The Problem
Nationwide, intensive care unit (ICU) utilization for initially stable patients with non-ST segment elevation myocardial infarction (NSTEMI) is highly variable and does not appear to be related to patient risk. Patients admitted to the ICU have similar risk of in-hospital mortality compared with those who are not admitted to the ICU. Inappropriate admission of low-risk patients to the ICU increases costs and occupies limited ICU beds without associated benefit to the patient. Inappropriate admission of high-risk patients to a non-ICU setting may lead to ICU transfers and worse patient outcomes. Risk-based ICU utilization—that is, admitting those at 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.
Our Solution
In partnership with Duke’s Division of Cardiology leaders, we determined an appropriate threshold ACTION ICU score for ICU admission. For initially stable (no cardiac arrest or shock on first presentation) NSTEMI patients with a score ≤ 5, we would recommend non-ICU admission, and for patients with a score ≥ 6, we would recommend ICU admission. Working with ED physicians, we created a modified best practice advisory (BPA) that triggers each time a patient with a serum troponin level above the upper limit of normal is seen in the emergency department.
