National Survey of Chest Pain Centers
Rationale and Potential Results
Robert J. Zalenski, MDAssociate Professor of Emergency Medicine
Wayne State University
Detroit, MI
Optimal care for a patient with acute chest pain poses several challenges at the individual, hospital, and societal level. For the patient, the need to seek medical care for chest pain is often uncertain, and delay in emergency department (ED) presentation leads to worse outcomes. For the hospital, patients must be rapidly identified and undergo an electrocardiogram (ECG) to determine eligibility for reperfusion therapies. Even for low-risk patients with normal or nonspecific ECGs, hospital admission frequently ensues to rule out acute myocardial infarction (AMI). Admission is often employed to maximize the probability of a desirable outcome and minimize medical-legal exposure of the physician, as the inappropriate discharge of AMI patients is the number one cause of malpractice payouts for emergency medicine physicians. For society, the cost of this approach to $3 billion annually.
An organizational innovation intended to meet most of these challenges is the chest pain center (CPC). CPCs are attached to or closely associated with the EDs of acute care facilities. CPCs can have multiple components. (1) The "attack program" is designed to more rapidly identify and treat patients with thrombolytic therapy. An "observation program" is designed to better detect diseased patients and reduce the incidence of inappropriate discharge. It may also better identify nondiseased patients and reduce unnecessary hospital admissions. The "outreach program" is intended to increase community awareness of the early symptoms of heart attack and to provide individual counseling to high-risk patients.
In order to determine the prevalence, structure, and services of CPCs, the Center for Health Service Research, in conjunction with the Deparment of Emergency Medicine, Cook County Hospital, conducted a national survey of U.S. hospitals. In a randomly selected sample, 475 hospitals in standard metropolitan areas with full-service EDs were selected. The survey was mailed in June 1995, with follow-up mailings for nonresponders in August and September 1995. The response rate was 62%.
The hospitals were selected from a data base provided by the American Hospital Association. The survey was mailed to ED directors who were first identified through telephone contacts. The survey was designed to gather information about the care of acute chest pain patients in EDs with and without associated CPCs.
The target publication date of the survey data is 1996, when the complete findings will be presented. We will examine the overall prevalence of CPCs, their bed size, physical characteristics, and personnel. We will examine the demographics of the hospital EDs to ascertain whether CPCs are associated with delivery of care to particular ethnic groups. We will also compare technology use in EDs with and without CPCs. Hospital characteristics will be analyzed to see if specific cardiac services, such as angiography or open heart surgery, are more common in EDs with CPCs.
The preliminary results provide evidence for the following trends: CPCs have a greater frequency of use of technologies to diagnose AMI, such as serial cardiac enzymes testing and imaging modalities. They also more frequently offer services such as patient counseling and community education, and participate in marketing efforts more frequently than do EDs without CPCs.
The cost-effectiveness of CPCs has been challenged in a recent publication, (2) which stated that chest pain EDs spend between $378,000 and $3.78 million per life saved. Although this study is based on a number of assumptions that are open to question, it issues a challenge to CPCs to define their relevant patient outcomes and show that these are improved with an acceptable cost to third-party payors and society. The information provided by this national survey will further our understanding of the current and future role of CPCs.
References
1. Graff L, Joseph T, Andelman R, et al. American College of Emergency Physicians information paper: chest pain units in emergency departments - a report from the Short -Term Observation Services Section. Am J Cardiol. 1995;76:1036-1039.
2. Shesser R, Smith M. The chest pain emergency department and the outpatient chest pain evaluation center: revolution or evolution? Ann Emerg Med. 1994;23:334-341.
Return to Index of Articles for Clinician;
Volume 14.4
- Faculty Listing 3
- Introduction: Community Message in Acute Myocardial Ischemia 4
- Concept of Community Chest Pain Centers in Emergency Departments 5
- Reawakening Awareness of the Importance of Prodromal Symptoms in the Shifting Paradigm to Early Heart Attack Care (EHAC) 7
- The Role of Emergency Medicine in the Future of American Medical Care: A Summary of the Josiah Macy, Jr, Foundation Conference 12
- From ACC/AHA Guidelines to Best Practice: Can "Acute MI Report Cards" Save Lives?Measuring Quality of Care for Patients With Cardiovascular Disease 16
- Improving Lay Responses to Cardiovascular Emergencies and the Potential of Shifting the Paradigm to Early Heart Attack Care 18
- National Survey of Chest Pain Centers Rationale and Potential Results 21
- Outpatient Rule-Out Myocardial Infarction in Observation Units 22
- Reducing Time to Thrombolytic Treatment 24
- Intervention Programs to Reduce Patient Delays in Acute Myocardial Infarction 29
- Public Education Using the Early Heart Attack Care Program Shawnee Mission Medical Center 31
- School Component: Early Heart Attack Care Program Development and Evaluation 33
- Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction 36
- Precipitating Factors in Acute Cardiovascular Disease 41
- Use of Myocardial Perfusion Imaging in the Emergency Department for Risk Stratification 44
- The Evolution of Chest Pain Centers: The Impact of Technological Advances on the Evaluation of Patients With Possible Acute Ischemic Coronary Syndrome 47
- Critical Pathways for Triage and Treatment of Chest Pain Patients in the Emergency Department 53
- Chest Pain Centers: An Emerging Model for the Emergency Evaluation of Chest Pain and Treatment of Acute Myocardial Infarction 56
- The Key to Success in the Chest Pain Emergency Department: The Observational Role of theNurse 59
- Triage in Moderate Risk Patients With Chest Pain: The Emerging Role of Real-Time Continuous ECG Monitoring 61
- Diffusion of Innovations: The Introduction and Impact of the Chest Pain Emergency
- Department and its Comparison to the Coronary Care Unit Development 64
- Economics of Chest Pain Centers: What Really Matters? 68
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