LOW RISK CHEST PAINLOW RISK CHEST PAINASSESSMENT PROTOCOLASSESSMENT PROTOCOLRESULTS OF WREXHAM RESULTS OF WREXHAM

MAELOR HOSPITALMAELOR HOSPITAL’’S PILOT S PILOT PROJECTPROJECT

FIONA WILKINSONFIONA WILKINSONCARDIOLOGY NURSE SPECIALISTCARDIOLOGY NURSE SPECIALIST

WREXHAM MAELOR HOSPITALWREXHAM MAELOR HOSPITALOCTOBER 2006OCTOBER 2006

WHY NEAR PATIENT TESTING?WHY NEAR PATIENT TESTING?BACKGROUNDBACKGROUND

Several trusts throughout the UK have a Several trusts throughout the UK have a system in place for assessing low risk system in place for assessing low risk chest pain admissions to A+E chest pain admissions to A+E ––Northern General, Sheffield Northern General, Sheffield Leighton hospital, CreweLeighton hospital, Crewe2 separate audits in Wrexham early 2005 2 separate audits in Wrexham early 2005 suggested 25% of admissions to the suggested 25% of admissions to the cardiology ward were inappropriatecardiology ward were inappropriate

WHY NEAR PATIENT TESTING?WHY NEAR PATIENT TESTING?BACKGROUNDBACKGROUND

A majority of the patients admitted A majority of the patients admitted were awaiting a TNI then discharged were awaiting a TNI then discharged if negativeif negativeAccess to diagnostics and emergency Access to diagnostics and emergency clinics was seen as a possible clinics was seen as a possible alternativealternativeA+E had purchased a near patient A+E had purchased a near patient testing systemtesting systemTask and Finish group set upTask and Finish group set up

THE PROJECT THE PROJECT –– AIM AND AIM AND PREPRE--LAUNCHLAUNCH

To bring about early, safe discharge To bring about early, safe discharge of patients presenting to A+E with of patients presenting to A+E with low risk chest painlow risk chest painSecondment of nurse to initiate Secondment of nurse to initiate protocol protocol –– title, Chest Pain title, Chest Pain Assessment NurseAssessment NurseA+E staff education A+E staff education

THE PROJECT THE PROJECT –– PREPRE--LAUNCHLAUNCH

Negotiation with cardioNegotiation with cardio--respiratory respiratory dept for ETT slotsdept for ETT slotsTraining for Chest Pain Assessment Training for Chest Pain Assessment NurseNurseDocumentation, audit and database Documentation, audit and database set upset upVisit to Northern General, Sheffield Visit to Northern General, Sheffield

THE PROJECT THE PROJECT –– PREPRE--LAUNCHLAUNCHINCLUSION CRITERIAINCLUSION CRITERIA

Chest pain possibly cardiac in originChest pain possibly cardiac in originNormal ECG Normal ECG Able to undertake ETTAble to undertake ETT

THE PROJECT THE PROJECT –– PREPRE--LAUNCHLAUNCHEXCLUSION CRITERIAEXCLUSION CRITERIA

Known IHD with recurrent or Known IHD with recurrent or persistent painpersistent painAbnormal ECGAbnormal ECGUnlikely cardiac origin i.e. pleuritic, Unlikely cardiac origin i.e. pleuritic, positional or reproduced by palpationpositional or reproduced by palpationCoCo--morbidity requiring admissionmorbidity requiring admissionSuspected or proven alternative Suspected or proven alternative cause e.g. PE, dissecting AAcause e.g. PE, dissecting AA

THE PROJECT THE PROJECT -- LAUNCHLAUNCH

March 06 March 06 –– July 06 ( 20 weeks )July 06 ( 20 weeks )Mon Mon –– Fri 9am Fri 9am –– 5pm5pmChest Pain Assessment Nurse on a Chest Pain Assessment Nurse on a bleepbleepall patients reassessed by nurse after all patients reassessed by nurse after referral from A+E clinicianreferral from A+E clinician

THE PROJECT THE PROJECT -- LAUNCHLAUNCH

Triple marker ( CKMB, TNI and Triple marker ( CKMB, TNI and myoglobinmyoglobin ) on ) on admission and at 2 hoursadmission and at 2 hoursECG on admission then hourlyECG on admission then hourlyIf all results normal patients undertook an ETT If all results normal patients undertook an ETT 2 or more risk factors required ETT on the same 2 or more risk factors required ETT on the same day ( aged over 65, diabetes mellitus, day ( aged over 65, diabetes mellitus, dyslipidaemiadyslipidaemia, hypertension, smoker or stopped , hypertension, smoker or stopped smoking <1yr, PMH of MI/CABG/PCI, positive smoking <1yr, PMH of MI/CABG/PCI, positive family history of cardiac disease under the age of family history of cardiac disease under the age of 65 ) 65 ) Chest Pain Assessment Nurse took every patient Chest Pain Assessment Nurse took every patient through the protocolthrough the protocol

THE PROJECT THE PROJECT –– PATIENT PATIENT RESULTSRESULTS

Results reviewed by Cardiologist, SpR or Results reviewed by Cardiologist, SpR or ACS Specialist NurseACS Specialist NurseMedications initiated as appropriateMedications initiated as appropriatePatient given health education as required Patient given health education as required or referred to cardiac rehab angina clinic if or referred to cardiac rehab angina clinic if proven IHDproven IHDCommunication with GPCommunication with GPPatients given follow up appointment for Patients given follow up appointment for repeat ECG and TNI after 48 hours of repeat ECG and TNI after 48 hours of presentationpresentation

