In the United States, ≈40% of patients with non–ST-segment–elevation myocardial infarction (NSTEMI) who initially present without cardiogenic shock or cardiac arrest are admitted to the intensive care unit (ICU).1,2 Importantly, ICU utilization for these initially stable NSTEMI patients varies substantially between hospitals, and severity of illness on presentation is similar for NSTEMI patients treated and not treated in the ICU, suggesting that ICU admission decisions are largely based on hospital policies and local clinician preferences.1
Risk-based ICU utilization—admitting those at the highest risk of developing complications requiring ICU care to the ICU and admitting those at lower risk to a non-ICU setting—has the potential to better align resource use with patient needs. For patients with initially stable NSTEMI, the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU risk score uses data available at the time of hospital presentation to predict risk of clinical deterioration requiring ICU care—in-hospital death, cardiac arrest, shock, respiratory failure, heart block requiring pacemaker placement, and stroke.3 Risk scores are infrequently used in clinical practice,4 but directly embedding a risk score calculator with associated decision support into the electronic health record (EHR) could increase uptake. The goal of this innovation was to achieve risk-based ICU utilization for patients with NSTEMI presenting to the emergency department (ED) by embedding the ACTION ICU risk score into the EHR as a modified best practice advisory (BPA).