Better Collaboration Between the Emergency Department and the Clinical Lab Can Improve Clinical Outcomes for Patients With ACS

By Djiby Diop, MD, MMS, MPH

 Given the current health care system, there is no doubt that the emergency department (ED) has emerged as the central entry point for patients with acute and chronic diseases. For many reasons, the ED has become a safety net for more patients than in the past, both insured and uninsured. Yet the ED cannot handle this influx alone. Working in collaboration with the clinical laboratory, the ED can vastly improve patient diagnosis and care, particularly in cases of acute coronary syndrome (ACS).

The increased use of the ED has led to many problems, including ED overcrowding, increased length of stays (LOS), delays in time-dependent treatment, safety issues, patient dissatisfaction, and poor clinical outcomes. Many of these problems are interrelated. For example, studies have shown that in the ED, LOS is an important determinant of patient satisfaction (1,2). And patient satisfaction has been shown to have a direct effect on patient compliance with treatment as well as medical malpractice lawsuits (3).

Overcrowding has become a national epidemic in many medium to large EDs across the United States. Causes of this overcrowding include increased patient volume; increased acuity and complexity of diseases presented by patients; the downsizing of hospital beds due to a lack of staffing and financing; economic effect of managed care; language and cultural barriers; a nursing staff shortage; more complex medical record documentations; a lack of follow-up care clinics that remain open during off-hours; and delays in laboratory radiology and other ancillary services (4). These factors have a negative impact on patient care, ranging from patient safety and patient dissatisfaction, to hospital diversions, poor clinical outcome, and lost revenues.

If there is one disease category where these factors can and do have a serious direct impact, it is on the diagnosis and management of patients who present to the ED with ACS. The diagnosis and treatment of ACS can be time-consuming and costly, both in terms of health care dollars and human resources.

This point becomes clear when one considers that of the 8 million patients who present with chest pain to EDs across the United States, 5 million are admitted for a diagnosis of ACS. Yet as many as 85% of these admitted patients end up having ACS ruled out. Furthermore, the electrocardiogram (ECG) on which the medical community so heavily depends is nondiagnostic in 50% of the patients found to have acute myocardial infarction (AMI) by cardiac enzymes (5,6,7).

It is for this reason that the clinical laboratory can play a crucial role in bringing solutions to the complex problems that face EDs. The development and implementation of an effective evidence-based ACS protocol will demand that the clinical lab provide or assist the ED physicians in developing biocardiac markers that are sensitive enough to aid in the effort to risk-stratify and prognosticate patients presenting with ACS.

The clinical lab can play a direct role in reducing overcrowding and decreasing LOS by offering a service line that provides the results of the cardiac markers to the ED physicians within 17 to 30 minutes from the time these tests are ordered. Meeting these goals will require the clinical lab to make the physicians aware of not only critical values but also the negative and positive cardiac markers, both of which are important in managing patients with ACS in a cost-effective manner.

According to the Institute of Medicine, there are nearly 98,000 in-patient deaths per year due to medical errors, with an unknown number of near-misses (1). Many of these errors occur in the ED. The problem, however, is not only those errors caused while the caregiver is performing a procedure or providing medication; medical errors also include acts of omission. For example, there are often delays in providing time-dependent treatment for patients suffering from ACS or delays in deciding how aggressive the treatment should be, ie, whether it should be medical (thrombolytics with adjunct therapy with antiplatelet and antithrombotic therapy), percutaneous coronary intervention (PCI), or open heart surgery (CABG). Having effective cardiac markers available will have important implications for the ED physicians making these decisions.

Clinical laboratory support is also crucial if the ED is going to meet the national standard of door-to-needle of 30 minutes and door-to-balloon of 90 minutes (8). This is important not only in averting or limiting the size of the AMI, but also in reducing or preventing its complications, such as left ventricular dysfunction (LVH).

With the clinical laboratory efficiently and effectively supporting ED physicians by providing cardiac markers that are highly sensitive and specific in a timely and dependable manner, the LOS will decrease, patient satisfaction will improve, and ED overcrowding and hospital diversions will be avoided.

An area of great interest to hospital administrators is physician efficiency and productivity. A short turnaround time will reduce endless periods of idle time, which often leads to ED inefficiency and throughput problems. Such an efficient system can only result in better clinical outcomes and a cost-effective health care delivery system. This, however, cannot occur until the clinical laboratory and ED physicians see each other as essential partners in the delivery of health care to patients presenting to the ED with ACS.

Djiby Diop, MD, MMS, MPH, is assistant professor of Emergency Medicine, director of Quality Assurance, and director of the Master of Public Health program at the University of Massacusetts Medical Center in Worcester, Mass.

References
1. Bursch B, Beezy J, and Shaw R. Emergency department satisfaction: what matters most? Ann Emerg Med. 1993; 22:3:586-591.
2. Matitra A, and Chikhani C. Patient satisfaction in an urban accident and emergency department. Br J Clin Pract. 1992; 46(3): 182-184.
3. Rubin Hr, and Wu AW. Patient satisfaction: its importance and how to measure it. In: Gitnick GL, Rothenberg F, Weiner JL, eds. The business of medicine. New York: Elsevier Science Publishing Co Inc, 1991: 397-409.
4. Derlet RW, and Richards JR. Overcrowding in the nation’s emergency department: complex causes and disturbing effects. Ann Emerg Med. 2000; 35:63-67
5. National Institute of Medicine Report 2000
6. JACHO
7. Galvani M, Fottani, Ferrini D, et al. Prognostic influence of elevated values of cardiac Troponin I in patients with unstable angina. Circulation 1997; 95:2053-2059.
8. ACC/AHA Guidelines 2002. Guidelines update for the management of patients with unstable angina and non-ST-segment elevation MI.