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Stephen Possick, MD

New test, Care Signature Pathways yield “monumental change” in heart attack diagnosis 

Last year, one of Yale New Haven Health’s laboratory vendors announced that it would no longer manufacture reagents for a blood test that helps diagnose heart attack.

This gave YNHHS the opportunity to adopt a different type of test that can more accurately and quickly rule out heart attacks, preventing unnecessary procedures and shortening patients’ lengths of stay. 

In February, YNHHS launched this test, called “high-sensitivity troponin assay,” along with Care Signature Pathways that provide guidelines for physicians on using it. The test and pathways are now standard across the health system.

Troponin is a protein in the heart muscles that doesn’t show up in the blood unless those muscles are damaged, as with a heart attack. YNHHS hospitals previously used a conventional troponin assay that could take up to 12 hours to show heart muscle damage. Patients would stay in the Emergency Department or be admitted to an inpatient unit while awaiting results. They might also undergo additional diagnostic procedures, such as electrocardiograms or stress tests.

The new high-sensitivity troponin assay is conducted shortly after a patient’s ED arrival, then at one hour and three hours. 

“It allows us to compare blood test results at different points in time and rapidly determine whether there’s been heart muscle injury,” said cardiologist Stephen Possick, MD, medical director for Care Signature, YNHHS, and assistant professor of Clinical Medicine, Yale School of Medicine (YSM). 

“If there’s no evidence of heart muscle damage, patients can be sent home,” said Joe El-Khoury, PhD, director, Clinical Chemistry, YNHHS, and associate professor of Laboratory Medicine, YSM. “If results indicate a heart attack, they can receive the treatments they need quickly.”

“We’re seeing patients discharged from the ED so we’re avoiding inpatient admissions, which is freeing up beds,” added Maura Shea, RN, executive director, Heart and Vascular Center Inpatient Services. “It is a monumental change in the care of our patients.”

The Care Signature Pathways (CSPs) for the high-sensitivity troponin assay include guidelines for which patients it is most appropriate and how different results will impact a patient’s plan of care. 

YNHHS has developed more than 350 CSPs so far for different clinical conditions. These pathways act as a kind of GPS, recommending steps clinicians can take to diagnose, treat and monitor patients. 

To develop a CSP, a steering committee comprising experts in the appropriate specialty or specialties conducts an extensive review of the latest medical literature on a particular condition. They convene other experts, including physicians and staff from throughout YNHHS, YSM and sometimes other institutions, to reach a consensus on what the CSP should include. 

Shea, Dr. Possick and Dr. El-Khoury served on the high-sensitivity troponin CSP steering committee, which convened about 25 experts from Cardiology, Internal Medicine, Emergency Medicine, Laboratory Medicine, Nursing and other areas. 

“Medical advances happen so quickly, no clinician can absorb and recall all the knowledge necessary to make the many complex decisions involved in patient care,” said Deborah Rhodes, MD, YNHHS vice president of Quality and Care Signature and associate chief medical officer, and professor of medicine, YSM. “Care Signature Pathways support the safest, most current processes.”

Completed CSPs and any related information and resources are uploaded to Epic, where clinicians can quickly access them. The pathways can be updated right in Epic to reflect new research findings or other changes. 

Dr. Rhodes and others involved in developing CSPs stressed that the pathways are not designed to promote “cookie-cutter” care.

“Each patient is unique, and clinicians must still use their judgement and expertise in making decisions about their care,” Dr. Rhodes said. “Our Care Signature Pathways are built by and for our own care providers to harness our unique resources, processes and expertise.”

Watch the high sensitivey troponin video to learn more about the high-sensitivity troponin assay and CSP process. Stay tuned for future communications about how Care Signature Pathways are transforming care at YNHHS.