Medicine floor services.

Computerized medical records of eligible patients were searched for demographic information and for admitting and transfer diagnoses (with the latter being categorized using a taxonomy we developed for classifying unplanned transfers, Table 1). Three independent observers (all of whom were board certified in Internal Medicine and had been practicing as Hospitalists at our institution for a minimum of three years) retrospectively reviewed each patient's hospital record to determine the cause of the unplanned transfer using this taxonomy. All three also made a judgment as to whether deterioration was evident at any time within the 12 hours preceding the unplanned transfer on the basis of clinical criteria used as our hospital's rapid response triggers (Table 2). When clinical triggers were found, each of the reviewers independently judged whether the unplanned transfer might have been prevented had different or earlier interventions been instituted. Each reviewer was blinded to the results of the other two.