Good afternoon everyone. Welcome back. I know many people are still filtering in from lunch. I hope you enjoyed your lunch Just to keep us on schedule. We'll go ahead and get started. You are in the chest pain. Am I registry track? So welcome Make sure you're in the place you intended to be I am so honored to introduce Cheryl Asuncion who will be sharing some exciting information about best practice programs Implemented at their facilities to help improve patient care presentations sharing information that hopefully will help all of you learn something new and Maybe perhaps think of new ways you can implement processes at your facility Cheryl Asuncion from JFK Medical Center Will be sharing her information Yeah, good afternoon everyone, thank you ACC for this opportunity to present today My name is Cheryl Asuncion, I am a cardiac nurse practitioner from JFK University Medical Center in Edison, New Jersey I am here today to present one of our quality initiatives on the impact of an advanced practice provider Lead protocol driven closed observation unit on heart score documentation compliance stress test utilization and length of stay Here are the following objectives for today's presentation Our unwavering dedication to the ACC and the NCDR has been a cornerstone of our healthcare institution for many years our quality teams enduring involvement with the NCDR dates back to 1999 over the years we have achieved prestigious designations from the ACC Notably our cap lab blazed a trail in New Jersey by becoming the first in the state and the eighth in the nation To get or attain ACC accreditation furthermore in 2019 We proudly became the first health care facility in New Jersey to earn the coveted heart care center designation Our remarkable achievement that underlines our unwavering dedication to delivering exceptional cardiovascular care To the community we serve So just a quick background established in 1967 JFK Medical Center stands as a distinguished nonprofit institution anchoring the health care landscape in central, New Jersey With a facility housing 498 beds. Our community hospital is a vital health care hub tirelessly serving the diverse and vibrant communities of Middlesex Union and Somerset counties JFK joined the Hackensack Meridian Health System in 2018 Marrying a complement of hospitals serving northern, central, and southern, New Jersey as You may already know chest pain is undeniably one of the most prevalent reasons why individuals seek urgent medical attention in the ED. The sheer frequency of patients presenting with this symptom places an immense workload in Hospitals and their dedicated staff members. Each year an estimated 5 to 8 million patients arrive at EDs across the nation And their chief complaint being chest pain. Among this substantial cohort Approximately 20 to 25 percent are swiftly diagnosed with ACS, a condition for which Treatments and management protocols are relatively straightforward. However, the remaining 6 million individuals Fall into the category of low-risk cases and their evaluation and subsequent treatment plan require a more nuanced approach JFK Medical Center much like any other health care institution faces the significant impact of chest pain presentation in the ED department In the year 2021 alone our hospital welcomed approximately 79,000 patients and among this considerable amount of patients around 6,000 annually or an average of 16 patients present every day with probable ACS Symptoms. Of these patients 23.9% Were ultimately diagnosed with ACS and the remaining 76% represented our low-risk chest pain population Currently 63% of these patients receive prompt evaluation and treatment and are discharged directly from our ED Meanwhile 29% of these patients are admitted for observation for further comprehensive assessment and appropriate management These statistics exemplify the dynamic challenges our health care professionals confront Daily while striving to offer a high quality patient-centered care. The next slides discuss current best practices out there that the team looked at and incorporated in our project So over the years ED physicians have been in search of effective tools to assist in the stratification of patients presenting with chest pain Their goal has been to reliably differentiate between those who can be safely be discharged from the ED Without the need for further workup and those who warrant more comprehensive and medical Evaluations. So in 2008 a tool emerged from the Netherlands in the form of the heart score a rapid risk stratification tool meticulously Designed for individuals with chest pain This invaluable tool empowers health care providers to categorize patients into three distinct risk groups Your low intermediate and high group it achieves this classification by considering a combination of factors Which includes the patient's chest pain history EKG findings Troponin results age and other pertinent risk factors by leveraging the heart score Healthcare professionals can now make a more precise and informed decision Promptly identifying patients who can be safely discharged home from the ED with confidence while reserving further testing and evaluation for those who require it an Observation unit within a hospital serves as a specialized area dedicated to closely monitoring and