Abstract 57: Reduction Of Cardiovascular Admissions From The Emergency Department: A Coordination Of Care Model Using Early Access To Specialists After Normal Working Hours

Abstract

BACKGROUND: Despite the implementation of diagnostic and treatment algorithms for many common cardiovascular (CV) complaints, identifying low- and intermediate-risk patients presenting to the emergency department (ED) who could be managed without hospital admission remains difficult. We hypothesized that the presence of an attending cardiologist in the ED after normal working hours can help reduce the number of avoidable CV admissions by providing ED physicians with the support needed to identify, manage, and safely transition patients to the outpatient setting. METHODS: Beginning 08/22/2011, an attending cardiologist was available to consult on ED patients on weekdays between 6PM and midnight. The study population included all patients seen in the ED of an academic medical center on weekdays from 08/22/2011 to 11/30/2011 presenting in the afternoon/evening with a primary diagnosis of chest pain, atrial fibrillation (Afib), congestive heart failure (CHF), and syncope (based on ICD-9 diagnostic coding). Consultations were requested by the ED attending for patients where the intention was for inpatient admission, or where the disposition decision was complex. Rates of inpatient admission and 30-day return visit to the ED were compared to the same time period in the previous year using the Fisher’s exact test. RESULTS: Among patients presenting to the ED with one of the diagnoses of interest during the study period, there was a significant decrease in the inpatient admission rate compared to the same period in 2010 (52.0% vs. 38.6%; p<0.001, see Figure). Baseline clinical characteristics of the 2 cohorts were similar. During the study period, 174 consults were performed by the evening attending cardiologist with the diagnoses of interest accounting for 53% (n=93) of these. The decrease in admission rate was largely driven by an increase in the proportion of patients with chest pain being managed with observation in the ED (36.9% vs. 51.1%; p<0.001), and a decrease in the percentage of patients with Afib being admitted (61.1% vs. 45.0%; p=0.02). The incidence of return visits to the ED within 30-days following discharge did not increase (13.0%, 46/353 vs. 8.8%, 35/399; p=0.08). CONCLUSION: A program involving cardiology staff in the coordination of disposition decisions in the ED after normal working hours resulted in a reduction in the number of inpatient admissions for common CV conditions without increasing the incidence of return visits to the ED within 30 days.