THE PROJECT THE PROJECT -- RESULTSRESULTS

50 patients completed the 20 week 50 patients completed the 20 week project protocol, 34 patients project protocol, 34 patients discharged ( 68% )discharged ( 68% )16 patients admitted ( raised 16 patients admitted ( raised markers, unresolved pain, ECG markers, unresolved pain, ECG abnormalities and abandoned/ high abnormalities and abandoned/ high risk/ inconclusive ETT )risk/ inconclusive ETT )

THE PROJECT THE PROJECT -- RESULTSRESULTS

15 week period comparison data for 15 week period comparison data for patients who went through the patients who went through the protocol and those that did not and protocol and those that did not and were consequently admittedwere consequently admitted39 patients through protocol, 23 39 patients through protocol, 23 discharged ( 58.98% )discharged ( 58.98% )retrospective review undertaken of retrospective review undertaken of A+E attenders with a cardiac triage A+E attenders with a cardiac triage in the 15 week periodin the 15 week period

THE PROJECT THE PROJECT -- RESULTSRESULTS

82 more patients could have been 82 more patients could have been seen if the project was run 24/7seen if the project was run 24/7mean LOS for those 82 patients was mean LOS for those 82 patients was 1.67 days1.67 daysestimated 419 patients annually estimated 419 patients annually could go through protocolcould go through protocol

THE PROJECT THE PROJECT -- RESULTSRESULTSPROTOCOLPROTOCOL59% had ETT59% had ETT33% saw 33% saw Consultant Consultant cardiologistcardiologistno patients no patients represented to A+E represented to A+E or admittedor admitted

NON PROTOCOLNON PROTOCOL29% had ETT29% had ETT19% saw 19% saw Consultant Consultant cardiologistcardiologist10 patients 10 patients readmitted readmitted

( ? why no coding ( ? why no coding available ) available )

THE PROJECT THE PROJECT -- COSTSCOSTS

triple marker triple marker ££28 per patient 28 per patient ––annual cost annual cost ££11,745 based on 419 11,745 based on 419 patientspatientsF grade nurse to facilitate protocol F grade nurse to facilitate protocol ££32,46432,464

TOTAL COST TOTAL COST ££44,209 PER ANNUM44,209 PER ANNUM

THE PROJECT THE PROJECT –– COST SAVINGSCOST SAVINGS

discharge rate ( 59% for 15 week discharge rate ( 59% for 15 week period ) = 247 patients would not period ) = 247 patients would not need to be admitted annuallyneed to be admitted annuallybed days saved 415.63bed days saved 415.63cost of LOS cost of LOS ££650.70 x 247 = 650.70 x 247 = ££160,722.90160,722.90TPNI test saving TPNI test saving ££4,253.344,253.34

TOTAL SAVING = TOTAL SAVING = ££164,976.24164,976.24

THE PROJECT THE PROJECT –– COST SAVINGSCOST SAVINGS

net cash release = net cash release = ££120,767.17120,767.17 if if protocol was to run 24/7protocol was to run 24/7net cash release = net cash release = ££17,010.9817,010.98 if if protocol was to run Mon protocol was to run Mon –– Fri 9am Fri 9am ––5pm 5pm

THE PROJECT THE PROJECT –– BENEFITS FOR BENEFITS FOR PATIENTSPATIENTS

Not having to be admitted to hospital, Not having to be admitted to hospital, reassurance and advice. reassurance and advice. During October 2006 all 50 patients ( 20 During October 2006 all 50 patients ( 20 week project ) were contacted by week project ) were contacted by telephone none had represented to A+E or telephone none had represented to A+E or been admitted with chest painbeen admitted with chest pain2 patients assessed on the protocol were 2 patients assessed on the protocol were found to have a high risk ETT and were found to have a high risk ETT and were referred to CTC for PCI referred to CTC for PCI

THE PROJECT THE PROJECT –– BENEFITS FOR BENEFITS FOR THE ORGANISATIONTHE ORGANISATION

Reduced number of admissionsReduced number of admissionsReduced costsReduced costsImproved communication between Improved communication between A+E Dept, CardioA+E Dept, Cardio--Respiratory Dept, Respiratory Dept, the Cardiology Ward and the the Cardiology Ward and the Modernisation TeamModernisation TeamChest Pain Assessment Nurse in A+E Chest Pain Assessment Nurse in A+E dept to provide advice when requireddept to provide advice when required

THE PROJECT THE PROJECT –– BENEFITS FOR BENEFITS FOR THE ORGANISATIONTHE ORGANISATION

Potential to broaden scope of project Potential to broaden scope of project e.g. toxicology screening, D e.g. toxicology screening, D dimerdimer12 months further funding secured 12 months further funding secured on the strength of this pilot projecton the strength of this pilot projectThe protocol aligns with the TrustThe protocol aligns with the Trust’’s s strategy for incorporation into NEW strategy for incorporation into NEW ERA ( North East Wales Emergency ERA ( North East Wales Emergency Response Area ) projectResponse Area ) project

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