providing brief medical care To these patients with the primary goal of determining whether they can be safely discharged or they require further medical attention The concept of observation units has been in existence for many years actually since the 1970s under different names These units play a pivotal role in health care by striving to expedite The disposition of patients within a defined time frame and usually that's aiming for discharge Within 24 hours to no more than two midnights They also come in various models and one notable approach is the protocol driven Close observation unit model in these units patients are managed by one single physician group or specialty and oftentimes it's your ED physicians or APP's or advanced practice for providers and additionally disease specific protocols management guidelines Inclusion exclusion criteria are typically established in this closed observation model Research such as the 2013 study Conducted by Ross and colleagues and another study by dr. Margarita Pena have consistently demonstrated the advantages of a closed protocol driven Observation model this model has been associated with lower health care costs shorter lengths of stay reduced Diagnostic uncertainty improved patient satisfaction enhanced utilization of hospital resources and better clinical outcomes The role of an APP was originally introduced in the 1960s to address the escalating need for primary care especially in underserved and rural communities APP's have evolved significantly over the past six decades and today their impact extends far beyond primary care Encompassing specialties such as cardiology oncology Orthopedics and many more their versatile skill sets allows them to participate in diagnosing and treating patients Managing specialized medical procedures and enhancing patient access to specialized care in numerous studies APP's have been proven to improve various health care metrics such as health length of stay expediting time to consultation and treatment Lowering mortality rates enhancing patient satisfaction and generating significant cost savings So prior to this process improvement initiative our process started with the ED physician in Consultation with the ED case manager in identifying a patient that would potentially be an observation Service candidate the ED physician then informs the patient's primary care physician About the patient and the decision to admit the observation The primary care physician will then accept the patient underneath their service or defer to one of our hospitalist groups for management Admitting orders are then placed timing of which is variable I know you will all agree with me it takes hours and sometimes it happens the next day when that physician rounds on that patient and Then further workup is then deferred to a consultant who again does not place orders in until rounding on that patient It becomes very cumbersome for the chest pain APN in this situations Of coordinating care for that patient with a consultant who has not examined their patient So that she can either defer cardiac testing on patients that are excellent candidates for outpatient follow-up Once patient completes testing the onus of communicating these results are then placed on To the primary RN which most oftentimes the primary and RN had to wait hours to hear from that attending And then when you get the discharge order usually it takes multiple phone calls between that RN and that and that attending physician because Sometimes in some cases medications have to be clarified or the you know The patient has questions about you know, they're testing or any other questions With an open concept observation unit devioid of standardized protocols and guidelines for patient management There was a landscape of variable care that often resulted in unnecessary and redundant testing Both our institutional data and the NCDR chest pain MI registry data provided unequivocal evidence of the pressing need for improvement our data illuminated several critical areas for enhancement including the reduction of overall and chest pain patient lens of stay an increase in heart score utilization and documentation compliance and a significant decrease in stress test utilization So when we examined our baseline data in 2021, it revealed an average overall observation length of stay ranging from thirty point eight to thirty eight point four Hours with chest pain patient length of stay at 27 hours The heart score had minimal utilization with zero percent usage in 2018 but a noteworthy increase to 69 percent by 2021 with a chest pain APN rounding on this patient population Stress test utilization prior to discharge was consistently high fluctuating between 78% as high as almost 90% These statistics presented an indisputable case for the urgent need to revamp the management of these patients with the ultimate goal of streamlining care reducing length of stay Enhancing diagnostic precision and improving the overall patient experience We began brainstorming on implementing a closed observation unit in January of 2022 a Multidisciplinary committee which included leadership ED and chest pain center medical directors and our newly appointed closed observation unit medical director as well as nursing and APN Leadership bed capacity and our quality