Reducing avoidable chest pain admissions and implementing high-sensitivity troponin testing

Abstract

NHS accident and emergency departments see 0.5 million patients presenting with a cardiac condition each year. The accurate assessment of chest pain and subsequent diagnosis or exclusion of myocardial infarction (MI) represent a significant challenge, with important consequences on patient outcome and healthcare resources. We conducted a cross-sectional analysis of patients admitted with cardiac chest pain to a busy district general hospital in London. The criteria used by physicians to admit patients for further cardiac investigations were measured against national guidance on chest pain assessment and diagnosis of MI. We found that poor adherence to guidance, unsuitable patient pathways and inappropriate diagnostic tools at the point of presentation led to unnecessary inpatient admissions to the hospital. Quality improvement methods were used with the aim to reduce avoidable admissions to hospital in patients presenting with chest pain. We describe a system to implement new high-sensitivity troponin testing into legacy chest pain pathways. This was achieved through local education of National Institute for Health and Care Excellence (NICE) guidance, the use of patient pro formas and the creation of two new chest pain pathway arms to enable physicians to streamline patients for appropriate inpatient or outpatient care. As a result of these changes, we reduced non-compliance with NICE guidance by 83% and achieved a 42% reduction in avoidable chest pain admissions. Overall, the improvements made by this project were sustained over 2 years and saved £21 000 per month in avoidable admissions.

Keywords: diagnostic errors; emergency department; governance; quality improvement; quality improvement methodologies.

Figure 1

Flowchart demonstrating the chest pain pathway at West Middlesex University Hospital prior to QIP implementations. Shaded areas represent the clinical setting of decisions within the pathway (red denotes A&E; blue denotes inpatient ward; and purple denotes outpatient). Decisions in A&E are made within a 4-hour time frame as per national care standards. A&E, accident and emergency; NSTEMI, non-ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; QIP, quality improvement project; STEMI, ST-elevation myocardial infarction; TnI, troponin I.

Figure 2

Run chart mapping time to primary endpoint measurement of avoidable inpatient admission. Annotations correlated to PDSA interventions. *Avoidable admission rate was calculated as the proportion of patients with non-MI chest pain admitted of the total number of patients with chest pain presenting to accident and emergency. hsTn, high-sensitivity troponin; PDSA, plan, do, study, act; RACP, rapid access chest pain.

Figure 3

Flowchart demonstrating the chest pain pathway at WMUH after QIP implementations. Shaded areas represent the clinical setting of decisions within the pathway (red denotes A&E; blue denotes inpatient ward; and purple denotes outpatient). Decisions in A&E are made within a 4-hour time frame as per national care standards. A&E, accident and emergency; CDU, clinical decision unit; hsTn, high-sensitivity troponin; MI, myocardial infarction; NSTEMI, non-ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; QIP, quality improvement project; RACPC, rapid access chest pain clinic; STEMI, ST-elevation myocardial infarction; TnI, troponin I.