Chest Pain Centers: An Emerging Model for the Emergency Evaluation of Chest Pain and Treatment of Acute Myocardial Infarction
Anthony J. Joseph, MD, MS, FACEPPresident and Founder
American Medical Consulting, Inc.
Columbus, OH
Quick Overview
Technological advances have also been made in the diagnostic arena. ST-segment monitors allow for monitoring of ischemia in patients complaining of chest pain who have normal or nonspecific electrocardiograms (ECGs). If significant ST-segment changes occur, then the monitor alarm sounds, whether the patient is experiencing pain or not. The first ECG positive for AMI is obtained at the earliest time possible, obviating serial ECGs. Advances in cardiac biomarkers (troponins) also permit earlier diagnosis as well as improved specificity. Echocardiography and technetium Tc-99m sestamibi imaging are being used more frequently to make an early diagnosis or to stratify risks.
An increased understanding of the process of AMI coupled with improved diagnostic capabilities and therapeutic modalities that restore blood flow have led to better outcomes. Yet the somewhat discouraging results from the Cooperative Cardiovascular Project (6) and recent National Registry of Myocardial Infarction (7) information show that patients with AMI who clearly meet eligibility criteria for treatments known to be effective are not getting them. Furthermore, many patients who are treated experience significant delays in their treatment, delays that are known to reduce the amount of viable myocardium. Why is this so?
From the dawn of reason humans have created constructs or models that help them understand themselves and cope with their environment. Models permit the development of an organized and systematic approach to human endeavors, whether it is landing a man on the moon or creating a clinical process for the early diagnosis and treatment of AMI. Perhaps the reason why some patients who meet eligibility criteria are not treated while others experience treatment delays and still other chest pain patients are sent home and suffer an AMI is a case of trying to put new wine into old wine skins. Perhaps it is time for a new model for the emergency evaluation of patients with chest pain and treatment of AMI. One such emerging construct is the chest pain center (CPC) model.
A CPC is a grass-roots community-based organization focused on early recognition and treatment of patients with AMI or underlying occult coronary artery disease and on prevention in future generations. A CPC has six essential components:
A CPC simply needs an organized and systematic way (triage protocol and clinical pathway) to diagnose (ECG and biomarkers) AMI and treat (thrombolytic therapy/direct angioplasty) in a timely manner. This takes place in the emergency Chest Pain Unit (CPU). These units go by many names: Chest Pain Emergency Room (CPER), Chest Pain Emergency Department (CPED), Chest Pain Evaluation Unit (CPEU), or Chest Pain Attack Unit (CPAU). A Chest Pain ER is not a Chest Pain Center; it is only one component.
A CPC needs an organized and systematic way to rule out MI that strives for a miss rate under 0.1% (zero defect model). This takes place in the Observation Unit (Obs Unit) or Clinical Decision Unit (CDU). This is a geographically designated area (preferably within or contiguous to the ED) that is operated under guidelines (a clinical pathway) for the ongoing evaluation and treatment of patients who complain of chest pain (constellation) after their emergency evaluation in the CPU is complete and they are found not to have an AMI.
Quick Overview
Using the traditional paradigm, if the diagnosis of AMI cannot be made, then the patient may be admitted or discharged. In the emerging chest pain paradigm, if the diagnosis of AMI cannot be made, then the patient may be admitted or discharged or go to a monitored diagnostic Obs Unit or CDU. Using this approach, the length of stay for these patients is dramatically reduced. As this occurs, the actual cost of the evaluation decreases concomitantly. With the reduction of cost, it is possible to evaluate a larger population. This in turn reduces the risk of sending a patient home prematurely, thus missing the AMI. Criteria for evaluation are:
Some form of management and feedback are needed for a clinical program to succeed. A TQMp;based management system fits nicely for tracking the process of patient care for chest pain evaluation and treatment of AMI. In order to track a process, some definition of that process must be agreed upon. Clinical pathways fill this need.
Clinical pathways are guidelines within which the technical, nursing, and medical staffs operate while caring for patients within the CPU or observation area. Clinical pathways must preserve the physician's judgment to act appropriately on behalf of his or her patients. They also organize and streamline care of the patients. Clinical pathways permit measurement of the progress of a clinical process. When combined with TQM principles, they form the basis for improvement.
Nurse and physician staffing considerations are crucial to success. Deming (8) emphasized training and retraining. This applies to nurses and doctors, too. Training focuses on three main areas:
The next most important frontier in reducing time to treatment is getting the patient to come in to the CPC sooner after symptom onset. An outreach program in this regard is a community education tool regarding heart disease. It may legitimately be used to position your organization within the community as a source of care for those needs.
In 1993, the recommendation was made by the National Heart Attack Alert Program Coordinating Committee that EDs strive to treat all AMI patients within 30 minutes of arrival. (9) The CPC model for the emergency evaluation of chest pain and treatment of AMI utilizes an organized and systematic approach to achieve that goal. The CPC model also resolves the difficult diagnostic dilemma of what to do with the patient with a low- to moderate-risk profile and does so in a cost-effective manner.
References
1. Reimer KA, Lowe JE, Rasmussen MM, et al. The wavefront phenomenon of ischemic cell death. Myocardial infarct size vs duration of coronary occlusion in dogs. Circulation. 1977;56:786-794.
2. Roberts R, Kleiman NS. The open artery: perspectives on coronary reperfusion in acute myocardial infarction. Decker Periodicals. 1992.
3. The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993;329:673-682.
4. The TIMI Study Group. Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI) Phase II Trial. N Engl J Med. 1989;320:618-627.
5. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI): Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet. 1986;1:397-402.
6. Ellerbeck EF, Jencks SF, Radford MJ, et al. Quality of care for Medicare patients with acute myocardial infarction. A four-state pilot study from the Cooperative Cardiovascular Project. JAMA. 1995;273:1509-1514.
7. Rogers WJ, Bowlby LJ, Chandra NC, et al. Treatment of Myocardial Infarction in the United States (1990 to 1993). Circulation. 1994;90:2103-2114.
8. W. Edward Deming. Out of the Crisis. Cambridge, Mass: Massachusetts Institute of Technology Center for Advanced Engineering Study; 1982:248-275.
9. National Heart Attack Alert Program (NHAAP) Coordinating Committee 60 Minutes to Treatment Working Group. Emergency department: rapid identification and treatment of patients with acute myocardial infarction. Ann Emerg Med. 1994;23:311-329.
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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