Accumulative of the last 12 months as at 1st of month As at 1st December

Reduced admissions from ED with non-cardiac Chest PainData from Christchurch hospital, NZ

How long patients without a major cardiac event stayed in hospital prior to any accelerated diagnostic pathway (Pre-ADP) compared to the current pathway (EDACS-ADP). Currently 50% are discharged within 10 hours compared to 10% previously and 90% within 60h hours compared to 150 hours.

Phases of ICARE-ACS related to specific studies that formed the evidence base for the project

Stepped wedge study design: A 6-month control period for each site followed by an intervention phase comprising a4-month implementation phase and ADP continuance phase. Study End is at the completion of the finalimplementation phase and follow-up data is collected on the final patients for 30-days

RESULTS

• Data collected on 31,332 patients

• 11,529 patients pre-implementation

• 19,803 patients post-implementation

Pre Post

n

Female (%)

Maori (%)

MACE in 30d (%)

11,529 19,807

46.5 45.6

10.4 10.5

13.6 12.9

Non-ACS patients

Median reduction length of stay =

2.9 h (2.4-3.4)

SAFETY

• For patients discharged within 6h, there was no change in 30-day major adverse cardiac events (MACE) rates;

• 0.52% before vs. 0.44% after, P=0.96.

SAFETY

PRE POST

Sensitivity 99.7 (99.3-99.9) 99.4 (99.0-99.7)

Negative predictive value 99.5 (98.8-99.8) 99.6 (99.3-99.7)

P=0.28

•NO PATIENT MANAGED ACCORDING TO PATHWAY HAD MACE

jamanetwork.com

Available at jama.com and on The JAMA Network Reader at

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Chapman AR and coauthors

Association of High-Sensitivity Cardiac Troponin I Concentration With Cardiac Outcomes in Patients

With Suspected Acute Coronary Syndrome

Published online November 11, 2017

What is the optimal threshold to rule out myocardial infarction?

22,457patients

Secondary analysis of different thresholds

32,837 patientsThe NPV for 30d MI or death was 99.8% (99.7%–99.8%)

Figure 1. Measured implementation of a ‘low cardiac risk chest pain pathway’ in an urban Emergency Department using single troponin measurement rule-out of myocardial infarction. ECG, electrocardiogram; hs-cTnI, high sensitivity cardiac troponin I MACE, major adverse cardiac event; NSTEMI, Non-ST elevation myocardial infarction; STEMI, ST-elevation myocardial infarction.

ED presentation with possible ACS

STEMI Possible NSTEMI

EDACS ≥ 21 and/or 1st hs-cTnI ≥5 ng/L EDACS <21 and 1st hs-cTnI <5ng/L(n=332)

ECG, no red flags, and >2 hours from symptom onset/ last pain

Early discharge withfollow-up 24h hs-cTnI

(n=332)

Usual management[Exceptions: patients with hs-cTnI ≥ 5 ng/L but early discharge with no 30-day

MACE (n=7)]

No 30-day MACE(n=330)

Raised 24h hs-cTnI(n=2)

‘low-risk single hs-cTnI rule-out pathway’

Patients presenting with chest pain of possible ischaemic origin in the last 72 hours

Managed in the communityManaged in rural hospital with

NOT LOW-RISK for AMI pathway

Start of RACPP†

for Evaluation

Screening

NO

STEMI* or other serious differential diagnosis?

RED FLAGS: New ischaemic changes1 on 0h ECG? History strongly suggestive of Crescendo angina?

Haemodynamically unstable?

EDACS§ ≥ 16?

0h i-STAT¶ cTnI** ≥ 0.04 μg/L?Or AQT90†† cTnT‡‡ ≥ 18 ng/L?

Clinically deteriorating? STEMI? New ischaemic changes1 on 2h ECG?

NOT LOW RISK

NO

NO

NO

NO

NO

YES

YES

YES

YES

YES

YES Not eligible for pathway

Figure 2: Low-risk pathway

2 hours after initial assessment

LOW-RISK for AMI‡

*ST segment elevation myocardial infarction†Rural accelerated chest pain pathway‡ Acute myocardial infarction§Emergency department assessment of chest pain score¶Abbott point-of-care i-STAT**cardiac troponin I†† Radiometer AQT90 FLEX‡‡ cardiac troponin T

2h i-STAT¶ cTnI ≥ 0.04 μg/L?Or AQT90 cTnT ≥ 18 ng/L?

1. ST segment depression (≥0.5mm in two contiguous leads, abnormal T-wave inversion (>1mm), Q waves (>30ms, ≥1mm deep) in 2 contiguous leads, or new bundle-branch block

iSTAT cTnI ≥ 0.08 ug/L?OR

iSTAT cTnI between 0.04 ug/L and 0.07 ug/L AND a rise or fall of ≥ 0.02 ug/L?

ORAQT90 cTnT ≥ 18 ng/L?

Chest Pain Patients presenting or referred to a Rural Hospital and classified as NOT LOW-RISK for AMI* by Initial Assessment using Accelerated Chest Pain Pathway

Initially managed in the rural hospitalConsider further provocative testing

Inpatient assessment to determine cause of elevated cTnI.

Consider discussing with base hospital patients with AMI who are suitable for a revascularisation

procedure(s).

Start of rural hospital ‘not low-risk’ evaluation iSTAT† cTnI‡ at presentation ≥ 0.08 ug/L

OR AQT90§ cTnT¶ ≥ 18 ng/L?

Clinically deteriorating?New ischaemic changes1 on 3-6h ECG?

NO

NO

NO

YES

YES

YES

HIGH RISK for

AMI.

INTERMEDIATE-RISK for AMI

Figure 3: Not low-risk pathway

3-6 hours after initial assessment

*Acute myocardial infarction†Abbott point-of-care iSTAT‡ cardiac troponin I§Radiometer AQT90 FLEX¶ cardiac troponin T

AMI can be defined as a rise and fall (>20% change) of cTnI or

cTnT associated with:• Symptoms of acute

myocardial ischemia;• New ischemic

electrocardiographic (ECG) changes;

• Development of pathological Q waves.(31)

1. ST segment depression (≥0.5mm in two contiguous leads, abnormal T-wave inversion (>1mm), Q waves (>30ms, ≥1mm deep) in 2 contiguous leads, or new bundle-branch block

New Zealand care framework for assessment of possible ACS:

1. A clear clinical (pathway) documentation process

2. a structured and reproducible process of ACS risk stratification (e.g. clinical score such as modifiedTIMI, HEART, MACS, EDACS, Modified Goldman, TRAPID-AMI)

3. guidance for consistency of sampling time-points for performing cTn and ECG testing (e.g. on arrivaland after a further specified timepoint(s).

4. guidance about how to combine clinical risk stratification, and ECG and troponin testing with astructure on how to guide patient management (admission, discharge and further investigations)

5. guidance and timeframes for performing follow-up testing; e.g. stress testing

6. guidance for selection of patients for telemetry and removal from telemetry

7. clear discharge planning, which includes patient education and lifestyle modification advice (whereappropriate).

8. A robust quality assurance program

Details of ICARE-ACS pilot and national implementation stakeholder involvement

Plan Do Study Act (PDSA) Cycle as followed

0 100 200 300 400 500 600

New…

Wales

Scotland

Hong Kong

England

Northern…

Australia

Qatar

USA

Canada

Annual ED Attendance Rate/1000 persons versus Country

Rounded Annual AttendanceRate/1000 persons

411

405

400

332

298

261

258

245

484

438