The Chest Pain Observation Unit

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					    The Chest Pain
    Observation Unit
   Steve Goodacre & Jane Arnold
          University of Sheffield
     s.goodacre@sheffield.ac.uk
       j.a.arnold@sheffield.ac.uk
http://www.shef.ac.uk/scharr/escape/
    Acute, undifferentiated chest
                pain
•   Normal or nondiagnostic ECG
•   No evidence of co-morbidity (e.g. CCF)
•   No evidence of alternative serious cause
    (e.g. PE, aortic dissection)
•   Not clinically obvious unstable angina
•   Not obviously non-cardiac (e.g.
    reproduced by chest wall palpation)
    Acute undifferentiated chest
                pain
•   Diagnostic ECG changes – 11%
•   Clinically obvious unstable angina – 34%
•   Serious alternative or co-morbidity – 13%
•   Negligible risk of ACS – 18%
•   Acute undifferentiated chest pain – 24%
     Management issues

•   Rule out AMI

•   Stratify risk of adverse outcome

•   Hospital admission is wasteful

•   Discharge home is risky
            Current practice
              B J Cardiol 2003;10:50-4


•   Very variable
•   Admission rates vary from <20% to >80%
•   Most hospitals do not use short stay
    facilities, troponin testing or exercise
    testing in A&E
•   Most guidelines refer to diagnosed ACS
•   7% of patients discharged home have
    evidence of ACS (Collinson et al)
    The Chest Pain Observation Unit

• Nurse-led, A&E based, protocol-driven care
• Clinical predictors to select patients
• Period of observation & cardiac biochemical
  testing
• Exercise treadmill test
• Admit with diagnosis if positive
• Safe to discharge if tests negative
        The Sheffield CPOU

•   Established 1999
•   Initially 2 CP Nurses – open 9-9, Mon-Fri
•   Now 4 CP Nurses – open 9-9, every day
•   2-6 bays in A&E trolley area
•   Treadmill machine in A&E
        Patient Selection

•   Low risk group

•   Normal ECG

•   Chest pain of unknown origin

•   No co-morbidity
    The Sheffield CPOU Protocol

•   ECG analysis
•   CK-MB(mass) on arrival & at least 2 hours
    later
•   Troponin T at least 6 hours after worst pain
•   Followed by immediate exercise treadmill
    test
•   Discharged home if tests negative
The Chest Pain Observation
           Unit
The Chest Pain Observation
           Unit
       CPOU – the literature
           J Accid Emerg Med 2000;17:1-6.




•   Mostly from US
•   CPOU care is safe – few missed AMI
•   CPOU care is practical – most patients
    discharged after assessment
•   CPOU is cost-saving in US
•   Little robust evaluation of outcomes
          The Sheffield CPOU
               Emerg Med J 2002;19:117-121

•   534 patients over one year
•   23 AMI (4.3%) – by old definition
•   461 (86.3%) discharged after assessment
•   357 (66.9%) avoided admission entirely
•   No AMI discharged
•   89% of discharged followed-up 3 days
    later - one case with elevated troponin T
     Randomised controlled trial
                  BMJ 2004;328:254-7


•   442 days randomised to CPU or routine
    care
•   All patients attending with chest pain were
    screened for eligibility
•   Those with AUCP selected and invited to
    participate
•   Follow-up at 2 days, one month, and six
    months
          Outcome measures
•   Proportion admitted
•   Proportion with ACS who were discharged
    (troponin T > 0.03ng/ml at follow-up)
•   Major adverse cardiac event rate
•   Health related quality of life
•   Reattendance and readmission
•   Health service costs
                    Results

•   CPU reduced admissions (37% v 54%, p<0.001)
•   Fewer discharged with ACS (6% v 14%, p=0.264)
•   One cardiac death in each group
•   MACE rate: 3.8% versus 3.4% (p=0.796)
•   ED reattendance: 12.7% versus 17.2% (p=0.05)
•   Hospital (re)admission: 7.7% versus 10.5%
    (p=0.122)
  Quality of life over six months
  1
0.9
0.8
0.7
0.6
                                  CPU
0.5
                                  Routine care
0.4
0.3
0.2
0.1
  0
      0   1   2   3   4   5   6
      Costs over six months

600                           Interventional
                              cardiology (p=0.514)
                              Outpatient clinics
500
                              (p=0.007)
                              Reattendance /
400                           readmission (p=0.331)
                              Diagnostic tests
300                           (p<0.001)
                              Parenteral drugs
200                           (p=0.008)
                              Initial admission
100                           (p=0.002)
                              CPU treadmill test
 0                            (p<0.001)
                              Initial six hours
        CPU    Routine care
                              (p<0.001)
    Total costs over six months

•   CPU: £478 per patient
•   Routine care: £556 per patient
•   Difference: £78
•   95% CI: -56 to 210
•   P=0.252
                    But…

•   Single centre study
•   Cost savings uncertain and may not
    generalise to other hospitals
•   Insufficient statistical power for cardiac
    event rates
•   Health outcomes may be influenced by
    patient awareness that they were in a trial
Setting up a Chest Pain Unit

 •   Location

 •   Chest Pain Nurse

 •   Biochemical Markers

 •   Treadmill testing facilities
        The ESCAPE Multicentre Trial
    Effectiveness & Safety of Chest pain Assessment to Prevent Emergency Admissions




•     Can CPOU care be established in a
      variety of NHS hospitals?
•     Is CPOU care effective throughout the
      NHS?
•     Is CPOU care cost-effective?
•     How & where are the cost savings
      realised?
               Methodology

•   18 hospitals willing to participate
•   9 randomised to set up a CPU in 2004
•   9 randomised to delay setting up any
    CPU until at least 2005
•   Measure costs and outcomes at all
    hospitals, before and after CPU set-up
           Intervention Sites

•   DoH CTSG will reimburse £106 per patient
    in the first year
•   Estimated 500 patients per year receive
    CPOU care
•   UP to £50,000
    Summary – low risk chest pain
•   Current practice is very variable
•   Discharge home is risky
•   Hospital admission is wasteful
•   CPU offers improved care at lower cost
•   CPU needs up-front investment
•   The ESCAPE trial is the next logical step
      Any Questions?

     s.goodacre@sheffield.ac.uk
      j.a.arnold@sheffield.ac.uk
http://www.shef.ac.uk/scharr/escape

				
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