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Rural accelerated chest pain pathway receives recognition

Pinnacle MHN has developed a rural chest pain assessment method, referred to as a pathway, that allows low-risk patients in rural communities to be safely assessed and managed by their general practice, rather than travelling significant distances to hospital - often needlessly.

The programme has since received validation by the Cardiac Society of Australia and New Zealand (CSANZ) by way of an award.

The aim of the programme was to equip general practice with a risk stratification tool, diagnostic point of care troponin (POCT), and funded clinical time to identify and manage low risk patients in general practice.

"We believe this is a first of its kind in primary care - nationally and internationally," says Tim Norman, lead researcher and Pinnacle project manager. "Our secondary partners have been using the chest pain risk stratification tool (Emergency Department Assessment of Chest Pain Score, known as EDACS) for a number years, which was based on the work completed by Dr Martin Than, a Christchurch ED physician considered a lead expert in this area."

"The originality of this concept is the redesign of the tool to identify low or not low risk patients in primary care. However the rate limiting step for general practice to prevent ED presentations is a timely cardiac enzyme result. For a rural practice this could take up to six hours to obtain, compared to 10-20 minutes with the application of POCT".

Proof of concept

A grant from the Heart Foundation and Waikato Medical Research Foundation helped fund the trial of a new method for assessing chest pain among people in rural Waikato. 

The pathway was run as a proof of concept and kicked-off in October 2016. It included the introduction of a chest pain assessment tool and point of care machine into 12 participating rural GP practices across the Waikato region.

The proof of concept officially ended 30 April 2018 with the following preliminary findings from the research group.

  • The combination of EDACS and POCT testing, currently shows patients are safely managed in the community.
  • ED presentations show there has been no re-presentation of a low risk patient managed in primary care. 
  • There have been no major adverse cardiovascular events (MACE) for the low risk cohort to date.
  • 7 MACE events have occurred with the not low risk cohort referred to hospital to date.
  • The coinciding blood sample tested at the lab showed only one result as positive in practice and negative in lab (due to stricter safety range being applied in practice).
  • General practice is now speaking the same clinical language as our secondary partners, therefore creating an easier referral process.
  • A standardised approach to the assessment of chest pain appears to be effective, however deviation from protocol remains challenging.

The findings of the pilot were presented at the recent Cardiac Society of New Zealand meeting. As the lead researcher, Tim Norman was awarded the Affiliate's prize for his work on this pilot study and his presentation at the conference.

"This provides validation for the work and recognises the pathway could provide a change to the chest pain model of care," says Tim. "This is an example of integration with our tertiary partners. We work from the same song sheet and we equip and fund general practice to complete the care of patient in practice/closer to home and refer to tertiary care when the risk is appropriate. The tangible benefits for the patient being treated closer to home are obvious."

The preliminary results demonstrate the success of the programme in managing low risk chest pain in general practice. The project ran for 18 months and collected data from 205 patients. More than 58 per cent, 104 of the cohort, were treated in primary care who would otherwise have been refered to the emergency department and 100 per cent of low risk patients did not go on to re-present to an emergency department OR have a major acute coronary event within 30 days.

So what's next? 

"Although the proof of concept has been achieved and has formally ended, the local DHB has agreed to continue sponsoring the existing practices until a business model can be addressed," says Tim. "We are working towards national endorsement, national policy and national registry by expanding the primary care programme in the midland region, including rural and urban practices and into all rural hospital settings."

Practices in Tairāwhiti are the next to come on board, with a training evening attended by 30 people representing Gisborne practices.

Image: Tim Norman with CSANZ judge and keynote speaker Dr Linda Worrall-Carter, Her Heart Founder and CEO. 

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