Cardiology/original researchAn Analysis of the Association of Society of Chest Pain Centers Accreditation to American College of Cardiology/American Heart Association Non–ST-Segment Elevation Myocardial Infarction Guideline Adherence
Introduction
Emergency departments (EDs) in the United States treated more than 115 million patients in 2005, including more than 5 million with undifferentiated acute chest pain.1 Emergency physicians are responsible for rapidly identifying and initiating evidence-based treatment in patients with acute coronary syndromes. The American College of Cardiology/American Heart Association (ACC/AHA) publishes evidence-based guidelines for the management of non–ST-segment elevation myocardial infarction (NSTEMI).2 The ACC/AHA guidelines recommend that patient risk stratification be performed by consideration of history, physical examination, and an ECG. If early diagnostics are inconclusive, serial ECGs and serial cardiac marker tests may be indicated. According to this information, patients are stratified into ST-segment elevation myocardial infarction (STEMI), NSTEMI, unstable angina, or noncardiac chest pain cohorts, and appropriate therapy is initiated.
Despite widespread dissemination of the ACC/AHA guidelines, adherence has been inconsistent.3, 4 The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative and the Society of Chest Pain Centers (SCPC) were formed to help in the care of this population and improve adherence. The CRUSADE initiative was established to improve adherence with ACC/AHA recommendations by providing feedback to each member site on adherence rates and comparison rates. The SCPC was formed in 1998 to educate physicians and assist hospitals in the development of protocolized, evidence-based risk stratification and treatment pathways and protocols for patients with suspected acute coronary syndrome. These pathways incorporate many of the ACC/AHA recommendations, thus helping with evidence-based care. In 2003, the SCPC initiated an accreditation process based on 8 key principles to evaluate the triage and diagnostic processes. To date, approximately 440 centers have been accredited or are in the process of being accredited by the SCPC.5 The association of accreditation with adherence to the ACC/AHA recommendations for patients with NSTEMI has not been evaluated.
Our primary objective was to evaluate the association between SCPC accreditation and adherence to the ACC/AHA evidence-based guidelines for NSTEMI. A secondary analysis was performed to describe the association between accreditation and patient outcomes.
Section snippets
Study Design
A secondary analysis of the CRUSADE initiative study design was performed to assess the association between SCPC accreditation and adherence to treatment guidelines and patient outcomes.
The CRUSADE initiative is a voluntary, observational, quality improvement initiative begun on January 1, 2001, that was designed to improve the quality of evidence-based care for patients with NSTEMI and acute coronary syndrome.6, 7 In confirmed NSTEMI patients, participating hospitals were asked to collect and
Results
The registry contained a total of 189,065 entries at analysis. The number was narrowed to 35,141 patients after limiting of the analysis to 2005. Patients were excluded from this analysis for several reasons. First, 1,646 were excluded because of negative cardiac biomarker results. An additional 174 were excluded because of death within 24 hours because the hospital did not have a full 24 hours to comply with the ACC/AHA guidelines, leaving 33,321 patients. Finally, 83 patients from hospitals
Limitations
There are several issues that should be considered in the interpretation of the results of this study. First, this study is a retrospective observational one and does not establish a causal relationship between SCPC accreditation and guideline adherence. Further studies are required, including prospective longitudinal assessments of care at these hospitals. Second, although the CRUSADE registry is among the largest acute coronary syndrome registries in the world, it enrolled only a subset of
Discussion
Accreditation by the SCPC is associated with improved ACC/AHA guideline adherence to aspirin and β-blocker administration and no difference in door-to-ECG times or heparin and glycoprotein IIb/IIIa administration, as evaluated by the CRUSADE registry of NSTEMI patients. Although our analysis did not demonstrate a difference in death, myocardial infarction, cardiogenic shock, postadmission infarction, congestive heart failure, or major bleeding, larger studies have demonstrated that better
References (16)
- et al.
ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina)
J Am Coll Cardiol.
(2002) - et al.
The prognostic significance of serial myoglobin, troponin I, and creatine kinase-MB measurements in patients evaluated in the emergency department for acute coronary syndrome
Ann Emerg Med.
(2003) - et al.
The Erlanger chest pain evaluation protocol: a one-year experience with serial 12-lead ECG monitoring, two-hour delta serum marker measurements, and selective nuclear stress testing to identify and exclude acute coronary syndromes
Ann Emerg Med.
(2002) - et al.
Chest pain unit concept: rationale and diagnostic strategies
Cardiol Clin.
(2005) - et al.
National Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Adv Data No. 386
(2007) - et al.
Association between hospital performance and outcomes among patients with acute coronary syndromes
JAMA
(2006) - et al.
Does concordance with guideline triage recommendations affect clinical care of patients with possible acute coronary syndrome?
Med Decis Making
(2007)
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Supervising editor: Keith A. Marill, MD
Author contributions: AC was responsible for study conception and design and drafting of the article. F-SO was responsible for analysis and interpretation of data. AC, SWG, F-SO, WFP, JKM, CBC, EDP, EMO, WBG, and MTR revised article critically for important intellectual content. AC, SWG, F-SO, WFP, JKM, CBC, EDP, EMO, WBG, and MTR were responsible for final approval of the submitted article. AC takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. CRUSADE is funded by the Schering-Plough Corporation. Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals Partnership provides additional funding support. Millennium Pharmaceuticals, Inc., also funded this work. WFP and JKM are directly involved with the Society of Chest Pain Centers. No other conflict of interest exists as related to the topic of this manuscript.
Publication date: Available online March 12, 2009.
Reprints not available from the authors.