Ischaemic heart disease

Chest pain protocols proved safe and efficient

Queensland hospitals are assessing chest pain faster, discharging low risk patients sooner and saving millions of dollars thanks to two new rapid assessment procedures.

Roll out of the two-hour Accelerated Diagnostic Protocol (ADP) has shaved 36 minutes off the time patients normally spent in the ED, shortened hospital stays by about 10 hours and reduced admission rates just over 13%.

An economic evaluation estimated $13.5 million in savings per year for Queensland hospitals as a direct result of using the ADP.

The study, published in the MJA, was one of two led by specialists at the Royal Brisbane and Women’s Hospital.

Cardiologist Professor Will Parsonage told the limbic EDs have been suffering under an ‘intolerable’ system of testing and patient observation practices for the assessment of chest pain amid pressure from increasing numbers of patient presentations and demanding hospital admission and exit targets.

Yet despite the proliferation of ADPs designed to address those problems and shown to safely predict which patients with suspected acute coronary syndrome (ACS) were low risk, very few make their way into routine clinical practice.

“Physicians are generally fairly conservative particularly around something like chest pain which is perceived to be surrounded by levels of risk that are potentially quite high and if you go back to the 90s there were a number of landmark papers suggesting that we didn’t do chest pain assessment very well – that we probably missed and under-recognised acute coronary events and that led to bad outcomes.”

Professor Parsonage said by the time people started writing guidelines for chest pain assessment, most places promoted a very conservative approach.

It placed a considerable burden on hospital staff and resources and was inefficient because only about one in five people with chest pain in the ED were at risk of having a heart attack.

The Accelerated Chest Pain Risk Evaluation (ACRE) study, which reported outcomes for 23,699 patients, identified 21.3% of patients as being at low risk for ACS.

According to Professor Parsonage, ACRE was a simple solution to a big problem.

“The biggest barrier to changing the model of care in this area, and the one we overcame, was that chest pain tends to span silos in hospitals. Just getting emergency doctors and cardiologists in the same room, which is what we did when we started ACRE, broke down a lot of those barriers because clinicians don’t normally have the opportunity to do that; it’s just not the way hospitals run anymore. When we made this a shared problem instead of a problem between one or the other [department] then that was when success followed on.”

A second ADP was tested in the Improved Assessment of Chest Pain (IMPACT) study. Some 1366 patients presenting to the ED with suspected ACS were stratified into groups at low, intermediate or high risk of an ACS.

Low and intermediate risk patients underwent troponin testing at presentation and two hours later. Intermediate risk patients underwent objective testing after the second troponin test and low risk patients were discharged without further objective testing. Meanwhile high-risk patients were treated according to current guidelines

The protocol allowed doctors to identify nearly 18% of patients as low risk for ACS. These patients didn’t require further testing beyond a clinical evaluation, ECG and a blood test and were safely discharged within five hours.

IMPACT picked up nearly 60% of patients who were at an intermediate risk of having a heart attack. Those with heart disease were identified early and admitted while those without were safely discharged within seven and a half hours compared to the 24 hours using traditional care.

The overall 30-day ACS rate was 6.6%, with no ACS events in the low risk group, and 14 (1.8%) in the intermediate risk group.

“All of those events were captured by the evaluation process proving that we could accelerate the investigation pathway and still maintain the levels of safety that everybody expects – the goal being not to miss a diagnosis and send somebody home inadvertently,” Professor Parsonage said.

A health economic analysis estimated that if all Queensland hospitals adopted IMPACT, it would result in released capacity worth $12.4 million annually.

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