Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project.

OBJECTIVE: To evaluate hospital length of stay (LOS) and admission rates before and after implementation of an evidence-based, accelerated diagnostic protocol (ADP) for patients presenting to emergency departments (EDs) with chest pain. DESIGN: Quasi-experimental design, with interrupted time series analysis for the period October 2013 - November 2015. Setting, participants: Adults presenting with chest pain to EDs of 16 public hospitals in Queensland. INTERVENTION: Implementation of the ADP by structured clinical re-design. MAIN OUTCOME MEASURES: Primary outcome: hospital LOS. SECONDARY OUTCOMES: ED LOS, hospital admission rate, proportion of patients identified as being at low risk of an acute coronary syndrome (ACS). RESULTS: Outcomes were recorded for 30 769 patients presenting before and 23 699 presenting after implementation of the ADP. Following implementation, 21.3% of patients were identified by the ADP as being at low risk for an ACS. Following implementation of the ADP, mean hospital LOS fell from 57.7 to 47.3 hours (rate ratio [RR], 0.82; 95% CI, 0.74-0.91) and mean ED LOS for all patients presenting with chest pain fell from 292 to 256 minutes (RR, 0.80; 95% CI, 0.72-0.89). The hospital admission rate fell from 68.3% (95% CI, 59.3-78.5%) to 54.9% (95% CI, 44.7-67.6%; P < 0.01). The estimated release in financial capacity amounted to $2.3 million as the result of reduced ED LOS and $11.2 million through fewer hospital admissions. CONCLUSIONS: Implementing an evidence-based ADP for assessing patients with chest pain was feasible across a range of hospital types, and achieved a substantial release of health service capacity through reductions in hospital admissions and ED LOS.

Use of the Theoretical Domains Framework to evaluate factors driving successful implementation of the Accelerated Chest pain Risk Evaluation (ACRE) project.

BACKGROUND: The translation of healthcare research into practice is typically challenging and limited in effectiveness. The Theoretical Domains Framework (TDF) identifies 12 domains of behaviour determinants which can be used to understand the principles of behavioural change, a key factor influencing implementation. The Accelerated Chest pain Risk Evaluation (ACRE) project has successfully translated research into practice, by implementing an intervention to improve the assessment of low to intermediate risk patients presenting to emergency departments (EDs) with chest pain. The aims of this paper are to describe use of the TDF to determine which factors successfully influenced implementation and to describe use of the TDF as a tool to evaluate implementation efforts and which domains are most relevant to successful implementation. METHODS: A 30-item questionnaire targeting clinicians was developed using the TDF as a guide. Questions encompassed ten of the domains of the TDF: Knowledge; Skills; Social/professional role and identity; Beliefs about capabilities; Optimism; Beliefs about consequences; Intentions; Memory, attention and decision processes; Environmental context and resources; and Social influences. RESULTS: Sixty-three of 176 stakeholders (36 %) responded to the questionnaire. Responses for all scales showed that respondents were highly favourable to all aspects of the implementation. Scales with the highest mean responses were Intentions, Knowledge, and Optimism, suggesting that initial education and awareness strategies around the ACRE project were effective. Scales with the lowest mean responses were Environmental context and resources, and Social influences, perhaps highlighting that implementation planning could have benefitted from further consideration of the factors underlying these scales. CONCLUSIONS: The ACRE project was successful, and therefore, a perfect case study for understanding factors which drive implementation success. The overwhelmingly positive response suggests that it was a successful programme and likely that each of these domains was important for the implementation. However, a lack of variance in the responses hampered us from concluding which factors were most influential in driving the success of the implementation. The TDF offers a useful framework to conceptualise and evaluate factors impacting on implementation success. However, its broad scope makes it necessary to tailor the framework to allow evaluation of specific projects.

Diagnostic Yield of Routine Stress Testing in Low and Intermediate Risk Chest Pain Patients Under 40 Years: A Systematic Review.

OBJECTIVE: Chest pain is one of the most frequent causes for presentation to emergency departments (EDs). The majority of patients will undergo diagnostic workup including stress testing to rule out an acute coronary syndrome, but very few patients will be diagnosed with a cardiac cause for their pain. Patients under 40 years represent a lower risk group in which routine stress testing may be of little benefit. This systematic review sought to determine the diagnostic yield of routine stress testing in low- and intermediate-risk chest pain patients under 40 years. METHODS: Electronic databases were searched for relevant studies. The quality of the included primary studies was assessed using the National Health and Medical Research Council evidence hierarchy and the McMaster Critical Appraisal Tool for Quantitative Studies. Descriptive statistics summarized the findings. RESULTS: Five primary studies were included in the review (all level III-3 evidence); 7 additional sources of relevant data were also included. Diagnostic yield of routine stress testing in low- and intermediate-risk patients under 40 years is reported between 0% and 1.1%. Combined data from included primary studies demonstrated just 4 out of 1683 true positive stress tests (0.24%), only one of which was definitively confirmed by coronary angiogram; additional data sources identified just 1 out of 310 true positive stress tests (0.32%). CONCLUSIONS: Diagnostic yield of routine stress testing in low- and intermediate-risk chest pain patients under 40 years is low. However, better quality studies are required to be able to draw definitive conclusions.