Development of NSTE-ACS Care Network in Phetchabun

Abstract

             Background : Thai Minister of Public Health developed the service form for Thai peoples who had cardiovascular diseases since 2009, for the purpose of improvement of quality of life and to reduce the mortality rate of Thai cardiovascular patients, called Cardiac Service plan.
              After the cardiac service plans were developed. There was much improvement in caring for patient with acute coronary syndrome with ST elevation
( STE-ACS ). There were many provinces developed their own cardiac network to treat STE-ACS patients with thrombolytic agents such as Streptokinase. It has effect on continually decreasing mortality rate
              However there are no specifi c service pattern for the treatment of NSTE-ACS patients and the mortality rate of patients with NSTE-ACS is still continually higher
              Phetchabun is a province located at lower northern part of Thailand surrounded with high land. The distance more than 180 kilometers from Phetchabun hospital to Phitsanulok hospital (cardiac center) is the obstacle to transferring the patients for coronary intervention within 90 minutes which are the golden period for emergency coronary intervention
              Objectives :
              1. To study the NSTE-ACS patients in Phetchabun province who were admitted at Phetchabun hospital.
              2. To develop the network of NSTE-ACS treatment including appropriate guidelines and standing order.
              3. To study the effectiveness of the process comparing with period before the implementation
              Methods : The medical records of NSTE-ACS patients who were admitted at Phetchabun hospital from October 2017 to December 2017 were evaluated. From January 2018 to March 2018, NSTE-ACS network of Phetchabun province was developed and GRACE risk score was chosen to be the tool for patient evaluation and risk stratification to select the patients who were suitable to be transferred from community hospital to Phetchabun hospital for further treatment. Standing protocols were used to control the medical treatment. We collected NSTE-ACS patients from April 2018 to June 2018 and the effect of the implemented guidelines and standing order were studied by using the descriptive statistics such as chi-square tests compared to the period before the guideline implementation.
              Results : The study revealed that GRACE risk score is the effective tool for evaluation and risk stratification for NSTE-ACS patients in Phetchabun province. NSTE-ACS patients who had more than 130 scores had higher mortality rate with statistically significance. The development of appropriate guidelines and standing orders protocols had an effect on the completion of medical treatment which were given to the patients especially beta-blockers and diuretics with statistically significance ( p-value = 0.009 and 0.04 respectively). After the guidelines and standing order protocol were applied, more NSTE-ACS patients were evaluated with echocardiography. The mortality rate of NSTE-ACS patients was obviously decreased (from 22 % to 8 %) although there were no statistically significance (p-value = 0.093).
              Conclusion : The development of NSTE-ACS network of Phetchabun provinces by using GRACE risk score for evaluation and risk stratification including standing orders protocols for conducting the medical treatment can help the physicians to select the right patients who were suitable to be transferred for emergent treatment and improve the completeness of medical treatments and investigation which were given to the patients.