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

Abstract

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.

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

“…A cost minimisation study is considered a less attractive methodology than other health economic analyses; 14 however, it is a simple and pragmatic methodology that can be justified in this instance, as we have already demonstrated that the clinical outcomes (no recorded 30-day MACE) were comparable to accelerated chest pain pathways used in urban EDs. 1,3 Although limited by sample size, this study suggests that the assessment of chest pain in general practice results in cost savings for low-risk patients compared with transporting the patient to a urban hospital ED. Widespread investment and roll-out of the RACPP in rural (and other) settings has the potential to reduce costs for both patients and the NZ health service.…”

“…1 Some rural general practices have access to lower precision point-of-care troponin (POC-cTn) and have adopted the rural accelerated chest pain pathway (RACPP) that incorporates POC-cTn. 3,4 A recent prospective evaluation of the RACPP demonstrated that the clinical outcomes (30-day MACE) are equivalent to ADP used in urban emergency departments. The RACPP reduced the requirement for patients with low-risk chest pain (44% of all patients with chest pain) who presented to rural general practice to travel to a distant ED.…”

“…The RACPP reduced the requirement for patients with low-risk chest pain (44% of all patients with chest pain) who presented to rural general practice to travel to a distant ED. 3 The adoption of the RACPP by rural general practices, therefore, has the potential to reduce costs for both patients and the healthcare system.…”

Musculoskeletal chest pain prevalence in emergency department presentations: A retrospective case notes review

“…In all chest pain patients, the priority is to exclude potentially serious and lifethreatening causes. Work to expedite the identification of those with high-risk chest pain 24,25 supports the identification of low-risk groups, but this is not sufficient to positively identify MSK chest pain in these settings. A high level of undifferentiated cases (47%) observed in the present study and other research 1,9 highlights the challenge of identifying cause(s).…”