The Impact of a Non-Emergency Department Based Cardiac Direct Access Unit on Hospital Admissions

From the 2019 HVPAA National Conference

Ms. Lynn Mackinson (Beth Israel Deaconess Medical Center), Mrs. Gail Lopez (Beth Israel Deaconess Medical Center), Dr. Karen Cajiao (Beth Israel Deaconess Medical Center), Dr. Joseph Wallins (Massachusetts General Hospital), Dr. Cynthia Phelan (Beth Israel Deaconess Medical Center), Dr. Michael Gavin (Beth Israel Deaconess Medical Center)

Background

Per earlier reports, 61% of patients with a cardiac complaint and 70.8% with chest pain evaluated in our emergency department (ED) were observed or admitted. National admission rates for atrial fibrillation and CHF are 62% in 2014 and 77.3%respectively. We previously demonstrated that involving cardiologists early in the management of patients in the ED can reduce admission rates.

We opened a cardiology managed, outpatient Cardiac Direct Access (CDAc) unit to perform urgent, same day evaluation of patients with cardiac symptoms in an effort to avoid ED visits and reduce observation and inpatient stays. The CDAc unit includes 5 clinic rooms and 6 overnight observation beds and is staffed with an attending cardiologist who takes direct referrals from primary care providers, urgent care centers, and specialists from Monday through Friday, 8am – 11pm.

Objective

To assess inpatient and observation utilization among patients referred for urgent evaluation by a cardiologist in a non-ED setting.

Methods

We performed a retrospective chart review of 710 consecutive patients referred to the CDAc between November 2016 and November 2017. Final disposition was determined using charge data. Readmissions were determined by chart review and 30-day follow up phone calls to address return visits to outside hospitals (n=473, 67% of patients were reached). We have collected patient reported measures (Press Ganey Associates, Inc.) since October, 2017 and report on data from Fiscal Year 2018.

Results

Patients were referred by primary care (n=404, 57%), cardiac (n=251, 35%) and non-cardiac specialist (n=55, 8%) physicians. The most common reasons for referral were chest pain, arrhythmia, and suspected heart failure. Disposition of patients evaluated in the CDAc are reported in the figure. Mean length of stay for observation in the CDAc was 20.5±12.8 hrs. Within 30-days after discharge from the CDAc, 14 (2.0%) returned to the CDAc, 38 (5.4%) were admitted to a hospital, and 20 (2.8%) were seen in an ED.

Press Ganey data from FY 2018 reported CDAc patients’ ‘overall rating of care’ score at 95.7 out of 100. CDAc received a 95.5 average ‘likelihood of recommending’ score and 95 out of 100 in the category of ‘staff worked well together to provide care’.

Conclusions

We demonstrated that early management of patients in a CDAc unit appears to increase the percentage of patients discharged without observation or admission to the hospital. Patient reported measures suggest a highly satisfactory patient experience of care in CDAc.

Clinical Implications

Favorable observation and inpatient utilization rates among patients seen in a cardiology-directed observation unit suggest that CDAc units can serve as a high value alternative to the ED for appropriately selected patients. This study motivates a prospective study of rigorously matched ED and CDAc cohorts to compare utilization, safety and cost-effectiveness.

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