Reducing Patient Risk and Enhancing Care Through the Development and Implementation of a New Chest Pain Pathway, Expedited by and for the COVID-19 Era

Martin P Than; John W Pickering; Philip Adamson; Thomas Clendon; Christopher M Florkowski; John Lainchbury; Jacques Loubser; Alison Nankivel; Sally J Aldous

Reducing Patient Risk and Enhancing Care Through the Development and Implementation of a New Chest Pain Pathway, Expedited by and for the COVID-19 Era

EJIFCC. 2021 Feb 28;32(1):27-40. eCollection 2021 Feb.

Authors

Martin P Than¹, John W Pickering^{1

2}, Philip Adamson³, Thomas Clendon³, Christopher M Florkowski⁴, John Lainchbury³, Jacques Loubser¹, Alison Nankivel³, Sally J Aldous³

Affiliations

¹ Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand.
² Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand.
³ Cardiology Department, Christchurch Hospital, Christchurch, New Zealand.
⁴ Canterbury Health Laboratories, Christchurch Hospital, Christchurch, New Zealand.

PMID: 33753972
PMCID: PMC7941060

Abstract

The COVID-19 pandemic raised major concerns relating to hospital capacity and cross-infection patients and staff in the Emergency Department (ED) of a metropolitan hospital servicing a population of ~500,000. We determined to reduce length of stay and admissions in patients presenting with symptoms of possible myocardial infarction; the most common presentation group. After establishing stakeholder consensus, the existing accelerated diagnostic pathway (ADP) based on the ED Assessment of Chest-pain Score (EDACS), electrocardiogram, and troponin measurements with a high-sensitivity assay (hs-cTn) on presentation and two hours later (EDACS-ADP) was modified to stream patients following an initial troponin measure as follows: (i) to a very-low risk group who could be discharged home without follow-up or further testing, and (ii) to a low-risk group who could be discharged with next-day follow-up community troponin testing. Simulations were run in an extensive research database to determine appropriate hs-cTnI and EDACS thresholds for risk classification. This COVID-ADP was developed in ~2-weeks and was implemented in the ED within a further 3-weeks. A comparison of all chest pain presentations for the 3 months prior to implementation of the COVID-ADP to 3 months following implementation showed that there was a 64.7% increase in patients having only one troponin test in the ED, a 30-minute reduction of mean length of stay of people discharged home from the ED, and a 24.3% reduction in hospital admissions of patients ultimately diagnosed with non-cardiac chest pain.

Keywords: COVID-19; accelerated diagnostic pathway; acute myocardial infarction; coronavirus; emergency department; emergency room; high-sensitivity cardiac troponin; prognosis.