Improving the Care of Patients with Non-ST-elevation Acute Coronary Syndromes in the Emergency Department: The CRUSADE Initiative

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Abstract
Although acute coronary syndromes (ACS) represent a well-recognized source of morbidity and mortality for patients with cardiovascular disease, evidence-based therapies shown to improve outcomes for ACS are frequently underused in appropriate patients, especially in the emergency department (ED). Despite dissemination of expert recommendations from the American College of Cardiology/American Heart Association (ACC/AHA) and ED-focused recapitulation of them in the emergency medicine literature, significant barriers continue to limit the adoption of guidelines in clinical practice and appear to hinder the use of beneficial therapies and interventions in the ED. Unique and creative approaches are therefore needed to stimulate better adherence to practice guidelines and improve the quality of care for patients with non-ST-elevation myocardial infarction (NSTE) ACS. The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines) quality improvement and educational initiative provides an innovative and multifaceted approach to the education of emergency physicians and cardiologists in the care of patients with NSTE ACS. The CRUSADE initiative is a multidisciplinary cooperative effort involving over 400 EDs and medical centers. It includes an ACS registry designed to characterize demographic patterns and risk stratification results in patients who meet diagnostic criteria for high-risk NSTE ACS. It also measures the use of ED treatment modalities including aspirin, heparin, beta-blockers, and platelet inhibitors as recommended in the ACC/AHA guidelines. The results of a given institution's treatment patterns will be reported back to the practitioners, with comparisons with national norms. These reports can be used as quality improvement tools to improve care at participating institutions. Beyond a static registry, these reports are coupled with educational efforts by the CRUSADE steering committee, scientific publications of risk stratification practice and success, as well as ED patterns of care, and tailored educational interventions, to reinforce compliance with the ACC/AHA guidelines. This initiative represents a truly innovative approach to improving care for ACS patients in the ED as well as on the cardiology service. This article describes the CRUSADE initiative and its implications for the practicing emergency physician. It is the intent of CRUSADE to improve patient care in the ED by tracking and encouraging compliance with evidence-based guidelines for the evaluation and management of NSTE ACS.