Trial of assessing chest pain underway in rural Waikato

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Pinnacle Midlands Health Network (Pinnacle MHN) plans to use a $15,000 grant from the Heart Foundation to help fund the trial of a new method for assessing chest pain among people in rural Waikato.

Pinnacle MHN has developed a rural chest pain method, referred to as a pathway, that will allow low-risk patients in rural communities to be safely assessed by their general practice, rather than travelling significant distances to hospital.

“Our organisation serves one of the largest rural populations in New Zealand. It’s our focus to provide rural general practice with the tools and pathways that enable patients to be treated by the right person, at the right place, at the lowest cost to the health system. This pathway will contribute to that goal,” says Pinnacle MHN CEO John Macaskill-Smith.

The trial will include the introduction of a chest pain assessment tool and point of care machine into 12 rural GP practices across the Waikato Region, explains project manager Tim Norman.

“Currently, when a patient presents at their GP clinic with chest pain, there are a number of tests the doctor undertakes to confirm whether a patient is at risk of experiencing a major cardiac event, including taking a blood sample. Depending on where the clinic is located, this may mean a lengthy delay (up to 2 or 3 hours in some areas) whilst the sample is transported to the nearest laboratory, and then analysed. We aim to speed-up the process.

“The chest pain assessment tool we are trialling in rural GP practices is similar to Emergency Department Assessment Chestpain (EDAC) a tool developed by the Director of Emergency Medicine research at Christchurch Hospital, Dr Martin Than, and currently in widespread use in hospital emergency departments throughout New Zealand.

“EDAC has been successfully used in emergency departments for some time so we decided to adapt it for use in primary care. We have specifically adapted it to suit a rural primary care setting. Under the pathway we have developed, GPs are able to identify if a patient is at low or high risk of a major cardiac event via a series of questions.

“Those who are identified as high risk are sent directly to hospital. Those who are identified as low risk are then further assessed by a point of care machine known as an i-STAT handheld blood analyser supplied by Abbott Point of Care, who are also supporting the trial.

“Blood is routinely taken during a suspected heart event to check for cardiac enzymes and the presence of the protein troponin, which indicates possible cardiac muscle damage. With this new pathway, once the GP takes the patient’s blood it is immediately tested in the i-STAT to confirm that the patient is at low risk of a cardiac event. As an additional cross check during the trial, a second sample is also sent to the local laboratory.

“The simple test using the i-STAT will take a maximum of 20 minutes to administer and diagnose. The GP then combines this information with the results of the EDAC assessment and other routine tests such as echo cardiogram giving them a complete picture of what is going on,” explains Tim.

He says the tool is relevant in rural GP practices because up to 70% of people who present with chest pain at Emergency Departments are discharged and require little or no medical follow up.

“We know that around 3,500-4,000 people present to ED with chest pain in the Waikato alone every year. We are confident that this new chest pain pathway has the ability to significantly reduce those numbers, benefiting individuals and the overall health system.

“It’s important to stress that the safety and care of the patient is paramount at all times, and that the rural chest pathway being trialled does not replace good clinical judgement for GPs. It’s an alternative way of identifying who is at low and high risk of a heart episode.”

Tim says the potential benefits of the new rural chest pain pathway for rural patients include: being able to stay closer to home, and a reduction in unnecessary ambulance transfers, ED presentation and hospital admissions. The pathways may be particularly beneficial for those who are frail and or elderly.

The project which comprises three GP clinics a week will run for around 12 months and will collect data from 500+ patients.

“There is no reason why this trial couldn’t be up-scaled to fit the needs of bigger, urban GP clinics and After Hours’ centres. We’ve already had interest from other regions keen to see if their patients can benefit from this new way of assessing the risk of a heart event,” Tim says.

“A future option to explore is the possibility of ambulance crews being able to refer patients they assess into the pathway. We are in discussion with St John medical director Dr Tony Smith about this option. 

“We’re grateful to our sponsors, including the Heart Foundation, for bringing this trial to fruition.”