Utilizing a Fast Track Nuclear Medicine Stress Test Protocol to Reduce Length of Stay for Low-to-Moderate Risk Patients with Chest Pain

2010 Objectives: Decreasing length of stay and increasing patient safety are two of the most integral metrics in healthcare today. With the continued shift to the pay-for-performance model, hospitals must improve these metrics or chance lost revenues. At Cleveland Clinic - Euclid both metrics were improved by reorganizing the way patients admitted to observation with chest pain get nuclear medicine stress tests. According to the CDC, chest pain is the third most common reason that people visit the Emergency Department(ED). Of those patients admitted for chest pain, more than 60% do not have acute coronary syndrome 1. By having a protocol to safely and efficiently identify the patients that would benefit from a nuclear stress test, unnecessary admissions and length of stay can be reduced. The systematic treatment of chest pain improves accountability among the departments as well as improves patient care. Methods: To create an effective process, we must focus on the patients, remove inefficiencies and have a process that encourages communication and teamwork. When a patient enters the Emergency Department with chest pain, ED physicians evaluate the cardiac risk factors of the patient using standard cardiac risk scoring. High risk patients are admitted to an inpatient floor, low-to-moderate risk patients are admitted to observation or held in the ED to be seen by cardiology. The ED is responsible for reconciling medications, updating the patient problem list and obtaining an accurate cardiac history to facilitate cardiology evaluation. Appropriate low to intermediate risk patients enter the cardiac fast track protocol for nuclear medicine stress imaging. Fast track nuclear imaging is an expedited nuclear medicine stress only exam that is capable of being completed in 1 hour. It provides a reduction of radiation exposure to the patient, as well as reducing the time of the exam in half. A resting scan is only performed when a defect is identified. In the modern era of Nuclear Medicine where few departments have Mo-99 generators, two contingency doses are always on hand for fast track patients. To provide continuous care and optimize safety, a nurse practitioner is present in the nuclear medicine department, as well as responsible for performing the stress test. If SPECT/CT is available, it can improve the accuracy of the images by increasing both the sensitivity and specificity considerably. An integral part of the protocol to get patients discharged in a timely manner is nurse practitioner follow-up with the admitting physician. At Cleveland Clinic - Euclid a nurse practitioner communicates with the admitting doctors to make sure that there are no other contributing factors requiring care before discharge after the nuclear stress test is complete. Results: Prior to establishing the nuclear medicine fast track protocol, data was collected from 40 patients over 3 months who fit the criteria for the fast track protocol. The average length of stay for those patients was 24.4 hours. After implementation of the protocol, the first 20 patients with the same criteria had their length of stay reduced to 12 hours. Length of stay for chest pain observation patients was reduced and a safer stress test environment was created. All stakeholders were more thoroughly informed of the patient’s care through the entire process. Conclusions: A nuclear medicine cardiac fast track protocol for chest pain patients can help cut down length of stay, as well as reduce costs of unnecessary admissions. The rapid diagnosis of acute coronary syndrome through nuclear medicine fast track testing also allows for a more informed decision to admit or discharge the patient. With the successful implementation of the fast track protocol at Cleveland Clinic - Euclid, we have hopes to expand this service throughout the enterprise. 1 LaSalvia, L., MD,MIB, Nadkarni, P. MD, & Bal, T. A. MD,MBA. (2010, December). Chest Pain Triage in the Emergency Department: An Integrated Diagnostics Approach