Chest Pain Center FAQs
As a benefit to facilities that are pursing accreditation, our Accreditation Specialists conduct monthly "Ask the Experts" webinars. Information about topics to be addressed in upcoming webinars is posted in the CPC Accreditation tool.
Our accreditation experts have also posted the answers to several frequently asked questions about a number of important healthcare and related accreditation topics.
- Acute Coronary Syndrome Accreditation FAQs answered by Keri Morris
- Therapeutic Hypothermia FAQs answered by Anna Ek
- Door-to-Balloon Time FAQs answered by Kevin Wehrle
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FAQ: Acute Coronary Syndrome (ACS) Accreditation
Keri Morris, BSN, RN, AACC, CCCC
Accreditation Service Line Specialist
A: The vision for the ACS service line is to extend the focus beyond STEMI patients and help hospitals improve the care of the NSTE-ACS (NSTEMI and UA) and LOW-RISK patient populations. In most cases, these processes seem to be less defined. Of important note, currently there are no national registries capturing the LOW-RISK population at all. Our Accreditation Conformance Database (ACD) collects these metrics, so we can provide useful feedback on the hospital's process as it aligns with the recommended management and treatment strategies. The LOW-RISK population accounts for 80% of the chest pain patient volume. Our accreditation tool guides hospitals in building hardwired protocols and pathways to efficiently risk stratify and manage these patients. There is a great focus to minimize the variability between providers and improve the utilization of resources to reduce costs while elevating the delivery of care.
A: STEMI patients are the most critical upon presentation. They are the quintessential emergency. Hospitals have done an amazing job at building solid processes to facilitate reperfusion of the culprit lesion. With a NSTEMI, the patient is still having a heart attack but has not progressed to a STEMI yet. The UA patient is displaying signs and symptoms of a heart attack but it is not evident on the ECG or cardiac biomarker (Troponin). Often the plan of care remains variable, dependent upon such factors such as the time of day, day of the week, risk stratification method, provider-dependent strategy, hospital resources, etc. Accreditation frequently reveals these variabilities and assists hospitals in developing pre-determined pathways to ensure the right care is delivered at the right time to the right patient. The guidelines are out there, but hospitals continue to struggle with operationalizing the science. For the LOW-RISK patient care, pathways are even less well-defined, yet this group reflects the majority of the volume which brings a huge liability.
A: The LOW-RISK population is an ongoing challenge. Despite an array of diagnostic modalities and strategies, there remains this task to appropriately identify those patients who require extended work-up or rule-out versus those who can safely be discharged from the ED. Failure to detect a patient with ACS and inadvertently discharging them can result not only in harm to the patient, but significant liability to the provider and hospital. On the other hand, patients not at high risk of having an acute event who are inappropriately admitted and undergo expensive evaluations set the facility up for RAC audits. I believe ACC Accreditation Services plays a vital role in setting the standard of care for the LOW-RISK patient. By taking science to the bedside™ through the accreditation tool, facilities are given a road map to guide them in delivering evidence-based care. By collecting performance and outcomes data in the ACD, we are able to demonstrate the impact our tool has on the components of value-based purchasing and reimbursement programs.
FAQ: Therapeutic Hypothermia
Anna Ek, BSN, RN, AACC
Accreditation Review Specialist
Anna Ek has a strong background in cardiac, surgical, and PACU nursing. She began her nursing career during the time of thrombolytic trials which ignited her longtime passion for cardiology. She has a strong interest in EMS practices and has met with EMS throughout the United States. She is a strong advocate of EMS and the part they play in the pre-hospital care of the cardiac patient. In addition, Anna has a keen interest in induced hypothermia therapy and continues to research its effects on the post-cardiac arrest patient.
Anna Ek is the in-house expert on drastically improved outcomes for the patient population because of therapeutic hypothermia treatments and "cooling centers."
A: Therapeutic hypothermia applications and protocols have not changed much in the last ten years. What has changed is the availability for patients to receive treatment post cardiac arrest in many regions of the country and world. More people in the country are aware of and are trained on bystander CPR and use of AEDs, vastly impacting survivability with intact neurological status. The impact of EMS assuming the care of the patient and transporting the patient to "cooling centers" has also drastically improved outcomes for this patient population.
The staff within the hospital setting have the patient under critical care for at least 24 hours of cooling time. During this time the patient is cooled, has vital signs, lab work, EEG and ECG monitoring constantly. It requires extra staff, technology and resources 24/7, thus the appropriate destination for EMS. We are encouraged by the community education aspect and its potential in the young cardiac arrest patient survival. Too many student athletes and people with no heart attack risk factors or coronary artery disease are dying. The newest campaign by the Sudden Cardiac Arrest Association emphasizes this difference.
We have this discussion with our partner facilities and are invigorated by the rapidly increasing participation in this effort. Community education is part of our criteria for ACS, heart failure and atrial fibrillation. We are hopeful that this topic will soon enter the community's conscience as well.
A: There are more hospitals providing this care every day. We find the majority of them in metropolitan areas, but it is a possibility in mid-size and smaller facilities as well. It does require resources and staff to implement the protocols appropriately.
