Impact of medical practice guidelines on the assessment of patients with acute coronary syndrome without persistent ST segment elevation
1 Internal Medicine 2 Cardiology, 3 Medical Intensive Care and 4 Emergency Center, University Hospital (CHUV), Lausanne, VD, Switzerland
Objective. To assess the impact of introducing clinical practice guidelines on acute coronary syndrome without persistent ST segment elevation (ACS) on patient initial assessment.
Design. Prospective before–after evaluation over a 3-month period.
Setting. The emergency ward of a tertiary teaching hospital.
Patients. All consecutive patients with ACS evaluated in the emergency ward over the two 3-month periods.
Intervention. Implementation of the practice guidelines, and the addition of a cardiology consultant to the emergency team.
Main outcome measures. Diagnosis, electrocardiogram interpretation, and risk stratification after the initial evaluation.
Results. The clinical characteristics of the 328 and 364 patients evaluated in the emergency ward for suspicion of ACS before and after guideline implementation were similar. Significantly more patients were classified as suffering from atypical chest pain (39.6% versus 47.0%; P = 0.006) after guideline implementation. Guidelines availability was associated with significantly more formal diagnoses (79.9% versus 92.9%; P < 0.0001) and risk stratification (53.7% versus 65.4%, P < 0.0001) at the end of initial assessment.
Conclusion. Guidelines implementation, along with availability of a cardiology consultant in the emergency room had a positive impact on initial assessment of patients evaluated for suspicion of ACS. It led to increased confidence in diagnosis and stratification by risk, which are the first steps in initiating effective treatment for this common condition.
Keywords: acute coronary syndrome, chest pain, clinical practice guidelines, emergency, risk
Address reprint requests to Jean-Blaise Wasserfallen, Internal Medicine, University Hospital (CHUV), CH-01011 Lausanne, VD, Switzerland. E-mail: jwasserf{at}chuv.hospvd.ch
Accepted for publication June 4, 2004.
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