The study was done at 3 hospitals in North Carolina: Wake Forest Baptist Medical Center (WFBMC), with approximately 114000 ED visits annually; Davie Medical Center (DMC), with approximately 12000 annual ED visits; and Lexington Medical Center (LMC), with approximately 37000 annual ED visits. The target population was adult ED patients (≥21 years old) investigated for possible ACS, but without evidence of ST-segment elevation myocardial infarction (STEMI) on electrocardiography (ECG). Inclusion criteria were the same throughout the pre- and post-implementation periods. Patients with a chief complaint of chest pain and at least one troponin ordered, without evidence of a STEMI on ECG, were accrued. This included patients with known coronary artery disease (prior myocardial infarction, prior coronary revascularization, or known coronary stenosis ≥70%). In addition, patients with other complaints that were concerning for ACS were included if the provider used a study specific EHR flowsheet for possible ACS, which was available in both the Pre- and Post-cohorts.
At WFBMC and DMC, participants were accrued into the pre-implementation cohort (November 2013-October 2014) or the post-implementation cohort (February 2015-January 2016). A wash-in period (November 2014- January 2015) was used to train providers and beta-test an electronic health record (EHR)-based HEART Pathway clinical decision support tool. LMC accrued patients into the pre-implementation (January-July 2015) and post-implementation cohorts (August 2015- January 2016), with a 1-month wash-in period. Patients were accrued into each cohort based on the date of their initial ED visit; later visits for chest pain were considered recurrent care. To prevent accruing more ED repeat users/high utilizers (who often have more co-morbid conditions) into the pre-implementation cohort, patients with an ED visit for possible ACS at each site in the year before the study began (N=523) were excluded from analysis. Patients transferred within the network or visiting multiple sites were classified based on their original ED visit. For transfers, care at the receiving hospital was considered part of their index encounter.
At WFBMC and DMC, participants were accrued into the pre-implementation cohort (November 2013-October 2014) or the post-implementation cohort (February 2015-January 2016). A wash-in period (November 2014- January 2015) was used to train providers and beta-test an electronic health record (EHR)-based HEART Pathway clinical decision support tool. LMC accrued patients into the pre-implementation (January-July 2015) and post-implementation cohorts (August 2015- January 2016), with a 1-month wash-in period. Patients were accrued into each cohort based on the date of their initial ED visit; later visits for chest pain were considered recurrent care. To prevent accruing more ED repeat users/high utilizers (who often have more co-morbid conditions) into the pre-implementation cohort, patients with an ED visit for possible ACS at each site in the year before the study began (N=523) were excluded from analysis. Patients transferred within the network or visiting multiple sites were classified based on their original ED visit. For transfers, care at the receiving hospital was considered part of their index encounter.
