Dr. Simon Mahler is one of the recipients of the 2013 AAMC/Donaghue Foundation grant Advancing Effectiveness Research and Implementation Science in Our Own Backyards. Dr. Mahler is an associate professor of Emergency Medicine at Wake Forest Baptist Health in Winston Salem, North Carolina. He oversees clinical outcomes research for the Emergency Medical Systems (EMS) Division of the Department of Emergency Medicine and holds leadership positions within the Clinical Research Unit of the Department of Emergency Medicine and the Wake Forest School of Medicine Critical Illness and Injury Recovery and Research Center (CIIRRC). In these roles he works to cultivate multidisciplinary and translational research spanning the full spectrum of medical care (from pre-, in-, and post-hospital environments). Download Dr. Mahler's ROCC Star profile.
Briefly describe the HEART pathway as a clinical decision making tool.
Each year, 8-10 million patients complaining of chest pain present to an emergency department (ED) in the US. When caring for these patients, physicians use liberal testing strategies to prevent missing an acute coronary syndrome (ACS). This results in >50% of ED patients with chest pain receiving a comprehensive cardiac evaluation (serial cardiac biomarkers and stress testing or angiography) at an cost of $10-13 billion annually, yet less than 10% of these patients are ultimately diagnosed with ACS. When these evaluations are completed on low-risk patients, they are associated with a substantial number of false positive and non-diagnostic tests, which often leads to invasive testing. There is a growing consensus within the US health care system regarding the need to more efficiently evaluate patients with chest pain.
The HEART pathway is a clinical decision aid designed to identify low-risk patients with chest pain for early discharge from the ED, focusing comprehensive chest pain evaluations on higher-risk patients who are more likely to benefit from testing. It provides test ordering and disposition decision-support to ED practitioners and personalized care planning for patients with acute chest pain. The HEART Pathway, combines a well validated tool called the HEART score with 0- and 3-hour cardiac troponin tests. Studies have demonstrated that the HEART Pathway can classify 20-40% of patients with acute chest pain for early discharge while maintaining a negative predictive value (NPV) for major adverse cardiac events (MACE) greater than 99% at 30 days.
Describe how the integration of the HEART pathway into the electronic health records has bridged your research with both clinical and educational enterprises at Wake Forest.
Full integration of the HEART Pathway clinical decision support into our electronic medical records is an example of how clinical research can be rapidly translated into clinical practice. Prior to HEART Pathway implementation our clinicians were using their gestalt to estimate a patient’s risk of ACS and to determine their testing and disposition decisions. The problem with gestalt is that many studies have shown that physicians tend to overestimate the risk of patients with chest pain, leading to unnecessary hospitalizations and cardiac testing. Now, when a health care provider sees a patient with chest pain in a Wake Forest ED they are able to quickly and easily determine whether that patient is high or low-risk using a more objective/standardized method. Furthermore, they receive real-time decision support regarding the appropriate testing and disposition for each patient. This has been a real cultural shift for our clinicians, but adoption has been tremendous and the feedback largely positive.
In addition to creating linkages between research and our health system operations this project also has impacted our educational enterprise. Prior to implementation in the Fall of 2014 nearly 500 healthcare providers (nurses, physicians, and advanced practice clinicians) across multiple departments were trained on use of the HEART Pathway. In addition, we have integrated the HEART Pathway into medical student education as part of a case-based “approach to chest pain” small group session within the 3rd year Internal Medicine Clerkship. Each small group has a multidisciplinary team of instructors consisting of a primary care physician, emergency physician, and cardiologist, emphasizing our team-based approach to acute chest pain care. Also, as an extension of the HEART Pathway project we have created a longitudinal quality improvement and patient safety curriculum for our medical students and a quality improvement academy for our graduate medical learners. We are excited about these additions to the medical school and GME curricula, because they should provide our learners with the knowledge and skills needed to participate in process improvement projects like the HEART Pathway in the future. Through the connections created between our research infrastructure, health system clinical operations, and the educational enterprise at Wake Forest, the HEART Pathway project has generated a framework for rapid knowledge translation at an academic medical center.
How have you succeeded in collaborating with colleagues outside of the emergency medicine department to promote the use of the HEART pathway? What role has leadership at Wake Forest played in advancing the project?
From the beginning of this project, key stakeholders within our health system (the CMO and CIO) and departmental leadership (Emergency Medicine, Internal Medicine, Family Medicine, Cardiology, and Hospitalists) were engaged in the implementation of the HEART Pathway. We were able to quickly garner support for our project by closely aligning the priorities of our project to the strategic plans of the health system. For example, one reason our project is appealing to our health system leadership, is how the HEART Pathway aligns with our transition into value-based purchasing payment models; providing high-quality care at a lower cost.
Institutional support and multidisciplinary collaboration have been key drivers of our successful integration of the HEART Pathway into the electronic medical records (EMR) and rapid adoption by providers. Our CMO, Dr. Howerton, has been instrumental in the success of this project by helping remove barriers as they come up. For example, training approximately 500 health care providers across multiple departments and disciplines, would have been impossible without the direct involvement health system leadership. Furthermore, by including the HEART Pathway as a part of the strategic vision for the health system, leadership has helped to give the project a high-priority.
Please share any preliminary findings from your research.
Our prospective pre/post interrupted time series study comparing the risk stratification of patients with acute chest pain before and after implementation of the HEART Pathway is ongoing. Data for this implementation study has been collected on >9,000 patient encounters. However, prior to our implementation study we piloted the HEART Pathway by randomizing 282 patients with acute chest pain to risk stratification via the HEART Pathway or usual care based on American College of Cardiology/ American Heart Association (ACC/AHA) guidelines. In this trial, use of the HEART Pathway increased early discharges by 21.3% (39.7% vs 18.4%, p<0.001), decreased objective cardiac testing at 30 days by 12.1% (68.8% vs 56.7%, p=0.048), and decreased LOS by 12 hours (9.9 vs 21.9 hours, p=0.013) compared to usual care. No patients identified for early discharge had adverse cardiac events within 30 days and the HEART Pathway was not associated with increased recurrent care. These findings suggest that full implementation of the HEART Pathway should have a big impact on the value of care for patients with acute chest pain.