A: While it takes resources to have therapeutic hypothermia at a hospital, it is not a huge financial barrier up front. The training on the cooling equipment is generally done by the sales representative for the staff. The probe, pads or blankets are not cheap, but considering overall costs, it lessens intensive care time and length of stay when the patient improves. These are truly critical patient scenarios and these loved ones deserve every possibility for survival. Long term care and therapy is where much of the care for a lot of these patients takes place, much as in the acute care setting. They may have some residual neurological and physical deficits that need to be addressed.
A: I wouldn't call it a trend; it is an evidence-based treatment protocol. I see it as standard of care for appropriate patient populations. Therapeutic hypothermia is not appropriate for all cardiac arrest patients, but I imagine that we will see non-cardiac arrest applications for other scenarios such as MI and stroke. We have seen it grow exponentially in its availability and application.
A: No, because EMS will generally take patients to facilities that have a Cath lab, bypassing non-PCI facilities. Perhaps we will see therapeutic hypothermia in facilities for other applications in those instances. We may see some rural facilities treat these patients in order to keep the patient in their own community.
A: Applications such as stroke, MI and other morbidities determined in the future.
FAQ: Door-to-Balloon Time: 47 Minutes!
Kevin Wehrle, RN, AAC
Accreditation Review Specialist
Kevin has a solid background in cardiac nursing and a passion for the community hospital setting. He has a strong desire to improve the ACS and Early Heart Attack Care education that is needed for the public. During his extensive nursing career, he developed a strong commitment for the critical care patient while working in the Intensive Care Unit and the Catheterization Lab. While at the hospital he advanced from a staff nurse into a leadership role as a Manager, then on to Cardiovascular Service Line Director with the added responsibility of being on the Steering Committee for developing an Interventional Angioplasty program with Open Heart surgery. Since joining us, he has reviewed a multitude of hospitals and truly appreciates the great things that are being done to improve ACS patient care processes.
Read the Q&A with Kevin Wehrle, who talks about PCI, our process, and how one hospital reduced door-to-balloon times!
A: PCI or Percutaneous Coronary Intervention is a non-surgical procedure to restore blood flow to a stenotic (narrowed) area within the affected coronary artery. PCI designation is treated a little differently when reviewing the documentation in that the hospital must have a written reperfusion strategy and support this process throughout the manual. In order to achieve PCI designation, a hospital must have on-site 24/7 emergent cath lab capabilities as well as having successfully performed 36 primary PCIs for STEMI over the last 12 months prior to the site visit.
A: When it comes to treating the STEMI patient, the only difference is where the interventional procedure takes place — either on-site at that specific hospital or at a facility that has the capability to perform the interventional procedure. In that case, the original facility would have to arrange for a patient transfer to the PCI-capable hospital. Now, please take into consideration that there are hospitals across the country that have an on-site cath lab and will utilize the PCI procedure as their primary reperfusion strategy; however, they may not have the Accredited Chest Pain Center with PCI designation. The only thing holding back the "PCI" designation would be the fact that they have not met the minimum number of 36 primary PCIs for STEMI over the previous 12 months.
A: If they do meet the criteria of more than 36 primary PCIs for STEMI over that period, we will look at their percentage that the door-to-balloon (D2B) time is under 90 minutes. For the current Cycle IV criteria, we want hospitals to have a D2B time under 90 minutes 85% of the time for the previous 6 consecutive months. Areas that directly affect the overall D2B time in the cath lab include but are not limited to the following: response time of the interventional team from first notification, cardiology response time, time spent in the ED prior to being delivered to the cath lab, and arrival in the cath lab to reperfusion.
A: There are a couple of basic things that we recommend to every facility. They are early activation processes, and a collegial/collaborative relationship between all departments working on the ACS patient. Early activation processes can be initiated from the EMS providers in the field by the ECG or report and will allow for staff to get prepared for the patient prior to arrival. A collegial/collaborative relationship will help eliminate the duplicated steps and increase the awareness for a seamless transition of care. Research has shown that steps done prior to the cath lab will help save 5-8 minutes of procedure time.
A: During a site visit in Florida, I had the opportunity to meet a patient who was admitted after experiencing a heart attack a couple of days prior. He relayed to me that he had experienced chest pain over the weekend and called 911 when the pain wouldn't subside after taking Nitroglycerin. When the EMS providers arrived on the scene, they immediately acquired an ECG and transmitted it to the hospital. He stated that the EMS crew was "very knowledgeable" about what was going to happen and reassured him that the staff would be waiting for them when they got to the hospital. He went on to tell me that he stopped in the ED for a "quick look" by the ED physician and they delivered him straight to the cath lab where the staff and cardiologist were waiting to "do their thing." As he stated to me on that day "they never slowed down and took great care of me without any interruptions." The subsequent door-to-balloon time was 47 minutes, and the patient has become an advocate for early recognition and activation for the local community.
A: Yes, it is and the entire staff attributed their success to the concepts and best practice ideas that they had learned from the accreditation process and the collegial/collaborative approach we offer to facilities. My partner and I left that hospital with huge smiles on our faces and knowing we are directly affecting ACS patient care across the country.