65 Quality improvement and cost savings associated with an update to the acute chest pain pathway and introduction of 3 hour rule-out troponin assay in a busy district general hospital setting

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Abstract

Introduction

Management of acute chest pain involves the urgent and careful clinical assessement of a patient, to ensure timely treatment of a potentially life-threatening heart attack and the identification of other, non-cardiac causes of chest pain. Troponin measurement is a useful resource in the management and risk stratification of new onset chest pain. At Mid Cheshire NHS Hospitals Trust (MCHT) we use the AccuTnI+3 high-sensitivity Troponin assay by Beckman Coulter. In line with current European Cardiology Society (ESC) recommendations, we changed from a 0 and 12 hour Troponin protocol to a 0 and 3 hour protocol (see figure 1). We audited this process to determine the effects of safety, quality and cost to the trust.

Methods

We identified all patients coded to have presented to A and E with chest pain in March 2016 (assessed using the 12 hour protocol) and September 2016 following introduction of the new 3 hour protocol in April 2016. Clinical records were then retrospectively analysed and potential cost and bed savings to the trust calculated.

Results

In March (see table 1), 135 patients were assessed for chest pain in A and E. 5 patients had positive Troponin on admission, of which 2 were diagnosed with NSTEMI. 42 patients were admitted overnight in order to assess 12 hour troponin. All of which were subsequently discharged home on the post-take ward round. The 12 hour troponin was never raised if the admitting troponin was negative. In September, 120 patients were assessed for chest pain; 5 had positive troponin, of which 1 was an NSTEMI. No patients were admitted overnight to wait for a 12 hour troponin result. Twelve patients were admitted overnight, despite a negative 3 hour troponin, for further assessment. All were discharged home at the post-take ward round. 6 patients were re-admitted within 30 days of discharge from the March cohort, with one fatality secondary to congestive cardiac failure. In September, there were 13 re-admissions with chest pain, none had a positive Troponin result or missed myocardial infarction. There was no change in rates of referral to the Rapid Access Chest Pain Clinic on discharge (9 in March, 5 in September). Based on a cost of £300 per bed day, changing to the updated pathway generated a cost saving of between £100 000 to £150 000 per year to the trust. Average length of stay for those admitted for the assessment of chest pain, excluding those diagnosed with other medical conditions was 20 hours in March and 7 hours following introduction of the new protocol.

Conclusion

Implementation of a 3 hour rule-out troponin protocol improved the quality of care delivered to patients at MCHT. Patients were given a diagnosis more quickly and the practise of admitting patients overnight for a 12 hour troponin has stopped. This has had significant cost and bed savings for a busy district general hospital.

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