None listed
Conditions
Brief summary
Over 450,000 patients present to an Australian Emergency Department with chest pain every year. The current processes used to rule out heart attack for these patients are lengthy and costly, taking a median of 26 hours at a cost of $2,127 per patient. This contributes to overcrowding in the Emergency Department, and is not sustainable within a healthcare system that has growing demand and finite resources. This project will implement and evaluate a new chest pain assessment strategy to be used on presentation to the Emergency Department. The strategy incorporates results from blood tests with shared decision-making to identify low-risk patients who can rapidly be discharged with no further testing. The goal is to realise a safe, efficient, and patient-focussed method for the assessment of chest pain. The new strategy will be termed LEGEND (Limit of detection in the EmergENcy Department). In the first instance, this will be implemented at seven Queensland hospitals. Data collected before and after the implementation of LEGEND will be used to assess 1) whether LEGEND reduces hospital length of stay, 2) whether LEGEND is safe for identifying heart attack, and 3) whether LEGEND reduces healthcare utilisation and healthcare costs. It is anticipated that this strategy will reduce the need for healthcare resources and will place patient needs at the centre of clinical decision making.
Interventions
The intervention is a new method for the assessment of patients who present to the Emergency Department with chest pain. The intervention will be implemented as standard care in the participating hospitals. It will be delivered in the Emergency Department by the Emergency clinician responsible for patient assessment and management. As soon as possible after presentation to the Emergency Department (within 2 hours of presentation), patients will receive an electrocardiogram (ECG) and will have a
The intervention is a new method for the assessment of patients who present to the Emergency Department with chest pain. The intervention will be implemented as standard care in the participating hospitals. It will be delivered in the Emergency Department by the Emergency clinician responsible for patient assessment and management. As soon as possible after presentation to the Emergency Department (within 2 hours of presentation), patients will receive an electrocardiogram (ECG) and will have a blood test taken. Troponin concentrations in the blood will be assessed using a high sensitivity troponin assay. Patients with normal ECG findings and who have a troponin concentration below the limit of detection (2ng/L for the Beckman assay used in this study) will be considered to be low-risk and considered for discharge from the emergency department with no further testing. Such patients will be provided with a shared decision making form that includes a pictorial representation of their 30 day risk of acute myocardial infarction. This form has been developed specifically for this study, but is based on the chest pain choices work completed in the United States (https://cdn.prod-carehubs.net/n1/56fab03a15e99046/uploads/2016/03/UPenn-Decision-Aid-1.pdf). Shared decision making will be used to determine whether the patient can be discharged or undergo further investigation. Shared decision making will involve the treating physician and patient (and potentially treating nurse) discussing the patients risk for further events and discussing further treatment options. Such options include additional testing or discharge with no further testing. For patients who are discharged, a standardised discharge summary will be sent to the patient’s primary care physician. For patients with a troponin concentration above the limit of detection, the assessment will proceed as per standard care. Standard care differs slightly at each hospital. However, this typically includes serial troponin and ECG testing on presentation and at least 2 hours later (with some testing being up to 12 hours later). Some patients will also receive CT coronary angiography or a functional test for myocardial ischaemia (e.g., exercise stress test, myocardial perfusion scan, or stress radionuclide imaging).
Sponsors
Jaimi Greenslade
Study design
Allocation
Non-randomised trial
Intervention model
Other
Primary purpose
Diagnosis
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
Patients will be eligible for enrolment into the study if they are >=18 years old and the treating physician intends to investigate for acute myocardial infarction.
Exclusion criteria
1) have a clear non-AMI cause for their symptoms on presentation, 2) were transferred from another hospital, or 3) have previously been included in the study within a 6 month period.
Outcome results
None listed