Cardiac MRI in obs lowers admissions
Cardiac MRI in obs lowers admissions
Approach does not compromise patient safety
The use of a cardiac MRI in the observation unit at Wake Forest University Baptist Medical Center in Winston-Salem, NC, resulted in lower cost at the hospital of about $588 per patient because 79% were managed without admission, according to a study published online in the Annals of Emergency Medicine.1 Additionally, this success occurred while the nurse practitioners and physician assistants working those units under the guidance of an attending physician were able to diagnose and prevent all cardiac events that might have occurred within 30 days of the hospital visit.
Cardiac MRIs are not commonly used in ED patients, notes Chadwick D. Miller, MD, MS, an assistant professor of emergency medicine at the Wake Forest University School of Medicine and lead author on the study. "While it is growing, with more and more literature coming out, it is moving slowly because of the infrastructure needed software, equipment, a program of people trained to do exams and interpret them so there are upfront expenses and barriers to developing one," Miller explains. "That was one of the reasons we wanted to look at it: because you need a good rationale."
The MRI offers several advantages, he says. "One of the most important things is that it gives a pretty comprehensive evaluation of someone's heart," Miller says. "It allows us to look for areas of edema, one of earlier findings of heart attack, allows us to look at wall motion, allows us to do profusion testing at rest and during stress for blood flow, and gives delayed enhancement looks at areas of cardiac scarring or recent infarction. When you put the whole puzzle together, it can sort through whether the patient had a recent event."
Howard Blumstein, MD, FAAEM, the ED medical director and president of the American Academy of Emergency Medicine, says, "From my point of view, there are lots of advantages. As soon as we identify an ED patient as a moderate or high-risk candidate for an MI, we can send them right to the observation unit, which gets them out of the ED much faster." Such an approach bypasses the whole admission process in the ED and frees up an ED bed, Blumstein says. "It's incredibly valuable in these times of emergency room crowding," he says.
Financially, there also are advantages, Blumstein says. "They stay several hours or perhaps overnight, so there is the opportunity to bill for observation care, which is a little bit higher in terms of professional fees," he says. "It also frees up internal medicine consultants and lets us get to other patients much faster."
Patients were randomized
The study involved randomly assigning 110 ED patients with chest pain to "usual care," which involved admittance to the hospital, or care in the observation unit.
"The cardiac MRI had been traditionally relegated to more inpatient type tests. In the study, once the patients were randomized to the observation unit, the care pathway was that they underwent cardiac markers and stress cardiac MRI," Miller says.
Blumstein adds, "When someone comes into the ED and we're concerned they might possibly have acute coronary syndrome, we stratify them to low, moderate, or high risk. Per our established protocol, only low-risk patients go to observation, while moderate and high-risk patients get admitted formally to the hospital." What made the study unique, he points out, is that one group of patients received their MRIs in observation.
Reference
- Miller C, Hwang W, Hoekstra JW, et al. Stress cardiac magnetic resonance imaging with observation unit care reduces cost for patients with emergent chest pain: a randomized trial. Ann Emerg Med 2010;56:209-219.
Sources
For more information on using cardiac MRI in the observation unit, contact:
- Howard Blumstein, MD, FAAEM, ED Medical Director, Wake Forest University Baptist Medical Center, Winston-Salem, NC. E-mail: [email protected].
- Chadwick D. Miller, MD, MS, Assistant Professor of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC. Phone: (336) 716-6304. E-mail: [email protected].
More research being planned Although a study of patients who received cardiac MRI in the observation unit had impressive results, there is still more work to be done before recommending a shift in the standard of practice, says the head of the research project, Chadwick D. Miller, MD, MS, an assistant professor of emergency medicine at the Wake Forest University School of Medicine in Winston-Salem, NC. "We need a large-scale safety and multi-center study," Miller says. However, Howard Blumstein, MD, FAAEM, ED medical director at Wake Forest University Baptist Medical Center, where the study was conducted, sounds like a believer. "I have to admit we have not formally sat down and discussed it, but as medical director I'd certainly like to change," Blumstein says. "We have experience now that the MRI process for moderate and high risk patients is efficient and cost effective, and at least equal clinically, to justify changing what we do operationally." Miller does agree that cardiac MRI "should be seen as a viable care pathway for the observation unit. In that environment, it seems to be a promising way to manage these patients." Because of the time and financial investment it requires to purchase equipment and train providers, Blumstein says that ED managers who are interested in this approach need to be thinking ahead. "My advice to them is that further research is going to come down the pike over the next few years, so if I was in their position and their institution had not done anything yet, I'd start talking to radiology and cardiology about getting studies going," he says. It takes two or three years to put the requisite machines, software, and clinicians in place, Blumstein says. "By the time they're in place, additional research will be there to indicate how it can best be used," he predicts. "If you don't start your setup now, you'll be behind the curve." |
Plan in advance for MRI patients There are some factors that eliminate otherwise appropriate candidates for cardiac MRI from consideration, and you should obtain that information in advance, advises Howard Blumstein, MD, FAAEM, the ED medical director at Wake Forest University Baptist Medical Center in Winston-Salem, NC. For example, "if a patient is on medications that slow their heart rate down, you have to get it up, and it may be difficult to do that," Blumstein says. Patients with claustrophobia might refuse to take the test, he says, and larger patients might not fit in the machine. "In our experience, selection of patients is very important," he says. "You have to think of these things in advance and ask the appropriate questions of the patients." Without such advanced planning, "it torpedoes the whole process," says Blumstein. |
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