Acute coronary syndrome pathway use and differences in intervention times in rural hospitals: A retrospective cohort analysis

Background: The potential that clinical pathways support reduced time-to-intervention is of heightened importance in emergency department (ED) presentations with life-threatening conditions, such as acute coronary syndrome (ACS). There is limited contemporary evidence regarding ACS Pathway use in a hybrid documentation system or across rural facilities with varying ED capacities. This study examined ACS Pathway use and the associated time-to-interventions in one rural health district to assess this potential. Methods: Data from 202 ED self-presentations that received an acute myocardial infarction (AMI) diagnosis in one Australian rural health district were reviewed. The outcomes were documented ACS Pathway use and four binary time-to-intervention outcomes: electrocardiograph acquisition, troponin collection, aspirin administration, and transfer initiation (from smaller EDs only). Proportion tests and logistic regressions were conducted for each outcome, with ACS Pathway use the key independent variable for the time outcomes. Results: An ACS Pathway was documented in 35.6% of presentations, more commonly in smaller hospitals, for high-risk presentations, and those with a ST elevation myocardial infarction diagnosis. Regression results found significant percentage-point increases in the probability of timely troponin (17.61, 95% CI [0.43, 34.79]), aspirin administration (21.26, 95% CI [9.61, 32.91]), and transfer initiation (23.09, 95% CI [6.21, 39.98]) outcomes with Pathway use. Conclusion: The results suggest that ACS Pathway use should be promoted, especially among nurses and other key clinicians in rural EDs. Further research is needed to understand clinical decision-making and rural needs for the use and relevancy of an ACS Pathway in a hybrid documentation system.