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.

中文翻译：

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ICare-ACS（改善疑似急性冠脉综合征患者的护理流程）

背景：对于有急性冠状动脉综合征（ACS）症状的急诊科患者，安全缩短住院时间的努力取得了好坏参半。几乎没有评估过影响多个医院急诊科的全系统性工作。我们评估了在全国各地实施不同医院潜在ACS的临床途径的有效性。

方法：这是一项在新西兰7所急诊医院进行的多中心，实用的阶梯式前后楔形试验，该试验对31 332名患者进行了连续肌钙蛋白测定，以调查怀疑的ACS。该实施是评估可疑ACS患者的临床途径，包括纸质或电子格式的临床途径文档，结构化风险分层，到达后3小时内指定的心电图和肌钙蛋白检测的指定时间点以及合并风险的指导分层诊断，心电图和肌钙蛋白检测的加速诊断方案。监测实施情况> 4个月，并与前6个月的常规护理进行比较。主要结果指标是出现后6小时内出院的几率

结果：在实施前阶段（范围284-3465）中有11 529名参与者，在实施后阶段（范围395-5039）中有19 803名参与者。总体而言，平均6小时出院率从8.3％（范围为2.7％-37.7％）增加到18.4％（6.8％-43.8％）。临床途径实施后，在6小时内出院的几率增加。优势比为2.4（95％置信区间2.3-2.6）。没有ACS的患者，住院时间的中位数减少了2.9小时（95％置信区间为2.4-3.4）。对于在6小时内出院的患者，在30天的主要不良心脏事件发生率方面没有变化（0.52％对0.44％；P = 0.96）。在这些患者中，正确遵循临床路径不会发生任何不良事件。

结论：实施可疑ACS的临床途径可缩短住院时间，并增加6小时内安全出院的患者比例。

临床试验注册： URL：https://www.anzctr.org.au/（澳大利亚和新西兰临床试验注册处）。唯一标识符：ACTRN12617000381381。