team was formed and met regularly In these meetings we decided on the processes protocols observation inclusion and exclusion criteria so that we can all convene and come to mutual agreement. Advanced practice providers with varying cardiac and acute care experience were hired, oriented and educated, and EPIC templates were also built to allow ease of documenting in this fast-paced environment. So now our new process began in June of 2022 when we implemented an APP-led protocol-driven closed observation unit model. So all patients were now admitted under our COU medical director service. The process begins with the ED physician identifying the patients eligible for observation services based on predefined inclusion and exclusion criteria. Subsequently, the case is then discussed with the observation APP, who plays a pivotal role in assessing eligibility. In some complex cases, consultations may be sought from our medical director or covering physician to determine suitability. In this new process, the ED case manager now switched to a more advisory role. Once the patient is accepted, the ED physician admits them to observation, and then the APP promptly takes charge examining the patient and establishing admitting orders. Our approach places a strong emphasis on utilizing disease-specific protocols as guiding principles for the APP in formulating a tailored plan for each patient. Consultations and specific tests are only initiated when deemed necessary, such as stress testing for patients with chest pain. If needed, cardiac patient cases are discussed with our chest pain center director or medical director for recommendations. For those chest pain patients who are eligible for outpatient testing, we ensure a smooth transition coordinating stress test schedules, and then, you know, our navigator also sets up primary care or cardiology appointments prior to discharge. Daily multidisciplinary rounds continued in this observation unit, but it was more multidisciplinary because it now involved the medical director, the APP for the day, charge and primary RN, case management and physician advisor. Outstanding tests, home needs, as well as barriers to safe discharge are discussed during these rounds. The APPs overseeing the unit operate with full autonomy over patient care, a change that has greatly streamlined communication and planning from an RN perspective. Moreover, with APPs available onsite 24-7, patients have the opportunity to engage with their providers in person, ask questions and discuss findings before their discharge, fostering a patient-centered and transparent care experience. The journey towards optimizing heart score utilization within our healthcare institution have been marked by notable milestones. Prior to the ACC accreditation for chest pain and introduction of a dedicated chest pain advanced practice nurse, rounding on this patient population, our heart score, as I mentioned a while ago, was at 0% in, that was in 2018. However, through a collaborative effort between the ED and the dedicated chest pain APN rounding on these patients, we made progress by raising utilization to 69% by 2019. However, noncompliance to heart score documentation remained unchanged in the 20 to 30% in the first half of 2022. The turning point arrived when the implementation of our close observation unit was, you know, implemented in June of 2022. It wasn't until the heart score was seamlessly integrated into the APN's documentation template and through the rigorous re-education of our ED physicians that you can see that there was a huge drop starting in December of 2022. And currently, we probably report a noncompliance rate of as low as 2 to 3%. In contrast to the data presented in the previous slide, this graph just, you know, sheds light on the remarkable progress we've made in terms of heart score utilization compliance. We are now currently in the high 90s consistently since December of 2022. Stress testing has historically been heavily utilized in this population. Our baseline data shows, as I mentioned a while ago, that as many as 90% of these patients underwent stress tests. Recognizing the need for change, we embarked on a concerted effort to enhance the utilization of heart score as a risk stratification tool. And as you can see by that utilization range, about fourth quarter of the previous year to the first quarter of this year, we saw that our stress test utilization kind of like hovered over the 50 to 60% range. And last, we observed an upward trend in stress test utilization during the second quarter of this year, prompting a proactive response. So now we initiated another initiative where the APPs for the day would do daily huddles with our chest pain medical director at 6 a.m. and 6 p.m. to kind of like discuss the case with the chest pain medical director to see if a stress test was truly needed for that patient prior to discharge. The introduction of our closed observation model has yielded remarkable improvements in length of stay for observation patients. In the year 2021, you can see here that our overall length of stay for these patients averaged at about 32.01 hours. However, with the implementation of a closed observation model in June of 2022, we began to observe a subtle reduction in length of stay. Again, it wasn't until September