Project Summary

This implementation project is complete.

PCORI implementation projects promote the use of findings from PCORI-funded studies in real-world healthcare and other settings. These projects build toward broad use of evidence to inform healthcare decisions.

This PCORI-funded implementation project put a shared decision making process in place in emergency departments, or EDs, to help patients with chest pain and their doctors decide if the patient should be admitted for more testing or wait and receive care in an outpatient setting.

More than 8 million people go to the ED for chest pain each year in the United States. Many of these patients stay in the hospital for tests. But patients at low risk for a heart attack may not need to. When a patient is at low risk, they may prefer to get follow-up care in an outpatient clinic.

What was the goal of this implementation project?

Patients in the ED for chest pain who haven’t had a heart attack and their doctors can use shared decision making, or SDM, to decide whether to get heart imaging tests in the ED. SDM, is a process in which patients and doctors work together to make healthcare decisions. A PCORI-funded research study found that patients who used a decision aid with information on their personal risk for a heart attack and options for care understood more about their risks and options than patients who didn’t use a decision aid. They were also more involved in their care decision and more likely to decide to wait to receive tests instead of getting tests in the ED.

This project put the SDM process with the decision aid in place in six EDs to help patients with chest pain choose the care that works best for them.

What did this project do?

The project team put the decision aid in place in six EDs in three health systems in four states. These EDs had high volumes of patients with chest pain and served patients from diverse backgrounds. The EDs also had electronic health record, or EHR, systems.

The decision aid was a single printed page that showed patients their chest pain diagnosis, their risk of having a heart attack in the near future, and their options for more tests. The patients talked with the doctors treating them in the ED about the information in the decision aid.

The project team worked with the EDs to:

  • Build the decision aid into sites’ EHR systems
  • Train doctors, nurses, and other staff at sites to use the decision aid and on SDM
  • Adapt the approach for using the decision aid and working with patients on shared decisions at each ED site
  • Identify and prepare staff to promote the use of the decision aid at sites and serve as a resource for other staff

What was the impact of this project?

This project worked to make the SDM process part of regular care for chest pain in six EDs in three health systems. During the project:

  • A total of 1,349 patients received the decision aid. These patients worked with 210 ED doctors, 25 ED nurses, and other staff.
  • Patients who used the decision aid said that they had a better understanding of their risk for heart attack.
  • Using the decision aid was safe. Patients who used the decision aid didn’t have greater risk of a heart attack or death from any cause than patients who didn't use it.
  • The project team’s evaluation showed that after the SDM process was put in place, clinicians, such as doctors and nurses, found the SDM process to be acceptable and appropriate. But some barriers limited the uptake of the decision aid in practice, such as added time and effort.

In the original study, patients who used the decision aid were more likely to choose to go home and follow up with their primary care doctor later about tests instead of getting tests in the ED. But in this project, patients who used the decision aid had higher ED admission rates than patients who didn’t use it (26% versus 22%; p<0.001).

Several challenges limit the potential for further use of this decision aid. During the project, sites had trouble building the decision aid into their EHR systems and accessing it in EHRs during visits. More importantly, improved testing options became available, which lessened the need for the decision aid.

More about this implementation project:

Stakeholders Involved in This Project

  • American Heart Association (AHA)
  • Multidisciplinary care team including clinicians, ED quality directors and chairs, and hospital administrator

Publicly Accessible Project Materials

For more information about these materials, please contact the Project Team at [email protected].

The project team developed these materials, which may be available for free or require a fee to access. Please note that the materials do not necessarily represent the views of PCORI and that PCORI cannot guarantee their accuracy or reliability.

Project Achievements

  • Adapted SDM process to make it scalable to different EDs across 3 health systems
  • Demonstrated the feasibility of using a decision aid to help 1,349 patients presenting in the ED with chest pain to choose the care that is right for them

Implementation Strategies

  • Promoted SDM
  • Adapted the SDM approach to work with sites’ existing resources and workflows, including integrating a risk calculator and decision aid into sites’ electronic health record systems
  • Provided sites with tools to support implementation, including toolkit resources such as demonstration videos and support documents
  • Provided educational materials to patients as part of decision aid
  • Trained providers at sites on SDM and how to use the decision aid
  • Used a phased implementation approach, launching at a small number of EDs and then expanding to all EDs
  • Identified and prepared site champions at sites
  • Provided technical assistance to sites

Evaluation Measures

To document implementation:

  • Clinician awareness of decision aid
  • Clinician knowledge of the patient-centered pathway
  • Clinicians’ engagement of patients in SDM and risk communication
  • Barriers and facilitators to uptake among clinicians, operations supervisors, and clinical directors

To assess healthcare and health outcomes:

  • Patient involvement in decision
  • Patient satisfaction with decision
  • Number of patients admitted to observation
  • Number of patients discharged from ED to home
  • Patients’ subsequent ED admissions, adverse cardiac events, and mortality

Project Information

Erik P. Hess, MD, MS
University of Alabama at Birmingham^
Dissemination and Implementation of a Shared Decision Making Strategy in Emergency Department Patients with Possible Acute Coronary Syndrome: The Patient Centered Chest Pain Pathway**

Key Dates

December 2017
November 2021

Study Registration Information

Initial PCORI-Funded Research Study

This implementation project focuses on putting findings into practice from this completed PCORI-funded research study: Testing a Decision Aid for Patients with Low-Risk Chest Pain in the Emergency Room -- The Chest Pain Choice Trial

^This project was originally based in Minnesota at the Mayo Clinic.
**This project was previously titled: Implementation of a Shared Decision Making Intervention in Practice: The Chest Pain Choice Pathway


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Last updated: March 14, 2024