Clinical Decision Unit for Treating Patients with Chest Pain Now Open at UH Cleveland Medical Center

Certain patients will have CTA results enhanced with HeartFlow technology

February 2018

A multidisciplinary team at UH Cleveland Medical Center is implementing a new plan for treating patients who arrive at the Emergency Department complaining of chest pain. Under the new system, patients scoring 0 to 3 on the HEART (History, EKG, Age, Risk factors, Troponin) triage tool administered in the Emergency Department will be discharged home with follow-up, if troponin is negative and there are no acute EKG changes. However, patients scoring 4 to 6 on the HEART test will be triaged to a new short-term Clinical Decision Unit (CDU), where they may undergo coronary CT angiography (CTA) or a stress test, or both. Patients scoring 7 to 10 on the HEART test will be admitted as inpatients.

“This route, with the CDU, allows the patient to be evaluated within a 12- to 48-hour time frame,” says Evelyn Watson, BSN, RN-BC, Coordinator of Advanced Cardiac Imaging with UH Harrington Heart & Vascular Institute. “Instead of sending the patient to the floor which ties up a bed, they are admitted to the CDU. We’ve implemented it so they can get a coronary CTA or stress test done while they’re in the CDU. It will help prevent inpatient admissions, and we’ll be able to do the testing sooner. We have some dedicated slots for stress testing so we can get these patients through the CDU and through their stress testing in a timely fashion. The CT department is also notified, so they can get a CTA within the hour.”

“What’s different is that we’re using CTA from our CDU,” adds ED physician Robert Hughes, DO. “Instead of being discharged home or being admitted to the hospital, these people are put into a short-stay status, still under the care of ED physicians, APPs and residents, and they’re provided that risk stratification imaging. So it’s doing it more rapidly and intensively so we can get people home safely.”

Team members from Emergency Medicine, Cardiovascular Medicine and Radiology have been attending training sessions on the new care path for the past few weeks. A UH group also traveled to Beaumont Hospital in Troy, Mich. to observe that health system’s CDU CTA program.

Christopher Miller, MD, Chair of Department of Emergency Medicine at UH Cleveland Medical Center; Sanjay Rajagopalan, MD, Division Chief of Cardiovascular Medicine; Robert Gilkeson, MD, Director of Thoracic Imaging, and Melissa Cole, CNP, Systems Director of the Center for Emergency Services at UH Cleveland Medical Center, along with Dr. Hughes, have taken the lead in bringing the new program to UH. The program will be piloted at UH Cleveland Medical Center, but ultimately will be extended to UH system sites with the appropriate technology to do high-quality cardiac CT exams

Under the new system, certain patients with chest pain who undergo a coronary CTA will have those results enhanced with HeartFlow technology.

“HeartFlow takes the results of a CTA of the chest and heart and applies fractional flow reserve, which is typically measured during a cardiac cath,” Dr. Hughes says. “They’ve essentially created a computer algorithm that takes a person who has a CT scan finding of 50 percent lesion and determines just how functionally limiting that blockage is. It’s a really cool tool to stratify those people who have moderate risk and find out who is truly in danger of having a heart event.”

Although the new program features evidence-based guidelines, Dr. Hughes emphasizes that it is not rigid.

“Our program allows for clinical decision-making at the bedside and the joint decision between the physician and the patient,” he says.

For more information about the CDU CTA program, please contact Dr. Sanjay Rajagopalan at 216-844-3800.