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viernes, 15 de julio de 2016

Clinical Pathway Use

emDocs - July  14, 2016 - Authors: Long B and Sheridan B
Edited by: Koyfman A  & Bright J
Clinical decision rules (CDR) can improve decision-making in specific situations in the ED, potentially decreasing further testing and improving disposition times. This part of the CDR series will look in detail at a current clinically significant CDR and pathway – The HEART pathway.
Part 1 of this series listed the essentials a CDR should possess: answers a relevant question, addresses a common clinical problem, appropriately derived, externally validated, improves clinical practice, applicable to practice and patients, and ease of use. http://www.emdocs.net/clinical-decision-rules-part-1/
Part 2 examined applying a CDR to actual clinical practice, which involved several steps: determining the rule that would most affect patient care in your setting, identify obstacles to implementation (provider and institution), achieving buy-in (from all members of the team including nurses and other specialties/consultants), publicizing pathway use, and monitoring and refinement of the rule once in place. http://www.emdocs.net/clinical-decision-rules-part-2/
Part 3 will evaluate actual risk of missed MI in chest pain patients, followed by a look at several clinical rules and pathways.
  • Risk stratification in patients with low risk chest pain has significantly evolved over the past decade. Multiple tools have been derived and evaluated for patient disposition decisions.
  • TIMI and GRACE are not sensitive enough to use in the undifferentiated patient in the ED with chest pain.
  • Decision pathways using these scores should be used with caution, though patients with two negative biomarkers and negative ECG for ischemia are at low risk for MACE.
  • The HEART score and pathway provide the best sensitivity and NPV capability, while classifying a large percentage of patients as low risk.
  • By combining the use of this rule with shared decision making, this pathway provides safe, efficient care, protecting the patient and physician.