Navigating the challenges of outpatient evaluation for patients with acute coronary syndrome

In 2021, new guidelines were released for acute coronary syndrome (ACS).¹ The guidelines recommend that patients presenting with ACS symptoms in the emergency department (ED) be classified using validated risk scores. These include the HEART score, which accounts for the patient’s history, electrocardiogram (ECG), age, risk factors and troponin values, and the thrombolysis in myocardial infarction (TIMI) risk score.

Guidance suggests that low-risk patients can be discharged from the ED if they also have a non-ischemic ECG and negative high-sensitivity troponins. This protocolized clinical decision pathway can assist in determining a very low 30-day risk for major adverse cardiovascular events. It can also help reduce ED admissions and unnecessary testing.

Ultimately, it’s recommended that these patients have outpatient cardiology follow-up for consideration of outpatient cardiac testing. Given the frequency of chest pain as a presenting symptom in the ED, the implications of this guidance are vast. It would help alleviate concerns around hospital and ED overcrowding. In fact, one study showed that instituting these protocols increased ED discharges by over 20%.²  

As a result of this change in guidance, our InterQual® Level of Care content development team, which I proudly lead, needed to enhance the criteria in this subset at the Observation level of care in terms of patient safety. This change was not just a procedural update. It was an important step in our commitment to the highest level of patient safety.

Conceptually, this was challenging to accept and apply to patients presenting with chest pain. It required a significant change in the way patients with suspected ACS are evaluated.

As an actively practicing physician driven to ensure patient safety, it is important to me to also consider patients with lower risk scores who may be affected by issues related to social determinants of health (SDOH). Because appropriate cardiac testing must be scheduled within a reasonable time frame of the ED visit, it is essential to identify patients who may have limited access to health care, transportation issues or may not have a primary care physician to help coordinate care. 

During the development cycle, our clinical team thoroughly investigates the most recent evidence-based literature and determines the severity of illness of the patient and intensity of services provided during their complex hospital journey. We review and critically appraise societal guidelines, systematic reviews and meta-analyses, assign an InterQual evidence classification, and cite them to support related criteria within the content.

Once new and revised criteria are drafted, we query a panel of appropriate specialties to the topic being reviewed from more than 1,100 actively practicing external peer reviewers (EPRs). They are board-certified physicians and thought leaders in their respective specialties with extensive clinical experience across the U.S. in both community and academic practice settings.

When enhancing the InterQual ACS criteria, a new pathway was included at the Observation level of care to capture the patient population classified as low-risk based on HEART or TIMI risk scores with non-ischemic ECGs and negative high-sensitivity troponins.

By determining their pre-test probability (PTP) scores based on age, sex and symptoms, we developed and included criteria to allow for review of the patient who we are attempting to further risk-stratify by estimating the likelihood of having coronary artery disease (CAD).

If the PTP score is above a certain threshold and the patient has identifiable risk factors (diabetes, family history of CAD, etc.) despite being classified as low-risk, it would justify the need for in-hospital cardiac testing under the Observation level of care, especially for the patient who is unable to have outpatient cardiac testing performed or completed within 30 days because of issues related to SDOH. This was critical for us to incorporate in criteria to ensure patient safety and a safe discharge plan.

As part of our overall development process that includes external peer review, our EPRs validated this newly created low-risk pathway within the content. They confirmed its effectiveness in reflecting their guideline-driven practice patterns and achieving the approach to best capture standards of care and complexities involved with patients presenting with chest pain.

In summary, what lies at the heart of clinical content development is adhering to a single evidence-based content development process time and time again. This is what establishes consistency and most importantly, trust between our customers and the InterQual suite of products.

We will always follow the evidence when developing clinical content for the review of hospitalized patients with complex and acute medical conditions. InterQual’s clinical rigor demonstrates support for improving quality care and patient outcomes, and the ACS subset is just one of many noteworthy examples.