To the HEART of the matter

Low-Risk ACS: The HEART trial and how we got there

Author: Jason Brown, Capt, USAF, MD (EM Resident Physician, University of Maryland) // Editor: Alex Koyfman, MD

Background
In the first decade of the 21st century, a collection of risk-stratification tools were developed in an effort to better identify patients at the highest risk for a major acute coronary event (MACE). The first two were the Thrombolysis In Myocardial Infarction (TIMI) and Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (eptifibatide) Therapy (PURSUIT). These were followed by the Global Registry of Acute Coronary Events (GRACE) and Fast Revascularisation in InStability in Coronary disease (FRISC). These scoring systems were developed via multivariable logistic regression of preexisting data sets derived from patients that have already ruled in for ACS; meaning, these were the most highly associated risk factors for people with disease.

These four scoring systems were invaluable to cardiologists. They gave good, reproducible data that helped determine how to treat patients with known ACS. However, they did little to change how emergency physicians practice. Whether or not to admit a case of ACS was never the question in these studies. TIMI, PURSUIT, GRACE, and FRISC were all very useful in stratifying patients with ACS into treatment groups based on their likelihood of mortality at variable intervals.

Further complicating the issue is the fact that even very low scores in these risk-stratification tools did not correspond to negligible rates of MACE. For instance, a publication by Pollack et al in 2006 showed a MACE rate of 2.1% with a TIMI of 0 and a 5% MACE rate for a TIMI of 1 for patients presenting to the ED with chest pain. Considering that you get 1 point for taking an aspirin in the last 7 days, these data are disconcerting for emergency physicians.

To the HEART of the matter…
The HEART score was one of the first prospective studies for the evaluation of chest pain patients in an emergency department setting using clinical gestalt and expert opinion to drive decision-making. The five components are History, ECG, Age, Risk factors, and Troponin; scored 0-2 per parameter with scores ranging from 0-10. Their initial investigation showed a 2.5% rate of MACE at 30 days with those patients scoring 0-3. These patient characteristics are very similar to the history and exam elements defined in the American Heart Association’s (AHA) 2010 position paper on the evaluation of chest pain in the emergency department wherein a low-risk patient was considered one with a <2.5% risk of MACE at 30 days.

http://www.heartscore.nl/score/
http://www.heartscore.nl/score/

In 2008, Six, Backus, and Kelder published an article wherein they applied the HEART score to an undifferentiated cohort of patients presenting to the ED with chest pain. They found a low rate of MACE in patients scoring 0-3 (2.5%) and postulated that this group of patients were suitable for early discharge from the ED. This was retrospectively validated in 2010 and showed MACE incidence of ~1% in those scoring 0-3. This was externally and prospectively validated in 2013 with MACE incidence 1.7% in those scoring 0-3.

Conclusion
The HEART score provides emergency physicians with solid, reproducible evidence that there is a cohort of patients presenting to the ED with chest pain who are suitable for early discharge.
Hopefully, the next iteration of the AHA guidelines will include HEART and recognize the utility in early discharge.

References // Further Reading:
1. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000;284(7):835-42.
2. Boersma E, Pieper KS, Steyerberg EW, et al. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation. 2000;101(22):2557-67.
3. Fox KA, Dabbous OH, Goldberg RJ, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006;333(7578):1091.
4. Lagerqvist B, Diderholm E, Lindahl B, et al. FRISC score for selection of patients for an early invasive treatment strategy in unstable coronary artery disease. Heart. 2005;91(8):1047-52.
5. Pollack CV, Sites FD, Shofer FS, Sease KL, Hollander JE. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med. 2006;13(1):13-8.
6. Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122(17):1756-76.
7. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-6.
8. Backus BE, Six AJ, Kelder JC, et al. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2010;9(3):164-9.
9. Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153-8.
10. http://www.ncbi.nlm.nih.gov/pubmed/25217099

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Medication Errors

Medication Errors

Certainly, the PedEM Morsels promote a need for vigilance!  Vigilance is required to find those troublesome conditions that masquerade as benign conditions (see Inborn Errors of Metabolism, Meningococcemia, and Neonatal Seizures for a few examples).  Vigilance, however, is not just useful when considering a diagnosis: it is also necessary when discussing anticipatory guidance and the medical plan.  Medication Errors are a significant problem that a little preemptive action can help avoid.

