Study Suggests CCU Can Be Skipped for Many NSTE-ACS Patients

The coronary care unit (CCU) became a staple of acute MI care decades ago, but it appears that in the current era stable NSTE-ACS patients fare just as well in the short-term if they are instead initially admitted to a cardiology telemetry ward, an observational study suggests. Nevertheless, most such patients continue to be admitted to the more expensive CCUs.

The finding of similar clinical outcomes “can reassure clinicians that the majority of stable NSTE-ACS can be safely managed in a telemetry ward environment,” study author  Sean van Diepen, MD, MSc, of University of Alberta Hospital (Edmonton, Canada), told TCTMD in an email. “Recognizing the high cost of critical care admissions, these findings also present future opportunities to reduce hospital costs.”

The use of CCUs for patients with acute MI was rapidly adopted starting in the 1960s based on the results of studies showing potential reductions in mortality, but there remains a lack of high-quality evidence surrounding the issue.

Recognizing the lower risk of contemporary NSTE-ACS populations, both US and European guidelines recommend admitting stable patients to telemetry units, but prior studies have shown that 50% to 64% are still sent to CCUs.

“Although small studies have suggested improved outcomes among NSTE-ACS patients admitted to CCUs, these analyses are likely confounded by admission, treatment, and healthcare provider biases,” van Diepen and colleagues write in their paper published online earlier this week in the American Heart Journal.

To further explore the issue, the researchers examined administrative data on 7,869 patients hospitalized with NSTE-ACS between April 2007 and March 2013 at 13 secondary or tertiary centers in Alberta. About two-thirds (65.3%) of patients were initially admitted to CCUs.

“I certainly expected to find that a sizable percentage of stable NSTE-ACS patients would be admitted to CCUs, but I did not expect the percentage to be so high,” van Diepen said.

Mean length of hospitalization was similar in patients admitted to telemetry wards and those admitted to CCUs (6.2 vs 5.7 days; P = .29). Telemetry patients, however, were less likely to undergo additional imaging or cardiac procedures (40.3% vs 48.5%; P < .001).

There were no differences between the 2 groups in any of the clinical outcomes examined (table).

 

The results were generally consistent across Duke Jeopardy Score and Charlson Comorbidity Index categories and in NSTEMI and unstable angina patients.

 

Reappraisal of Routine CCU Use

Although CCUs have become a key part of acute MI care, “in the context of rising healthcare spending, in which intensive care contributes almost 50% of hospital costs, the appropriate use of [ICUs] has garnered focused attention,” Michael Silverman, MD, and David Morrow, MD, MPH, of Brigham and Women’s Hospital (Boston, MA), write in an accompanying editorial.

This study, they continue, “turns this lens on the CCU and provides compelling evidence that the value of routine triage of all patients with [acute MI] to a CCU warrants reappraisal.”

Silverman and Morrow question why the benefits attributed to CCU use decades ago would be less substantial in the contemporary era and point to 2 main reasons: an evolution in the epidemiology and natural history of acute MI and changes in hospital environments beyond the CCU.

Since the 1960s, they note, the incidence of STEMI has dropped, reperfusion therapy has been developed, immediate or early coronary revascularization has become the primary strategy, and improvements have been made in secondary preventive therapies. All of those changes have resulted in a decline in in-hospital mortality following MI. In addition, cardiogenic shock and life-threatening arrhythmias have become less frequent.

At the same time, hospitals have developed methods for delivering an intermediate level of care involving continuous ECG monitoring in step-down units while focusing CCU use on patients requiring more advanced critical care therapies.

“Current professional society guidelines for the management of [acute MI] no longer provide formal recommendations for the location of care,” the editorialists write. “The guidelines encourage triage based on risk assessment, suggesting that high-risk patients be admitted to the CCU, whereas low-risk patients be admitted to an intermediate-care or [step-down unit] with continuous ECG monitoring.”

Such an approach would have important cost implications, van Diepen and colleagues note.

“In North America, CCUs are often equipped to provide 1:1 or 1:2 nursing to patient staffing ratios, advanced hemodynamic monitoring, and life-sustaining mechanical cardiorespiratory support,” they write. “Consequently, CCUs are estimated to account for up to 35% of hospital costs for as little as 5% of hospital beds.

“In an era of constrained healthcare costs and critical capacity strain, redirecting uncomplicated stable NSTE-ACS patients from CCU to ward beds presents opportunities to improve health resource allocation,” they continue. “Collectively, our findings suggest future opportunities to prospectively evaluate the potential cost savings, resource utilization, and clinical outcomes associated with reducing routine CCU admissions of uncomplicated NSTE-ACS.”

 

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Sources: 
1. van Diepen S, Lin M, Bakal JA, et al. Do stable non-ST segment elevation acute coronary syndromes require admission to coronary care units? Am Heart J. 2016;Epub ahead of print.
2. Silverman MG, Morrow DA. Hospital triage of acute myocardial infarction: is admission to the coronary care unit still necessary [editorial]? Am Heart J. 2016;Epub ahead of print.

 

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