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

• Published in: BMJ open Vol. 12; no. 4; p. e044801
• Main Authors: Norman, Tim, Young, Joanna, Scott Jones, Jo, Egan, Gishani, Pickering, John, Du Toit, Stephen, Hamilton, Fraser, Miller, Rory, Frampton, Chris, Devlin, Gerard, George, Peter, Than, Martin
• Format: Journal Article
• Language: English
• Published: England British Medical Journal Publishing Group 15.04.2022; BMJ Publishing Group LTD; BMJ Publishing Group
• Series: Original research
• Subjects: Acute coronary syndromes; Adolescent; Adult; Angina Pectoris; Biomarkers; Cardiovascular disease; Cardiovascular Medicine; Chest Pain - diagnosis; Chest Pain - etiology; Clinical outcomes; coronary heart disease; Electrocardiography; Emergency medical care; Emergency Service, Hospital; General Practice; Heart attacks; Hospitals; Humans; Ischemia; Laboratories; myocardial infarction; Pain; Patient satisfaction; Pilot Projects; Point-of-Care Systems; primary care; Prospective Studies; protocols & guidelines; Risk Assessment - methods; Rural areas; Training; Troponin; protocols & guidelines; primary care; coronary heart disease; myocardial infarction
• DOI: 10.1136/bmjopen-2020-044801
• ISSN: 2044-6055

ObjectivesTo 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.DesignA prospective observational pilot evaluation.SettingTwelve rural general (family) practices in the Midlands region of New Zealand.ParticipantsPatients 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 measuresThe 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.ResultsA 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.ConclusionsThe 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.