Concept of Community Chest Pain Centers in Emergency Departments
Raymond D. Bahr, MD, FACP, FACCMedical Director
The Paul Dudley White Coronary Care System
St. Agnes HealthCare
Baltimore, MD
Quick Overview
The problem and location of heart attacks, be they acute ischemia or infarction, lies in the community. Since the nucleus of the heart attack problem lies in the community, it is here where the ultimate coronary care unit (CCU) must reach. Thus, it becomes very important to interface early with the public when heart attack symptoms are developing.
What then is the formula for success? It requires shifting the paradigm of heart attack care to earlier recognition of symptoms so that acute prevention and its benefits are possible. The benefits of early intervention were demonstrated in the MITI trial,(7) in the GUSTO trial, (8) and in the GREAT study.(9) The barrier to early intervention still exists, however. Can we take advantage of prodromal symptoms of a heart attack (see Figure 1)? To do so we need to shift the paradigm of care to acute prevention. Early intervention amounts to acute prevention. Stopping the heart attack allows one to use this teachable moment to educate about primary risk factor reduction. Thus, disease prevention allows health promotion.
Figure 1
Reducing "Time to Treatment"
for Patients With Acute Myocardial
Infarction and Acute Coronary Syndrome
Infarction and Acute Coronary Syndrome
The ED is a natural target for this new paradigm. It is the hospital's "front door" for many patients, such as those experiencing chest pain or chest discomfort. A Chest Pain Center in the ED is a way that a community hospital can focus attention on heart attacks through chest pain evaluation (see Table 2, page 6). It then becomes a basic subunit that when multiplied by the 6,700 community hospitals in the United States provides widespread opportunity for the prevention of heart attack deaths. This basic subunit has been called the "community sarcomere." It allows for more efficiency, more focused attention, proper preparation to take place, and comprehensive management of chest pain patients with cardiac rehabilitation upon discharge. It allows for research activities to further develop critical pathways as well as provide the learning curve that can be shared by a variety of care givers. Such centers can act as damage control centers in preventing heart attacks.
Crashing myocardial infarction patients (those with total occlusion) make up only 20% of patients with chest pain. It is important to have a "clot team" that follows a protocol to reperfuse the infarct-related artery quickly, but it is also important to have a comprehensive triage and evaluation for chest pain patients. In an August editorial in 1969 (10) on the future of coronary care, Morris Fishbein placed emphasis on chest pain as a sign for the heart attack. He describes 64 patients admitted to Strong Memorial Hospital in Rochester, NY, where the decision time of the patient was greater than 3 hours. Careful inquiry showed that more than half of the patients had various symptoms, but principally intermittent or increasing chest pain 1 week before the onset of the actual heart attack. Thus, the way to get at the heart attack problem is to ensure that the public we serve is educated about the prodromal symptoms of heart attack so that chest pain patients do not delay in seeking help and that we as a healthcare team are prepared to provide prompt care.
Development of a low-probability myocardial ischemia critical pathway would allow EDs to screen low-risk patients and provide a basis for community outreach programs. What is the proper message that we can give to the community? The message needs to be specific enough to prevent inappropriate use of the ED by the public and informative enough to change behavior.
Developing the right message is up to all of us as healthcare providers. We need to interpret the facts that we have at hand in the absence of solid scientific information.(11) There are many different ways of delivering the word and inviting the public. The St. Agnes approach utilizes a mountain cliff scene showing risk stratification of presenting symptoms. It illustrates the consequences of ignoring symptoms or delaying seeking help. EHAC has been coined as an acronym for Early Heart Attack Care to give it status somewhat similar to CPR.
What is the value of a Chest Pain Center learning curve? The learning curve allows for a common wave length for care givers to participate. It also helps us to recreate the CCU experience which was very powerful and formed the basis for many of the discoveries in heart attack care over the last 30 years. It has a value added component. It also has components of resistance that can be identified and overcome in time.
References
1. Bahr RD. Growth in chest pain emergency departments throughout the United States: a cardiologist's spin on solving the heart attack problem. Coron Artery Dis. 1995;6:827-830.
2. Bahr RD. The changing paradigm of acute heart attack prevention in the emergency department: a futuristic viewpoint? Ann Emerg Med. 1995;25:95-96.
3. Bahr RD. Acute outpatient care and comprehensive management of acute myocardial ischemia in chest pain emergency departments. Md Med J. 1995;44:691-693.
4. Bahr RD, Tonascia J. Measuring heart attack care performance: new indices and understanding. Am J Emerg Med. 1996;14:89-90.
5. Bahr RD. Reducing time to therapy in AMI patients: the new paradigm. Am J Emerg Med. 1994;12:501-503.
6. 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.
7. Weaver WD, Cerqueira M, Hallstrom AP, et al (for the Myocardial Infarction Triage and Intervention Project Group). Prehospital-initiated vs hospital-initiated thrombolytic therapy: the Myocardial Infarction Triage and Intervention trial. JAMA. 1993;270:1211-1216.
8. The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993;329:673-682.
9. Rawles J on behalf of the GREAT Group. Halving of mortality at 1 year by domiciliary thrombolysis in the Grampian Region Early Anistreplase Trial (GREAT). J Am Coll Cardiol. 1994;23:1-5.
10. Fishbein M. The future of coronary care. Med World News. 1969:40.
11. Horton R. The interpretive turn. Lancet. 1995;346:8966. Editorial..
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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