 

Giving Medicine is Tricky

  • Medication errors are a common cause of adverse events and are more often seen in pediatric patients than adults.
    • Kids’ various sizes (both in weight and body surface area) and metabolic rates create challenges.
    • The fact many pediatric medications are liquid creates another challenge.
  • Even the experts are susceptible to error.
    • The chaotic environment of the ED, certainly enhances the chances of error (Leape, 1991).
    • Protective systems can help decrease medication errors in the hospital (Damhoff, 2014).
      • Some examples:
        • Electronic ordering systems
        • Avoiding often confused units of measure
        • Using weight-based dosing
        • Pediatric-specific pharmacy
        • Pharmacist in the ED
      • Still no system is fool-proof and requires vigilance.
  • If the experts are susceptible to error, how can we expect parents and care-givers to get it right?
    • An estimated 71,224 ED visits per year were made for unintentional overdose in children (Schillie, 2009).
      • ~34% were for over-the-counter (OTC) medications
      • ~14% were for medication errors / misuse
    • The odds are stacked against families!
      • Parents may not know the child’s specific and current weight at the time of medication administration.
      • Health Literacy and Numerical Literacy varies greatly amongst all patients and impacts interpretation of medication instructions (Bailey, 2009).
      • OTC medications may exist in various concentrations complicating administration.
      • It has been found that OTC medications often contain variable and inconsistent dosing directions (Yin, 2010).
      • OTC measuring devices have also been found to be inaccurate, inconsistent, and confusing.
      • There are a variety of measuring devices, often not standardized.
        • Measuring cups, syringes, droppers, “teaspoons,” etc.
        • Medicine cups have been shown to be related to a high occurrence of dosing errors (Tanner, 2014).

 

A Teaspoon Should NOT Be For Medicine

  • Parents who use teaspoon or tablespoon units had TWICE the odds of making an error! (Yin, Pediatrics 2014)
    • While a teaspoon is a unit of measure, it also often confused with the household utensil, which may vary greatly in actual size.
    • Abbreviations can be confusing: “tsp” can be misinterpreted as “tbsp” and vice versa.
  • Advocate for milliliters as the unit of measure.

 

Educate and Simulate

  • We all know that simulation strategies have benefited our processes of medical education… hands-on helps the memory.
  • Use this strategy for patients and parents as well.
  • The use of both education and demonstration have been found to be more effective at reducing liquid medication dosing errors (Yin, Academic Pediatrics 2014).
  • Establish systems in your ED that encourage this process to help avoid preventable medication errors.
    • Use a oral syringe with milliliter measurements.
    • Discuss the appropriate dose and frequency of the medication.
    • SHOW the family how to fill the syringe to the appropriate dose. Ensure that this is not ambiguous.
    • Have the family teach/show you how they will administer the medication at home.
    • Discharge with clear instructions illustrating the key points again.

 

References

Yin HS1, Dreyer BP2, Moreira HA2, van Schaick L2, Rodriguez L3, Boettger S2, Mendelsohn AL2. Liquid medication dosing errors in children: role of provider counseling strategies. Acad Pediatr. 2014 May-Jun;14(3):262-70. PMID: 24767779. [PubMed] [Read by QxMD]

Yin HS1, Dreyer BP2, Ugboaja DC2, Sanchez DC2, Paul IM3, Moreira HA2, Rodriguez L4, Mendelsohn AL2. Unit of measurement used and parent medication dosing errors. Pediatrics. 2014 Aug;134(2):e354-61. PMID: 25022742. [PubMed] [Read by QxMD]

Koumpagioti D1, Varounis C2, Kletsiou E2, Nteli C3, Matziou V4. Evaluation of the medication process in pediatric patients: a meta-analysis. J Pediatr (Rio J). 2014 Jul-Aug;90(4):344-55. PMID: 24726455. [PubMed] [Read by QxMD]

Damhoff HN1, Kuhn RJ2, Baker-Justice SN1. Medication preparation in pediatric emergencies: comparison of a web-based, standard-dose, bar code-enabled system and a traditional approach. J Pediatr Pharmacol Ther. 2014 Jul;19(3):174-81. PMID: 25309147. [PubMed] [Read by QxMD]

Neuspiel DR1, Taylor MM2. Reducing the risk of harm from medication errors in children. Health Serv Insights. 2013 Jun 30;6:47-59. PMID: 25114560. [PubMed] [Read by QxMD]

Tanner S1, Wells M, Scarbecz M, McCann BW Sr. Parents’ understanding of and accuracy in using measuring devices to administer liquid oral pain medication. J Am Dent Assoc. 2014 Feb;145(2):141-9. PMID: 24487605. [PubMed] [Read by QxMD]

