• Martin P Than, John W Pickering, Jeremy M Dryden, Sally J Lord, S Andrew Aitken, Sally J Aldous, Kate E Allan, Michael W Ardagh, John W N Bonning, Rosie Callender, Laura R E Chapman, Jonathan P Christiansen, Andre P J Cromhout, Louise Cullen, Joanne M Deely, Gerard P Devlin, Katherine A Ferrier, Christopher M Florkowski, Frampton Christopher M A CMA Department of Medicine, Christchurch Heart Institute, University of Otago, New Zealand (J.W.P., C.M.A.F., P.M.G., A.M.R., R.W.T.)., Peter M George, Gregory J Hamilton, Allan S Jaffe, Andrew J Kerr, G Luke Larkin, Richard M Makower, Timothy J E Matthews, William A Parsonage, W Frank Peacock, Bradley F Peckler, Niels C van Pelt, Louise Poynton, Richards A Mark AM Department of Medicine, Christchurch Heart Institute, University of Otago, New Zealand (J.W.P., C.M.A.F., P.M.G., A.M.R., R.W.T.). , Anthony G Scott, Mark B Simmonds, David Smyth, Oliver P Thomas, To Andrew C Y ACY Department of Cardiology (A.C.Y.T.), Waitakere Hospital, Auckland, New Zealand., Stephen A Du Toit, Richard W Troughton, Kim M Yates, and ICare-ACS Implementation Group.
• Emergency Department (M.P.T., J.W.P., M.W.A., R.C., J.M.D., O.P.T., J.M.D.) martinthan@xtra.co.nz.
• Circulation. 2018 Jan 23; 137 (4): 354-363.

BackgroundEfforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals.MethodsThis was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation RESULTS: There were 11 529 participants in the preimplementation phase (range, 284-3465) and 19 803 in the postimplementation phase (range, 395-5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%-37.7%) to 18.4% (6.8%-43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3-2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4-3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P=0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed.ConclusionsImplementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours.Clinical Trial RegistrationURL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.© 2017 American Heart Association, Inc.

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