Chest pain is one of the most common reasons people come to the hospital, but there isn’t one standardized way of treating it.
“Everyone’s greatest concern is that they’re having a heart attack,” said cardiologist Benjamin Scirica, MD, MPH. “The great majority are not, and a large portion of these patients don’t actually have a problem with their heart.”
The variation comes in with those in the gray area—they may be having a heart issue, but testing is needed to find out for certain. “There isn’t a great single test that determines who is having a heart attack or at risk of a pre-heart attack,” he said.
That means that there isn’t a standardized way that care providers treat these patients. Physicians may discharge patients home for follow-up with their doctors if they are assessed as low risk, and others use one or more tests—blood tests, stress tests, MRI or cardiac catheterization—to determine what is wrong.
In areas where there is such variation in practice, BWH clinicians are turning to SCAMPs as a way to develop guidelines for best practice. The hospital is quickly emerging as a leader in the use of SCAMPs, or Standardized Clinical Assessment and Management Plans, which collect and analyze data on clinical decisions to standardize care in a fast-evolving clinical environment. SCAMPs, which were originally developed at Boston Children’s Hospital, are one of the strategies being implemented in care redesign efforts throughout BWH and BWFH.
Designing a SCAMP
BWH has a dedicated SCAMPs team to partner with clinicians on designing and implementing a SCAMP and collecting and managing the data.
“SCAMPs enable us to transform care and standardize it in a way that still maintains flexibility for individual patients’ needs,” said Jeff Greenberg, MD, MBA, who is leading the SCAMPs team at BWH.
In designing a SCAMP for chest pain, Scirica’s goals were to find out what symptoms patients with chest pain presented with and what their co-morbidities were. The team enrolled 122 patients who had been admitted to the inpatient cardiology service in the SCAMP to collect data to answer these questions.
Scirica and his team then asked physicians to estimate when they first saw a patient, did they think: a) it was a heart attack, b) it had nothing to do with the patient’s heart, or c) that there was a chance this was a heart attack.
Option C is the gray area where the variation in treatment comes in. After reviewing the data collected and analyzed during the first six months of the SCAMP, Scirica and the team found great heterogeneity in practice.
“People use different tests, and there isn’t a clear reason why someone uses one over another in many cases,” he said. “In addition, BWH sees patients with lots of co-morbidities, such as kidney disease for example, which complicates matters.”
Already, there are steps in place to improve and standardize care for chest pain patients. “Some of the testing that these patients require can be done on an outpatient basis, rather than keeping the patient in the hospital,” he said. “We also want to ensure more rapid follow-up with a patient’s primary care provider or cardiologist when they come in with chest pain to try and prevent return trips to the ED.”
The next step is to put in place parameters that are reasonable best practices for most patients who present with chest pain. It doesn’t mean a “one size fits all” approach to care, though, as SCAMPs reinforce tailoring care and deviating from the standard when it makes sense for a particular patient.
Although there is a steep learning curve with a process like SCAMPs, Scirica emphasizes that it has been a positive experience. “There is a great interest in understanding the patients we see and our practice,” he said. “We had very rigorous conversations about what people felt was the most appropriate care. The degree of opinions highlights why SCAMPs are so important—we need to provide a level of care that is consistent across the institution.”
Celebrating SCAMP Successes
BWH recently celebrated the one-year anniversary of the launch of SCAMPs and its progress. Today, eight SCAMPs are underway at various stages in multiple departments.
James Locke, MD, chief of Cardiology at Boston Children’s Hospital and one of the creators of SCAMPs, attended the BWH celebration to speak to those involved in the SCAMP process. “There’s nothing more exciting than doing something new and different that actually makes patients better,” he said. “Together, Children’s and BWH will lead a large part of the country in a new way to do things.”
Philip Blazar, MD, of Orthopedic Surgery, and his colleagues launched the hospital’s first SCAMP on distal radius fracture last year.
“I’ve learned a lot in doing this,” he said. “We don’t always have to answer every question that comes to us with a prospective clinical trial—there are too many questions for us to answer them all that way. With the SCAMP approach, we can ask and answer questions and improve things for our patients and everyone else with a practical and rigorous approach.”