Yin HS1, Wolf MS, Dreyer BP, Sanders LM, Parker RM. Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications. JAMA. 2010 Dec 15;304(23):2595-602. PMID: 21119074. [PubMed] [Read by QxMD]

Schillie SF1, Shehab N, Thomas KE, Budnitz DS. Medication overdoses leading to emergency department visits among children. Am J Prev Med. 2009 Sep;37(3):181-7. PMID: 19666156. [PubMed] [Read by QxMD]

Bailey SC1, Pandit AU, Yin S, Federman A, Davis TC, Parker RM, Wolf MS. Predictors of misunderstanding pediatric liquid medication instructions. Fam Med. 2009 Nov-Dec;41(10):715-21. PMID: 19882395. [PubMed] [Read by QxMD]

Madlon-Kay DJ1, Mosch FS. Liquid medication dosing errors. J Fam Pract. 2000 Aug;49(8):741-4. PMID: 10947142. [PubMed] [Read by QxMD]

Leape LL1, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991 Feb 7;324(6):377-84. PMID: 1824793. [PubMed] [Read by QxMD]

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ALiEM Bookclub: Humble Inquiry

3148In this month’s ALiEM Book Club selection, Humble Inquiry: The Gentle Art of Asking Instead of Telling, author Edgar Schein describes a model of communication termed “humble inquiry” which he defines as “the fine art of drawing someone out, of asking questions to which you do not already know the answer, of building a relationship based on curiosity and interest in the other person”. Although a very quick read (100 short pages!), it is packed with profound insights about the way we communicate and a vision for what might be! Communication is so pertinent to our work in the medical field from encounters with our colleagues, our learners, and our patients. Striving to improve communication is a goal that every provider should have and this powerful book can help!

A free excerpt of the book can be accessed here.

Schein first clarifies the concept of “here-and-now” humility, which is necessary precursor for true humble inquiry. Here and now humility is the recognition of one’s own dependence on another, especially with regards to information. Recognition of dependency is not just for subordinates but it is even more essential for those working in teams or in positions of power.

Consider for example anytime either you have taken a clinical case presentation from a junior learner or had to provide a presentation. Traditionally, this experience was fraught with anxiety or fear, especially if working with a supervising doctor who readily employed communication styles that were considered in the realm of “pimping” – a method whereby evaluative and trivial questions are asked in ascending hierarchical order, using power status to embarrass and humiliate learners in a group environment. For example, when a medical student is presenting a patient with sepsis the supervising physician might interrupt and ask “who coined the term sepsis?” When the student inevitably doesn’t know he shakes his head and turns to the resident. The student feels inadequate when they finally return to discussing the case. Instead consider how differently such an encounter would go if your supervising doctor employed strategies of humble inquiry, which would acknowledge that the learner has just spent a significant amount of time with the patient and holds a wealth of information.

With use of humble inquiry, the information can be gleaned from the learner and together the learner and the attending can come up with a treatment plan with educational pearls taught in a comfortable learning environment. But how to go about doing this and employing the strategy of Humble Inquiry?

“Humble inquiry is the fine art of drawing someone out, of asking questions to which you do not already know the answer, of building a relationship based on curiosity and interest in the other person.”

How to practice humble inquiry? Schein suggests:

Do less talking.
Do more asking.
Get better at listening to and acknowledging others.

Consider your own prior positive educational experiences. Likely the educator minimized interruptions. Questions may have been raised that were not answerable, but helped to foster thoughtful discussion. Most of all, you probably felt listened to and satisfied that the management plan was mutually generated.

Sounds easy, right? Wrong.

Schein explores many impediments to humble inquiry.  In our organizations, norms about the expectations of superiors (attendings) and the preferred deference of subordinates (residents and medical students) make it unnatural for those in a position of power to ask for help. For example, in the current traditional model, the attending physician should not rely on the medical student. Furthermore, the task oriented, rather than personal nature, of many of our jobs makes fostering relationships difficult. Working through lunch and breaks instead of holding short teaching sessions or simply bonding over a meal happens far too frequently because there are so many clinical tasks to accomplish. Unfortunately, there are also forces within ourselves that prevent humble inquiry from being the norm. Occasionally the primitive instinct to be right, to one up another person, takes over. And sadly, sometimes the attending (or the resident, or the medical student) likes to be right, just because.

Applications for patient care

There are obvious advantages to humble inquiry that Schein outlines. Most examples were related to patient-safety issues but it seems that the advantages for patient-care might extend beyond allowing subordinates to speak up when they feel something is going wrong. There must be implications for patient care when junior learners, allied health care professionals, families and patients don’t just feel listened to, but are listened to.

