Old Habits Die Hard

he inspirational speaker Jim Rohn would say, "Motivation is what gets you started.Habit is what keeps you going."This maxim rings true for many of the daily routines we perform in medicine.For instance, when new locations of care are introduced within a hospital, their use is often motivated by the needs of their stakeholders.Chest pain units, for example, proliferated because they benefited patients (providing additional time and monitoring within the hospital to ensure they remain low risk for complications from chest pain), clinicians (freeing up emergency department space that was previously occupied for 6-12 hours for routine monitoring), and health care systems (care in these units may improve outcomes and reduce costs). 1 Yet, sometimes, these habits persist despite mounting evidence that suggests a need for change.For example, as health care transforms and certain locations of care become less important or even unnecessary, how do hospitals and health care systems demotivate their use?It is within this context that Kansal et al 2 sought to change their hospital's habit of intensive care use for patients with non-STsegment-elevation myocardial infarction (NSTEMI) in this issue of Circulation: Cardiovascular Quality and Outcomes.Modern cardiac intensive care units (ICUs) trace their origins to high rates of arrhythmias after myocardial infarctions.As a result, cardiologists in the 1960s introduced continuous inpatient electrocardiographic monitoring. 3However, these devices were massive and required patients to be in close geographic proximity. 4ixty years later, through the expansion of telemetry units, most NSTEMI patients no longer require ICU-level care.Modern ICU care is ideally targeted to patients who require close clinical supervision, such as those with shock or respiratory failure.Fortunately, early percutaneous intervention, highly trained clinicians, and widespread availability of telemetry have dramatically reduced the incidence of postmyocardial infarction complications, and most patients with NSTEMI are at low risk of mortality.In one large study of US patients with NSTEMI, 5 most NSTEMI patients had a predicted mortality of <4%.Current evidence suggests that ICU care is not associated with improved clinical outcomes for NSTEMI patients. 5,6Yet, nearly half of NSTEMI patients continue to receive ICU care 5 despite ICU care for NSTEMI being associated with a ≈$3000 increase in cost per hospitalization, independent of baseline factors, procedural variables, and complications. 7or these reasons, Kansal et al integrated an algorithm into their hospital's electronic health record to help emergency department clinicians identify NSTEMI patients at high risk of deterioration.Their hope was that in identifying high-risk patients, all others might be admitted to non-ICU locations, thereby decreasing the proportion Old Habits Die Hard Do Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction Need an Intensive Care Unit?EDITORIAL