Shared decision making in the management of low risk chest pain in the ED

Christopher Fischer

Why did we start?  
Chest pain is the second-most common reason for emergency department visits. Given the potential medical, legal, and psychological effects associated with missing the diagnosis of acute coronary syndromes, clinicians have a low threshold to admit patients for prolonged observation and advanced cardiac testing.
At CHA, there are over 1,000 annual admissions for patients with chest pain. Approximately 40% of admitted patients are discharged within 1 day without advanced cardiac testing.
We identified that there was a clear need for a clinical pathway for ED patients with chest pain that is evidence-based, sensible, best utilizes available resources, and includes patient perceptions and understanding of risks. The objective of this pathway is to identify patients who are at low enough risk of acute coronary syndrome or other adverse outcomes and could be safely discharged from the emergency department.

What did we do?
We developed and are in the process of implementing a clinical pathway for the evaluation of ED patients with chest pain that includes the following components:

1.        HEART Score decision aid: a validated decision aid that utilizes clinician impression of the patient's history, EKG, age, risk factors, and biomarkers obtained in the ED. This decision aid is seamlessly integrated into the electronic health record and provides real-time, point of care decision support for the ED physicians.

2.       Chest Pain Choice Shared Decision Making Tool: a validated patient-directed tool used to discuss risk stratification with patients, and engages patient in a risk-informed discussion with the ED physician that includes patient preferences.

What did we find?

  • Development and implementation of real-time clinician decision support requires close co-ordination of multiple stakeholders: clinicians, patients, IT, legal, researchers. Aligning the goals of all stakeholders requires significant ongoing effort.

  • Adopting validated tools to our practice environment is an iterative process (one size does not fit all), and the input of patients is vitally important.

  • Explicit discussions about risk-informed decision making are common amongst physicians, but explicit discussions about risk between clinicians and patients is less common. Patients may have different views about risk, and integration of those views into clinical decision-making requires a real-time discussion.

What does it mean?
Implementing a clinical pathway has the potential to improve care, use resources appropriately, and improve patient knowledge.