Implementation and evaluation of a rural general practice assessment pathway for possible cardiac chest pain using point-of-care troponin testing: a pilot study
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, avoi...
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Published in | BMJ open Vol. 12; no. 4; p. e044801 |
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Main Authors | , , , , , , , , , , , |
Format | Journal Article |
Language | English |
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England
British Medical Journal Publishing Group
15.04.2022
BMJ Publishing Group LTD BMJ Publishing Group |
Series | Original research |
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Abstract | 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. |
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AbstractList | 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. 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. 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. A prospective observational pilot evaluation. Twelve rural general (family) practices in the Midlands region of New Zealand. 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. 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. 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. 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. 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. |
Author | Pickering, John Du Toit, Stephen Hamilton, Fraser Miller, Rory Frampton, Chris Norman, Tim Egan, Gishani George, Peter Devlin, Gerard Than, Martin Young, Joanna Scott Jones, Jo |
AuthorAffiliation | 1 Project Office , Pinnacle Midlands Health Network , Hamilton , New Zealand 2 Department of Population Health , University of Waikato , Hamilton , New Zealand 9 Christchurch School of Medicine and Health Sciences , University of Otago Christchurch , Christchurch , New Zealand 11 MedLab Pathology , Sydney , New South Wales , Australia 5 Department of Medicine , University of Otago Christchurch , Christchurch , New Zealand 10 Department of Cardiology , Waikato District Health Board , Hamilton , New Zealand 7 Heart Foundation of New Zealand , Auckland , New Zealand 3 Department of Cardiology , Canterbury District Health Board , Christchurch , New Zealand 4 Emergency Department , Canterbury District Health Board , Christchurch , New Zealand 6 Department of Clinical Chemistry , Waikato District Health Board , Hamilton , New Zealand 8 Department of Medicine , University of Otago - Dunedin Campus , Dunedin , New Zealand |
AuthorAffiliation_xml | – name: 9 Christchurch School of Medicine and Health Sciences , University of Otago Christchurch , Christchurch , New Zealand – name: 3 Department of Cardiology , Canterbury District Health Board , Christchurch , New Zealand – name: 7 Heart Foundation of New Zealand , Auckland , New Zealand – name: 8 Department of Medicine , University of Otago - Dunedin Campus , Dunedin , New Zealand – name: 4 Emergency Department , Canterbury District Health Board , Christchurch , New Zealand – name: 11 MedLab Pathology , Sydney , New South Wales , Australia – name: 1 Project Office , Pinnacle Midlands Health Network , Hamilton , New Zealand – name: 10 Department of Cardiology , Waikato District Health Board , Hamilton , New Zealand – name: 2 Department of Population Health , University of Waikato , Hamilton , New Zealand – name: 6 Department of Clinical Chemistry , Waikato District Health Board , Hamilton , New Zealand – name: 5 Department of Medicine , University of Otago Christchurch , Christchurch , New Zealand |
Author_xml | – sequence: 1 givenname: Tim surname: Norman fullname: Norman, Tim organization: Department of Population Health, University of Waikato, Hamilton, New Zealand – sequence: 2 givenname: Joanna orcidid: 0000-0003-0996-735X surname: Young fullname: Young, Joanna organization: Department of Cardiology, Canterbury District Health Board, Christchurch, New Zealand – sequence: 3 givenname: Jo surname: Scott Jones fullname: Scott Jones, Jo organization: Project Office, Pinnacle Midlands Health Network, Hamilton, New Zealand – sequence: 4 givenname: Gishani surname: Egan fullname: Egan, Gishani organization: Project Office, Pinnacle Midlands Health Network, Hamilton, New Zealand – sequence: 5 givenname: John orcidid: 0000-0001-9475-0344 surname: Pickering fullname: Pickering, John organization: Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand – sequence: 6 givenname: Stephen surname: Du Toit fullname: Du Toit, Stephen organization: Department of Clinical Chemistry, Waikato District Health Board, Hamilton, New Zealand – sequence: 7 givenname: Fraser surname: Hamilton fullname: Hamilton, Fraser organization: Heart Foundation of New Zealand, Auckland, New Zealand – sequence: 8 givenname: Rory surname: Miller fullname: Miller, Rory organization: Department of Medicine, University of Otago - Dunedin Campus, Dunedin, New Zealand – sequence: 9 givenname: Chris surname: Frampton fullname: Frampton, Chris organization: Christchurch School of Medicine and Health Sciences, University of Otago Christchurch, Christchurch, New Zealand – sequence: 10 givenname: Gerard surname: Devlin fullname: Devlin, Gerard organization: Department of Cardiology, Waikato District Health Board, Hamilton, New Zealand – sequence: 11 givenname: Peter surname: George fullname: George, Peter organization: MedLab Pathology, Sydney, New South Wales, Australia – sequence: 12 givenname: Martin orcidid: 0000-0001-9399-5227 surname: Than fullname: Than, Martin email: martin@thanstedman.onmicrosoft.com organization: Emergency Department, Canterbury District Health Board, Christchurch, New Zealand |
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Keywords | protocols & guidelines primary care coronary heart disease myocardial infarction |
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Snippet | ObjectivesTo assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic... To assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic chest pain... Objectives To assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic... OBJECTIVESTo assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic... Objectives To assess the feasibility and acceptability, and additionally to preliminarily evaluate, the effectiveness and safety of an accelerated diagnostic... |
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SubjectTerms | 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 |
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Title | Implementation and evaluation of a rural general practice assessment pathway for possible cardiac chest pain using point-of-care troponin testing: a pilot study |
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