IMPROVING CHEST PAIN EVALUATION WITHIN A MULTIHOSPITAL NETWORK BY THEUSE OF EMERGENCY DEPARTMENT OBSERVATION UNITS

Background: Since 1993 the 13 VHA Southern New England (VHA-SNE) hospi tals have been engaged in a regionally sponsored initiative to analyze and Improve selected clinical processes. Nine of these hospitals have chosen to participate in an initiative in which observation units wer e postulated to offer a tool for improving the care of patients with c hest pain-the VHA Initiative to implement Chest Pain Treatment in Obse rvation Units. The five phases: In phase 1 of the initiative, the VHA- SNE's Clinical Benchmarking Work Group reviewed the medical literature , which confirmed longstanding systemic and pervasive problems in the evaluation of chest pain patients. The work group's preferred practice was the outpatient ''rule out myocardial infarction [MI] evaluation'' program during monitored observation; serial testing can accurately d iagnose low- and moderate-probability patients with MI, In phase 2 the study group surveyed the emergency departments in the nine hospitals, discovering significant variation in admission rates and practice pat terns. During phase 3 the work group identified a health care organiza tion demonstrating best-practice performance-one of the few hospitals in the nation with an operational outpatient ''rule out MI evaluation' ' program. A team site-visited that organization and recorded informat ion about its structure and processes. VHA-SNE then published a monogr aph that identified its current performance, described the best-practi ce approach, offered strategies to implement the model program, and an alyzed the financial implications and return on investment. In phase 4 a pilot hospital implemented the model program, which in phase 5 is b eing extended to the other hospitals represented in the work group, In formation regarding protocols, lessons learned, and barriers to implem entation was freely provided.