Applications for medical education

Learners are asked many questions but often these questions are not coming from a place of humble inquiry. What muscle is this? What dermatome does it supply? What is the appropriate treatment plan? Schein discusses other forms of questioning, described here, including diagnostic inquiry, confrontational inquiry and process-oriented inquiry that are much more common in medical education but don’t necessarily promote relationships or cooperation towards a common goal. There seems to be a role for humble inquiry in the teaching role.
We look forward to hearing your thoughts about the book and about humble inquiry in our discussions in the comments section and on twitter.
* Thanks to Dr. Goldstein at Queen’s University for directing me to this book. He recommends it to all medical students rotating through the anesthesia department!

Questions for Discussion

  1. How might you apply the concept of humble inquiry to patient care? To medical education?
  2. Think about a situation in which you were the subordinate or had a lower status than another other person yet felt respected and acknowledged. Can you identify what the other person did to make you feel that way?
  3. What are impediments in our culture and within ourselves to practicing humble inquiry? And is humble inquiry appropriate in all circumstances?

ALiEM Bookclub Google Hangout

Want to join in the bookclub discussion?

Tweet us directly at @ALiEMBook

Use hashtag #ALiEMbook.

 

Watch this for more background on Humble Inquiry:

 

Disclaimer: We have no affiliations financial or otherwise with the authors, the books, or Amazon.

Edited by:
Nikita Joshi MD

Author information

Eve Purdy, BHSc

Eve Purdy, BHSc

Medical student

Queen's University in Kingston, Ontario, Canada

Student editor at BoringEM.org

Founder of manuetcorde.org

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Jornadas Osatzen Donostia 2014

La semana pasada celebramos las Jornadas de Osatzen de este año. Para los que estábamos metidos en este lío fueron la culminación de varios meses de trabajo y los damos por bien empleados. A falta de una última reunión para evaluar las jornadas, que la haremos, nos sentimos satisfechos...
La asistencia fue importante; fueron muchos los residentes, ¡qué bien!, que acudieron a la cita. Ellos inauguraron las Jornadas con una mesa que a mí me pareció muy bonita y, además, con contenido: Visiones, percepciones y proyecciones de la AP era su título y a través de su video y de sus palabras hice mi propio viaje interior y, de alguna manera, me sirvieron para reconciliarme con lo que es nuestra especialidad: hermosa mezcla la que vivimos de emoción y razón en las voces de estos jóvenes compañeros.
Posteriormente tanto las mesa inaugural como la de clausura, los encuentros en Para saber más y los distintos talleres que se desarrollaron creo que fueron de interés y de calidad. También fueron numerosas las comunicaciones que tuvimos la ocasión de disfrutar de un nivel alto.
En mente está la idea de que podamos disponer de las presentaciones de los distintos eventos, os invito a consultar la página de las Jornadas en días sucesivos.
Y todo ello sin la participación de la industria farmacéutica, lo que equivale a decir que organizadas y realizadas en libertad, gracias a la generosidad de todos/as los compañeros/as que  nos brindaron su tiempo, su trabajo y su presencia de  forma desinteresada durante estos dos días: ¡muchas, muchas gracias! Eskerrik asko!
Y gracias también a todos/as los que asististeis a los diferentes actos, perdonad los errores, que los hubo...
Creemos que no hay marcha atrás y que mantener nuestra independencia es fundamental, en eso estamos. Nos veremos en otras, espero...

JC: PARAMEDIC trial m-CPR at St.Emlyn’s

St Emlyns - Meducation in Virchester #FOAMed

  In some ways you might be forgiven for thinking that 2014 was a bit disappointing in terms of EBM. A number of clinical trials that I’ve been looking forward to for some time have in effect produced negative results. Early goal directed therapy, target blood pressures for sepsis, hypothermia for post cardiac arrest patients […]

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Pediyatrik EKG

Özet Doğumda, sağ ventrikül sol ventrikülden daha geniş ve kalın olup, sağ ventrikül üzerinde in utero daha büyük fizyolojik stres varlığını göstermektedir (ör. göreceli olarak daha yüksek basınçlı olan pulmoner dolaşıma kan pompalar). Bu durum yetişkindeki sağ ventrikül hipertrofisi görüntüsünü andıran bir EKG görüntüsü meydana getirir: belirgin sağ aks, V1’de dominant R dalgası ve V1-3’te ...