How To Triage Chest Pain?


According to a recent study carried out called the Improved Assessment of Chest pain Trial (IMPACT), the answer to that question is yes. This research demonstrates how accelerated diagnostic protocols in emergency departments (EDs) for treating patients with chest pain may significantly reduce unnecessary testing while freeing up space for other patients. As many as three quarters of patients admitted with chest pain could be assessed more quickly using risk stratification tools, selective objective testing, and early troponin testing.

The IMPACT study involved 1366 patients who were admitted to Royal Brisbane and Women’s Hospital with suspected acute coronary syndrome (ACS) over a period of three years. Patients were asses using the IMPACT protocol and split into three groups: high risk, intermediate risk, and low risk groups. Results from the study showed that 333 patients were deemed to be high risk, 789 intermediate risk, and 244 low risk. Those patients coming up as high risk were treated under the guidelines set out by the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (CSANZ), while intermediate and low risk patients were sent for troponin testing when they were admitted and again two hours later. Intermediate risk patients were also sent for objective testing after the second troponin test had been conducted.

In a similar study researchers looked at and evaluated the 2-hour protocol put forward by the Accelerated Diagnostic protocol to Assess Patients with chest pain symptoms using contemporary Troponins (ADAPT) study. The ADAPT protocol was implemented in 16 public hospitals across Queensland as part of the Accelerated Chest & Respiratory pain Risk Evaluation (ACRE) project. As a result, hospital admissions were reduced by over 10% and the average length of stay in the Ed also reduced from 292 minutes to just 256 minutes after just 12 months of being implemented. A saving of over $13 million was made in total by reducing these factors.

“It’s pretty clear now that we can identify low risk patients and we can feel safe in discharging them, and we need to,” said Associate Professor Ian Scott, director of Internal Medicine and Clinical Epidemiology at Brisbane’s Princess Alexandra Hospital. “There are increasing numbers of patients coming into EDs, and the increased capacity freed up by not admitting large numbers of low risk patients is important when you are dealing with hospitals that are always under bed stress.” Scott also suggested how an education campaign could help raise acceptance of the protocols and perhaps some kind of financial incentive in which to further encourage uptake.

CSANZ president, Mark Webster, is also pleased with the results of the IMPACT study and says it’s reassuring, but there’s a major limitation in the lack of power. “When event rates are low – even in the intermediate risk group the rate was only 2% – large numbers are needed to be certain that there is discrimination between groups,” he said. “It would be reasonable to implement IMPACT, but continue prospective evaluation to evaluate larger numbers and confirm that the approach is safe.”

The author of the IMPACT study is Professor Louise Cullen and she said that by using this new low risk strategy they discovered that nearly 20% of patients didn’t require any further testing. Add this to the almost 60% of intermediate risk patients who had a reduced testing time, and anyone can see how the project has been a huge success. “The median length of stay for our intermediate risk patients….was 7.5 hours, by comparison to our previous research, which showed that it was nearly a full 24 hours that those patients required to stay for testing,” said Cullen.

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