of the same year when we fortified adherence to our standardized inclusion exclusion criteria and disease specific management guidelines that we witnessed a significant drop in length of stay. Patients were now consistently being discharged in less than 24 hours, achieving an impressive rate of 60 to 70%. Currently our length of stay stands at 19.96 hours with an outstanding 76.09% of our patients being discharged within the 24-hour mark. This remarkable progress signifies an improvement of 12.05 hours or an impressive 37.64 reduction from our baseline data. The discharge of patients within 24 hours has seen a staggering improvement of nearly 80%, underscoring the substantial impact of this initiative on patient care efficiency. The improvement in length of stay has been a significant focus of our efforts, particularly in our chest pain patient population admitted to observation. In the first quarter of 2022, our average length of stay like I mentioned in the previous slides was 27 hours, a figure that had remained consistent throughout 2021. Despite implementing a closed unit model in June of 2022, as you can see here, we didn't really see any substantial improvement in the length of stay of our chest pain patients. But as we completed the full complement of APPs that run the unit and reinforced again the management guidelines for these patients, you can see that our length of stay dropped a couple of hours and currently we are 22.73 hours, which is approximately about two hours below the US benchmark. And this represents a remarkable 4.27 hour reduction from our baseline, translating to a 15.8% improvement. We initially embarked on a journey with specific goals in mind, never anticipating the ripple effect our actions would have beyond these defined objectives. Our focus was primarily on achieving specific outcomes, but as we introduced an APP-led closed observation unit with careful, delineated inclusion and exclusion criteria, we inadvertently influenced other key metrics as well. In 2021, 31% of admitted patients from the ED were dispositioned to observation service. We frequently had a significant volume of patients left in the ED waiting for days to be assigned beds in our observation unit because of the immense number of patients that needed to be placed in the unit. So you can see here that it improved with the implementation of the closed observation unit and in September of 2022, when we reached a full complement of APP staff, that we witnessed a significant and sustained impact, which became evident by November. Our efforts have culminated in a noteworthy achievement, a substantial reduction in the number of patients designated for observation. Today, we proudly report a rate of 24.1%, representing a remarkable 22% decrease from our baseline figures. In 2021, you can see that our inpatient conversion also went down from a baseline of 35.78%, which was tripled the national benchmark of 10% to 18.2%, an almost 50% reduction. The graph presented here serves as a compelling testament to the tangible benefits of implementing a closed observation unit. In conclusion, historically, a substantial portion of patients with chest pain has been held for further evaluation, often resulting in extended hospital stay. Furthermore, the absence of standardized care in an open concept observation unit under attending physicians has led to unnecessary consultations and testing before discharge, contributing to longer lengths of stay and a misallocation of healthcare resources. As we analyze the data collected both before and after the implementation of our initiative, it becomes evident that the introduction of an APP-led closed observation unit equipped with specific inclusion and exclusion criteria has severely impacted the efficiency of how we manage these patients. And that concludes my presentation today. I have a couple questions in the queue here, so I'm going to start with what's rising to the top first. I think this question is for Cheryl. I noticed you referred to an ED case manager. Is utilization management or review not a part of the admission process? Our facility has a lot of barriers with this part of the admission process, as there are delays between decision to admit from the ED perspective and hospitalist decision, which don't always align with the utilization review report. So in our facility, when we first, before we launched this initiative, it's almost like the decision to observe a patient relied on that case manager reviewing that case. Most oftentimes, the case manager would review the case, not seeing the clinical picture based on the clinical picture, but just what lab showed or what was documented. So what we found was it wasn't really because the patient wasn't meeting any inpatient criteria, but because the physician in the ED was lacking certain documentation that would make that patient amenable for inpatient or observation. Thank you.

best practice programs

patient care

STEMI Auto-Launch protocol

inter-facility STEMI transfer times

automated healthcare process

door-in-door-out times

STEMI management

inclusion and exclusion criteria

APP-led closed observation unit

length of stay

closed observation unit

heart score documentation compliance

stress test utilization

patient care efficiency

risk stratification tool