Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations

The cost savings of the rural accelerated chest pain pathway for low-risk chest pain in rural general practice: a cost minimisation analysis

Introduction The rural accelerated chest pain pathway (RACPP) has been shown to safely reduce the number of transfers to hospital for patients who present with chest pain to rural general practice. Aim This study aimed to estimate the costs associated with assessing patients with low-risk chest pain using the RACPP in rural general practice compared with transporting such patients to a distant emergency department (ED). Methods This was a retrospective cost minimisation analysis. All patients with low-risk chest pain that were assessed in New Zealand (NZ) rural general practice using the RACPP between 1 June 2018 and 31 December 2019 were asked to participate. The costs incurred by patients were determined by an online survey. Patients were also asked to estimate the costs if they would have been transferred to ED. System costs were obtained from the relevant healthcare organisations. The main outcome measure was the total cost for patients who present with low-risk chest pain. Results In total, 15 patients (22.7% response rate) responded to the survey. Using the RACPP in general practice resulted in a median cost saving of NZ$1184 (95% CI: $1111 to $1468) compared with transferring the same patient to ED. Discussion Although limited by low enrolment, this study suggests that there are significant savings if the RACPP is used to assess patients with low-risk chest pain in rural NZ general practice.

A prospective multi-centre study assessing the safety and effectiveness following the implementation of an accelerated chest pain pathway using point-of-care troponin for use in New Zealand rural hospital and primary care settings

Aims

Most rural hospitals and general practices in New Zealand (NZ) are reliant on point-of-care troponin. A rural accelerated chest pain pathway (RACPP), combining an electrocardiogram (ECG), a structured risk score (Emergency Department Assessment of Chest Pain Score), and serial point-of-care troponin, was designed for use in rural hospital and primary care settings across NZ. The aim of this study was to evaluate the safety and effectiveness of the RACPP.

Methods and results

A prospective multi-centre evaluation following implementation of the RACPP was undertaken from 1 July 2018 to 31 December 2020 in rural hospitals, rural and urban general practices, and urgent care clinics. The primary outcome measure was the presence of 30-day major adverse cardiac events (MACEs) in low-risk patients. The secondary outcome was the percentage of patients classified as low-risk that avoided transfer or were eligible for early discharge. There were 1205 patients enrolled in the study. 132 patients were excluded. Of the 1073 patients included in the primary analysis, 474 (44.0%) patients were identified as low-risk. There were no [95% confidence interval (CI): 0–0.3%] MACE within 30 days of the presentation among low-risk patients. Most of these patients (91.8%) were discharged without admission to hospital. Almost all patients who presented to general practice (99%) and urgent care clinics (97.6%) were discharged to home directly.

Conclusion

The RACPP is safe and effective at excluding MACEs in NZ rural hospital and primary care settings, where it can identify a group of low-risk patients who can be safely discharged home without transfer to hospital.

Implementation and evaluation of a rural general practice assessment pathway for possible cardiac chest pain using point-of-care troponin testing: a pilot study

OBJECTIVES

To assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic chest pain pathway in rural general practice using point-of-care troponin to identify patients at low risk of acute myocardial infarction, avoiding unnecessary patient transfer to hospital and enabling early discharge home.

DESIGN

A prospective observational pilot evaluation.

SETTING

Twelve rural general (family) practices in the Midlands region of New Zealand.

PARTICIPANTS

Patients aged ≥18 years who presented acutely to rural general practice with suspected ischaemic chest pain for whom the doctor intended transfer to hospital for serial troponin measurement.

OUTCOME MEASURES

The proportion of patients managed using the low-risk pathway without transfer to hospital and without 30-day major adverse cardiac event (MACE); pathway adherence; rate of 30-day MACE; patient satisfaction with care; and agreement between point-of-care and laboratory measured troponin concentrations.

RESULTS

A total of 180 patients were assessed by the pathway. The pathway classified 111 patients (61.7%) as low-risk and all were managed in rural general practice with no 30-day MACE (0%, 95% CI 0.0% to 3.3%). Adherence to the low-risk pathway was 95.5% (106 out of 111). Of the 56 patients classified as non-low-risk and referred to hospital, 9 (16.1%) had a 30-day MACE. A further 13 non-low-risk patients were not transferred to hospital, with no events. The sensitivity of the pathway for 30-day MACE was 100.0% (95% CI 70.1% to 100%). Of low-risk patients, 94% reported good to excellent satisfaction with care. Good concordance was observed between point-of-care and duplicate laboratory measured troponin concentrations.

CONCLUSIONS

The use of an accelerated diagnostic chest pain pathway incorporating point-of-care troponin in a rural general practice setting was feasible and acceptable, with preliminary results suggesting that it may safely and effectively reduce the urgent transfer of low-risk patients to hospital.

Implementing "Chest Pain Pathway" Using Smartphone Messaging Application "WhatsApp" as a Corrective Action Plan to Improve Ischemia Time in "ST-Elevation Myocardial Infarction" in Primary PCI Capable Center "WhatsApp-STEMI Trial"

BACKGROUND

ST-elevation myocardial infarction (STEMI) is a life-threatening medical emergency that requires immediate medical attention. Each hospital should implement a clinical pathway with the main objective to reduce ischemia time from diagnosis to revascularization (because this has shown to save myocardial tissues and, subsequently, patients' lives), utilizing the most evidence-based approach and the most up-to-date management protocol. In this study, we aimed to assess the utility of structuring chest pain pathway (CPP) with the instantaneous case-by-case feedback protocol using WhatsApp and its impact on improving 2 major key performance indicators-the impact on initial emergency room (ER) door-to-electrocardiogram (ECG) time, and door-to-balloon time-in a predefined 6-month corrective action period.

METHODS

A prospective, quality improvement plan was set to reduce door-to-first-ECG and door-to-balloon times to less than 10 and 90 minutes, respectively, in all acute coronary syndrome cases (including STEMI cases), from August 2020 to April 30, 2021. Several measures were done to attain the goal, including strict compliance to CPP with documentation, ruling out possible mimickers, and reducing false activation and time delays in ER. Direct feedback on cases was provided using WhatsApp messaging app on smartphones; protocol and results of time lines were accessed by all healthcare providers associated with CPP, including ER nurses, ER doctors, Cardiology residents, specialists, Catheterization laboratory nurses, technicians, and interventionalists. Bimonthly meetings with all stake holders were reinforced, and minutes of meeting were reviewed and corrective actions were implemented the next day. On a daily basis, all cases were analyzed and tabulated by a dedicated nurse and a doctor from ER, and another nurse and doctor from the quality assurance department.

RESULTS

After a 6-month period of implementing improvement plan and sticking to a comprehensive chest pain clinical pathways strategy with a case-by-case review on a shared smartphone messaging application, the rate of door-to-first-ECG improved from 76% to 93% in patients with chest pain, and the door-to-balloon time targeting less than 90 minutes improved significantly from only 77% to 92% in STEMI patients. This was statistically significant with a P value of 0.0001 and 0.001, respectively, and the rate of false activation was reduced from 23% to 16% and 10% 3 and 6 months of time, respectively, with a significant P value of <0.01. Finally, a strict 100% rate of timely documentation on patients with chest pain was achieved.

CONCLUSIONS

An improvement plan of implementing the CPP, cut-time policy, and using smartphone WhatsApp messaging for a case-to-case instantaneous feedback has significantly improved key performance indicators and, subsequently, ischemia time in acute coronary syndrome patients (including STEMI patients) in 6 months time, indicating that this strategy works.