The impact of an acute chest pain pathway on the investigation and management of cardiac chest pain

Abstract

Emergency department (ED) presentation with chest pain accounts for approximately 20% of acute hospital admissions, and delays in the investigation and management of these patients increase the pressure on emergency and medical departments. We implemented a pathway within our trust to improve the efficiency of acute chest pain management. This included the development of a chest pain management algorithm, a short-stay heart assessment centre and a policy to immediately transfer acute coronary syndrome patients to cardiology. The introduction of the chest pain pathway resulted in fewer admissions from the ED with chest pain (34.2% vs 19.0%; p<0.0001), a reduction in time from ED attendance to cardiology transfer (9.3 hours vs 5.7 hours; p<0.0001) and a reduction in time to angiography (62.5 hours vs 26.6 hours; p<0.0001). Length of stay was reduced for cardiology patients (4.7 days vs 2.4 days, p<0.001) and mean length of stay for all patients attending ED with chest pain was reduced by 8.3 hours (27.5 hours vs 19.1 hours; p<0.0001). The changes have significantly improved the management of acute chest pain within our trust and we would suggest that adoption of these changes in other trusts could significantly improve the quality of the care for these patients throughout the NHS.

Keywords: Chest pain; acute coronary syndrome; service improvement.

Fig 1.

Chest pain algorithm implemented throughout the trust to guide the investigation and management of all patients presenting to the emergency department with chest pain. ACS = acute coronary syndrome; ECG = electrocardiography; GP = general practitioner; GRACE = Global Registry of Acute Coronary Events score; HAC = heart assessment centre; hsTnI = high-sensitivity troponin-I; LBBB = left bundle branch block; PPCI = primary percutaneous coronary intervention; RACPC = rapid access chest pain clinic; SpR = specialist registrar; TIMI = Thrombolysis in Myocardial Infarction score.

Fig 2.

Percentage of total attendances to the emergency department with a triage diagnosis of chest pain that were admitted to the hospital, clinical decisions unit, medical wards and directly to the cardiology ward before and after the introduction of the chest pain pathway. For all changes after introduction p<0.0001. CDU = clinical decisions unit.

Fig 3.

a) Time from emergency department attendance with chest pain to cardiology transfer. b) Time from emergency department attendance with chest pain to coronary angiography before and after the introduction of the chest pain pathway. c) Length of stay for all patients admitted to cardiology and those who had a coronary angiography during their admission before (teal) and after (blue) the introduction of the chest pain pathway. d) Overall length of stay for all patients attending emergency department with a triage diagnosis of chest pain. Data represented as median ± interquartile range. For all changes after introduction p<0.0001. CPP = after introduction of chest pain pathway.