ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway.

BACKGROUND: Efforts 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. METHODS: This 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. CONCLUSIONS: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. CLINICAL TRIAL REGISTRATION: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.

General practitioners' attitudes toward (and use of) complementary and alternative medicine: a New Zealand nationwide survey.

AIMS: This study aimed to update our understanding of how general practitioners view and use complementary and alternative medicine (CAM). METHOD: A nationwide cross-sectional postal questionnaire sent to 500 randomly selected general practitioners (GPs) of the 2358 who met the inclusion criteria of the study in December 2005. RESULTS: 300 completed questionnaires were returned thus giving a response rate of 60%. Twenty percent of the GP respondents practiced (and 95% referred patients to) one or more forms of complementary and alternative medicine. The most common CAM therapy practiced by GPs was acupuncture, and chiropractic manipulation was the most common GP-referred therapy for patients. Thirty-two percent of respondents had formal training and 29% had self education in one or more CAM therapies. Sixty-seven percent felt that an overview of CAM should be included in conventional medical education. CONCLUSIONS: The number of GPs practising CAM therapies has decreased over the past 15 years, although the number referring patients to CAM has increased. The finding 'that GPs feel information about CAM should be included in medical education' is consistent with earlier research and should be taken into account when developing the medical curriculum.