Fast assessment and management of chest pain without ST-elevation in the prehospital gateway
Pre-hospital triaging system for chest pain patients leads to a 30% reduction in hospital admissions, safe home treatment of the identified low risk patients and a more cost effective use of expensive hospital facilities. Overcrowding of emergency departments is a risk for patients and financially a considerable cost in the Western World (1). Chest pain is one of the main causes for cardiac emergency care department visits. However, the majority of chest-pain patients without electrocardiogram (ECG) changes will be diagnosed with stable coronary disease or a non-coronary chest pain syndrome (2). The aim of Famous Triage is to implement a pre-hospital triaging system for chest pain patients in whom acute coronary syndromes Non-ST-Elevation-Myocardial-Infarction (NSTEMI) and Unstable Angina (UA) cannot be ruled out. This triage (figure 1) is performed by calculation of a HEART score through a questionnaire combined with a cardiac blood marker measurement (3,4). In the Famous study, patients in the low risk group will not be transported to the emergency department. This pre-hospital triaging system will lead to the improvements of the following value based healthcare parameters:
Outcome of Health Care: pre-hospital risk stratification can reduce cost, deaths and overcrowding in emergency departments(1). The medical outcome of all pre-hospital triaged patients with chest pain without ECG changes is expected to be at least the same as patients admitted at the emergency department in the traditional process.
Safety: the HEART score is safe to decide whether chest pain patients should be further treated or discharged from an emergency department (3). Safety outcome is measured by registration of major adverse events (cardiac intervention, myocardial infarction), re-admission and survival after 30 days and six months after presentation and is compared with current standard care.
Service: Pre-hospital risk stratification can avoid unnecessary hospitalization of low-risk patients. We hypothesize that this will reduce stress sensation because of faster clarity in the chance of chest pain being from myocardial infarction and avoidance of unnecessary waiting at the emergency department. Service is measured by a short quality of life questionnaire like the Short Form 6D (SF-6D) Health Survey.
Waste: Further medical evaluation of low risk patients in the primary care setting would avoid unnecessary costly (inter) hospital transfers and expensive hospital admissions. 30% of chest pain patients have a low HEART score and could be left home.
In conclusion: Pre-hospital risk stratification is an initiative among paramedics, general practitioners, cardiologists and clinical chemists to consult each other when additional information for HEART score calculation is needed and to create a safety net for low risk patients. This standardized pre-hospital triage system has the potential to be scaled up to every dutch ambulance service. For the Netherlands a cost reduction of 50 million euro per year is achievable with comparable or even better medical outcome in chest pain patients without ECG changes.
- Sun et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med. 2013 Jun;61(6):605-611.
- Roffi M, Patrono C, Collet J-P, . 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2016; 37: 267–315.
- Backus et al.. A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology 168 (2013) 2153–2158.
- Ishak M, Ali D, Fokkert MJ, Slingerland RJ, Tolsma RT, Badings E, van der Sluis A, van Eenennaam F, Mosterd A, ten Berg JM and van ’t Hof AWJ. Fast assessment and management of chest pain without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score. European Heart Journal Acute Cardiovascular Care. January 13, 2017; DOI: 10.1177/2048872616687116.