Using just a few simple guidelines, they report in tomorrow's issue of the Journal of the American Medical Association, they have been able to cut down on the number of errors, saving lives and money in the process.
"The basic principle is to use the electrocardiogram and three clinical predictors," says Dr. Jeffrey L. Schaider, associate chairman of emergency medicine at the hospital. "Using those three indicators, we could predict with pretty good confidence which patients were at risk of major cardiovascular complications in the first three days."The three indicators are heart failure and low blood pressure, both signs the heart is not pumping blood as well as it could, and unstable angina, chest pain that indicates heart trouble. The Cook County doctors used those symptoms to assign more than 1,000 patients to different treatments, then compared their outcomes to those of more than 207 emergency room patients whose assignments were made before the rules were put into effect.
"We found that when we used the rule, we admitted fewer people to more intensive treatment, but sent more people with complications to intensive treatment," Schaider says. "The decision was simpler and safer, and it potentially can save a lot of money."
Among those patients assessed by the rules, 33 had major complications in the 72 hours after admission, and 33 were sent to the coronary care unit, a safety rating of 94 percent, the doctors report. That was slightly better than for patients assigned without the rules, where the safety rating was 89 percent.
The majority of patients did not have complications. In those assessed by the new rules, 350 out of 973 complication-free patients went to coronary care, to be on the safe side. By contrast, 42 of the 198 complication-free patients assigned without use of the rules got intensive care they didn't really need. As the Cook County doctors rate it, "efficiency was higher in the intervention group, 36 percent, than in the pre-intervention group, 21 percent."
The basic principle applied in Chicago was worked out by Dr. Lee Goldman, then at Brigham and Women's Hospital in Boston and now chairman of medicine at the University of California at San Francisco. Goldman published several papers in medical journals on theoretical application of the rules, but never used them in clinical practice.
"What we did was the latter," says Dr. Brendan M. Reilly, chairman of medicine at Cook County Hospital. "These rules put the patients into one of four categories, based on their risk of developing life-threatening complications. If you can predict that accurately, hopefully that will help the doctor make smarter decisions."
The rules are being put into effect at Cook County Hospital.
"We are pretty confident that these rules predict the likelihood of complications, and have major implications for the millions of people admitted to hospitals every year with this kind of problem," Reilly says.
What To Do