Reducing Chest Pain Hospital Admissions

From the 2019 HVPAA National Conference

Dr. Shyam Odeti (Ballad Hospital)


In United States, Chest pain (CP) accounts for 6% of all ED visits and 18% of all observation admissions. Only 7% of CP ED visits have true ACS, however 60-70% of patients are admitted to the hospital. JMH is a 140 bed hospital and we started Interventional Cardiology program with 3 cardiologists in 2014. Much to our surprise, we saw a drastic increase in patient influx far beyond what was originally anticipated. We had an approximately 30% increase in our total volume of patients admitted to the hospital in both inpatient and observation categories. We noticed 71% of CP patients admitted to the hospital . This lead to overall increase in observation patients to 32% and average observation length of stay of 36 hours. This lead to patients being held in ED and delay in care along with other financial and resource challenges.

The impoverished Appalachian communities of rural Southwest Virginia, a large portion of our patients (around 60%) were insured by Medicare or Medicaid or were self-payers. Patients are usually responsible for significant portion of the bills that result from Observation care. There is usually a large Co-pay during an observation stay. The financial burden on our patient population for these stays was significant. This led us to look for opportunities addressing these challenges.


To reduce low risk chest pain hospital admissions. To decrease the Observation Length of Stay. To reduce the variation in practices and improve Evidence Based Care.


Adopted the evidence based HEART Score to risk-stratify CP patients. Collaborate with the IT staff to integrate a “CP Pathway” into our EMR software. Include all our partners in the care of patients – Emergency physicians, Residents, Cardiology team, IT, and Nursing – in a Rapid Improvement Event (RIE) to develop a Chest Pain Algorithm based on close cardiology follow-up and direct stress test scheduling. Conduct extensive education to all team members using interactive sessions, meetings, email, posters, and monthly review of patient cases.


61% reduction in CP observations from FY 2015 (1139) to FY 2018 (445).

$7 million health care savings to the community

36hrs to 24hrs decrease in observation length of stay

30% to 25% decrease in total percentage of observation admissions

46% reduction in total chest pain admissions

Impact of the Project

This project serves as testament to our commitment to the community we serve by providing the best health care, reducing patient harm with invasive work up and simultaneously being cost efficient.

This project not only has eliminated our challenges with ED holds and bed availabilities.

Our cath lab’s “Door to Balloon time’ is in “Top Decile” in the country.

Expansion of the process through 21 Ballad hospitals to expand our best practices to all facilities of our organization.

Most importantly, we can proudly say that we have saved about $5411 for each of our 1356 patients who were not placed in observation and safely discharged home.


Due to the simplicity of this quality initiative this can be replicated in most organizations for this common admitting diagnosis. Chest Pain being one of the most common reason for ED physician involved in malpractice lawsuits, with evidence based tools and support we can avoid unnecessary cost and invasive interventions.


What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

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