[Comparison between chest pain units and stroke units : Essential components of the vascular emergency care system: comparison of structure, certification process, quality benchmarking and reimbursement]

German Radiological Society and the Professional Association of German Radiologists Position Paper on Coronary computed tomography: Clinical Evidence and Quality of Patient Care in Chronic Coronary Syndrome

This position paper is a joint statement of the German Radiological Society (DRG) and the Professional Association of German Radiologists (BDR), which reflects the current state of knowledge about coronary computed tomography. It is based on preclinical and clinical studies that have investigated the clinical relevance as well as the technical requirements and fundamentals of cardiac computed tomography. CITATION FORMAT: · Langenbach MC, Sandstede J, Sieren M et al. DRG and BDR Position Paper on Coronary CT: Clinical Evidence and Quality of Patient Care in Chronic Coronary Syndrome. Fortschr Röntgenstr 2023; 195: 115 - 133.

[German Radiological Society and the Professional Association of German Radiologists position paper on coronary computed tomography: clinical evidence and quality of patient care in chronic coronary syndrome]

This position paper is a joint statement of the German Radiological Society (DRG) and the Professional Association of German Radiologists (BDR), which reflects the current state of knowledge about coronary computed tomography (CT). It is based on preclinical and clinical studies that have investigated the clinical relevance as well as the technical requirements and fundamentals of cardiac computed tomography.

[Comparison between chest pain units and stroke units : Essential components of the vascular emergency care system: comparison of structure, certification process, quality benchmarking and reimbursement]

BACKGROUND

Chest pain units (CPU) and stroke units (SU) have both become established as essential components of clinical emergency care. For both instances dedicated certification processes are installed. Up to summer 2020, 290 CPUs and 335 SUs have been successfully certified.

OBJECTIVE

The aim of this review is to compare the structures and the current certification situation of CPUs and SUs. Also, the younger CPU certification process is compared to the long established SU certification standard.

MATERIAL UND METHODS

The comparison includes the historical background, the certification process, quality benchmarking, possible additive structures, the current status of certification in Germany, the transfer of the concept to the European level as well as reimbursement issues.

RESULTS

Both certification concepts show clear analogies. Evidence for SUs is supported by a positive Cochrane analysis and for CPUs there are many studies from the German CPU registry. The main differences include a uniform CPU system versus a multistep SU system of certification. Furthermore, SU have obligatory elements of quality documentation but only facultative quality indicator assessment for CPUs. From an economic viewpoint operation and procedural key (OPS) numbers guarantee a better reflection of the use of resources in the complex treatment of stroke, which could not yet be established for CPUs.

CONCLUSION

The well-established CPU concept could additionally benefit from a superordinate quality control. Adequate quality benchmarking appears to be fundamental for gap analyses and for the establishment of a separate remuneration structure. In this respect the German Society for Cardiology as the certifying institution is required to establish an appropriate mechanism within the framework of regular updates of criteria.

Unexpected high level of severe events even in low-risk profile chest pain unit patients

AIMS

Early heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile.

METHODS AND RESULTS

In this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5-2.8%. Those patients with preinfarction angina experienced fewer events.

CONCLUSIONS

When educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina.

Capacity changes in German certified chest pain units during COVID-19 outbreak response

Background

We sought to determine structure and changes in organisation and bed capacities of certified German chest pain units (CPU) in response to the emergency plan set-up as a response to the SARS-CoV-2 pandemic.

Methods and results

The study was conducted in the form of a standardised telephone interview survey in certified German CPUs. Analyses comprised the overall setting of the CPU, bed capacities, possibilities for ventilation, possible changes in organisation and resources, chest pain patient admittance, overall availability of CPUs and bail-out strategies. The response rate was 91%. Nationwide, CPU bed capacities decreased by 3% in the early phase of COVID-19 pandemic response, exhibiting differences within and between the federal states. Pre-pandemic and pandemic bed capacities stayed below 1 CPU bed per 50,000 inhabitants. 97% of CPUs were affected by internal reorganisation pandemic plans at variable extent. While we observed a decrease of CPU beds within an emergency room (ER) set-up and on intermediate care units (ICU), beds in units being separated from ER and ICU were even increased in numbers.

Conclusions

Certified German CPUs are able to maintain adequate coverage for chest pain patients in COVID-19 pandemic despite structural changes. However, at this time, it appears important to add operating procedures during pandemic outbreaks to the certification criteria of forthcoming guidelines either at the individual CPU level or more centrally steered by the German Cardiac Society or the European Society of Cardiology.