Forging a New Pathway for Chest Pain Patients
A clinical trial has proven that a novel outpatients service is reducing unnecessary hospital admissions by pioneering a new way to assess the large numbers of people who present to emergency departments (EDs) with chest pain.
The Rapid Access Cardiology Clinic (RACC) is a hospital-based, cardiologist-led service which provides rapid assessment and management of patients, significantly reducing the number who undergo unnecessary invasive tests.
The clinic operates daily, and accepts referrals for suspected cardiac chest pain, stable arrhythmias, and heart failure, from EDs, hospital physicians, and general practitioners (GPs).
Following an initial trial at Western Sydney Local Health District’s Westmead Hospital in 2016, the alternative clinical pathway has been successfully trialled and implemented into routine care at two other major Sydney hospitals for the management of low-to-intermediate risk chest pain patients.
Cardiologist and chief investigator Professor Clara Chow says over 80% of people who present to emergency departments with chest pain do not have acute coronary syndromes and are at low risk.
“Acute coronary syndromes and stroke are time critical events that demand an urgent medical response and so we’ve educated the public that people with chest pain should get to hospital in the shortest possible time,” she said. “And while this saves lives and prevents long-term consequences, it also sometimes results in unnecessary hospital admissions, transfers and invasive tests.”
With the support of Sydney Health Partners, the clinical trial demonstrated that at the hospitals using the RACC model of care, the proportion of people who were admitted after presenting to emergency with chest pain fell significantly, and fewer patients underwent unnecessary invasive testing.
An evaluation of patients treated at the Westmead Hospital RACC compared with patients receiving usual care found that the new clinic reduced the risk of subsequent adverse patient outcomes, such as unplanned hospital admission or cardiac-related death, by 59%.
A longer-term evaluation of over one thousand RACC patients at Sydney Local Health District’s Concord Hospital also showed excellent outcomes, with a total mortality rate of only 3%, predominantly from non-cardiac causes.
Professor Chow says one of the challenges faced when implementing the RACC pathway was managing the perceptions of the clinicians.
“Normally, ED doctors feel like they have to admit low-to-medium risk patients for tests. We had to convince them that by referring patients to the RACC, they were fulfilling their duty of care.”
“And cardiologists were worried that the RACC model of care would take patients away from the traditional one-on-one model of care.”
Such has been the effectiveness of the alternative treatment pathway, the research team found that General Practitioners began by-passing EDs altogether and referring their patients directly to a RACC via a telephone hotline.
“The RACCs have been adopted more quickly and demand has been greater than we expected,” said Professor Chow.
“We’ve asked referring GPs what they would have done if these rapid access clinics hadn’t existed, and a substantial number said they would have felt obliged to admit the patient to hospital.”
“In addition, patient surveys indicate that they really prefer to be treated in a clinic than be hospitalised.”
To assist ongoing surveillance and management of the patients after they are first assessed, RACC became the first outpatient clinical service of its in kind in NSW to integrate directly with the Commonwealth’s My Health Record (MHR) database.
A ground-breaking digital project developed a specialist letter template which enables RACCs to upload significant clinical data to the MHR platform and send secure messages to a patient’s GP to alert them to the information.
Professor Chow says the template was developed through extensive consultation to ensure it met the needs of patients, as well as clinicians and administrators.
“People with complex medical needs such as cardiology patients require integrated, accurate, and complete health records across multiple health platforms,” said Professor Chow.
“One of the things we sought to demonstrate was that if information about hospital discharges can go straight to My Health Record, then details about hospital outpatient discharges should be able to do the same.”
It is hoped the solution will be scalable across NSW, enabling all Local Health Districts and Speciality Health Networks to publish a wider variety of clinical documents.
“Without effective integration of patient information from the RACC into the MHR, there is a risk that important details about a person’s health will not be available for other healthcare providers and the effectiveness of our treatment will be compromised.”
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