Growth In Chest Pain Emergency Departments:
A Cardiologist's Spin On Solving The Heart Attack Problem
Raymond D. Bahr
Coronary Artery Disease 1995, 6:827-830It is important to realize, first of all, that this development is occurring in the midst of a healthcare crisis that seems to be bringing about more paralysis than proper analysis of community needs. It is occurring so fast that it would have been impossible to have such a plan so well conceived and implemented. We have to assume for the moment that its success is due to 'the power of an idea whose time had come...' -an idea so powerful that controlling it is an impossibility because, as one hospital's chief executive stated, 'It's the right thing to do for one's community.
Reasons for the exponential explosion in chest pain centers
 | |
| NUMBER OF CPERs | |
|---|---|
| Year | Projected from CCU explosion |
| 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 |
12 25 50 100 200 400 800 1600 3200 6400 |
| Fig.1. Growth in number of chest pain centers in the USA, 1988-1997 (projected). Growth phases: (A) gradual start; (B) jump start, fast upshoot; (C) linchpin, in no time. CCU, coronary care nit; CPER, chest pain emergency room. | |
2. Slow growth phase. When thrombolytic therapy was developed for the crashing myocardial infarction patient, many hospitals worked to develop 'fast track' protocols to accomplish early administration of thrombolytic therapy. The National Heart Attack Alert Program's guidelines urged that thrombolytic therapy be started within 30 min of arrival at the hospital [1]. Unfortunately, not all emergency rooms were or are able to achieve this. Later, the Myocardial Infarction Triage and Intervention (MITI) trial results pointed out inconsistencies in the performance of emergency departments once research studies had ended. This clearly highlighted the need to ensure that emergency departments became more consistent in their treatment of patients with heart attacks, and thus more accountable to their communities. As a result of treating heart attack patients with thrombolytic therapy, the number of chest pain emergency departments began to grow.
3. Exponential phase. At first community hospitals felt that a 'fast track' protocol with a critical pathway for crashing myocardial infarction patients was all that was necessary. However, an underlying problem was that most hospitals were readily admitting all patients with suspected myocardial ischemia. In fact, 70% of patients admitted to coronary care units (CCUs) have turned out not to have a myocardial infarction. Many of these patients demonstrated a 'low probability' for ischemia. The emphasis in chest pain centers has now shifted to providing a more efficient evaluation of such patients and managing them within the emergency department. Academic centers began to carry out clinical research on patients with a 'low probability of myocardial ischemia' treated in the emergency room, and have been able to show that significant cost reductions can be achieved, to the delight of managed care organizations (which are concerned with reducing costs through better management) (Table 1). This, then, truly started the exponential growth of chest pain centers throughout the United States [2-7]. This not only put into effect a rapid mechanism to sort out patients with a low probability of ischemic disease, but also allowed a more aggressive outreach program promoting the 'Early Heart Attack Care' (EHAC) message within the community. This has allowed high-risk prodromal chest discomfort patients to visit these chest pain centers.
| Table 1. The cost ($) of heart attack care in patients with a low probability of heart attack. | |||
| Area | Gible et al. [2] | Rodriguez et al. [3] | Lewis et al. [4] |
| 1. CCU 2. Telemetry Unit 3. Ward bed 4. Outpatient BOTTOM LINE (2 minus 4, above) |
4046 3574 2917 1343 2231 |
2810 1038 1772 |
2000 (less as outpatient) 2000 |
| These are charges; actual costs may be higher. This assumes that 70& of coronary care unit (CCU) admissions turn out to be negative for acute myocardial infraction. Estimated cost: $2-4 billion annually for the USA. If 50% of CCU admissions are low-probability for heart attack and can be identified in the chest pain center, the cost savings (outlined above) would average $2000 per patient, and the projected 80% discharge rate would amount to savings approximating $500 million annually. | |||
Of course it is recognized that chest pain is only one of myriad symptoms
which lead a patient to seek medical aid for possible myocardial infarction.
However, this is a good basis for a strategy for disease prevention and health
promotion. Presently no other strategy exists to remove heart disease
from its place as the number one killer of adults in the United States.
This in no way undermines consideration for diagnosing myocardial
ischemia in patients presenting with shortness of breath, syncope,
arrhythmia, shock, cardiac arrest, and so on, but in focusing on chest
pain the net is cast for the greatest yield. The strategy recruits
community hospitals to set up chest pain centers which focus on the
heart attack problem and bring together emergency physicians, nurses and
cardiologists to set up a comprehensive management plan for patients
presenting with chest pain. The rapid growth of CCUs (195O-1965) shows
what can be done in a short time. The value-added aspect of linking
research programs, public education and user-friendly chest pain
centers, it is hoped, will encourage care-givers to be part of this
overall strategy to tackle early heart attack care.
Reasons for the need to change the present heart attack care strategy
As Frank Davidov, executive vice-president of the American College of Physicians, points out [8], there are good reasons why the present heart attack prevention strategy should change. The first is the recognition that there are just too many heart attack deaths: each year heart attacks kill more Americans than all the soldiers killed in all the American wars. The second reason for change is that our involvement starts too late. The present treatment of heart attacks focuses on events related to occlusion of the coronary vessel and the subsequent cardiac arrest. Despite our efforts, we can do only so much within the hospital setting: heart attacks begin in the community. It does not make sense to start heart attack care only after the vessel has been totally occluded, especially when recognizable early symptoms occur in over 50% of patients [9-16]. Such early clues should allow timely preventive measures to take place.The third reason for change is that we have not educated the public into knowing what to do when a heart attack is beginning to take place. This is probably the result of the lack of a proper message being given to the public, as well as the natural tendency of adult Americans to ignore mild, intermittent chest symptoms until they become severe enough to send them to the emergency department. Americans need the equivalent of a 'smoke detector' message for impending heart attacks. They need to have a strategy to use late in the game, the equivalent of a 'two-minute drill' to protect themselves and others. They need to be vigilant when it counts.
The fourth reason for change is the reawakening personal awareness of the heart attack problem. Americans need to be reminded that heart attacks are not uncommon; that although they are something that occurs infrequently in their lifetime, they are occurring somewhere every day. Most Americans have had personal experiences with heart attack symptoms in loved ones, and some did not recognize them as being heart attack-related, and did not act. This point is uncovered frequently in lecturing on the subject of early heart attack care. People in the audience come alive when this message dawns on them and they recognize that they could have done something when those mild chest symptoms occurred in a 'stuttering' manner in one of their acquaintances. Sometimes the clues are there, but are not recognized until they are pointed out. Once this revelation occurs, these people become dedicated, enthusiastic and committed care-givers. The solution to the heart attack problem lies in such committed individuals who will stem the tide and turn the heart attack problem around, one day, it is to be hoped, demoting heart disease from its position as the number one health problem in the United States.
The fifth reason for change is the 'laissez faire' attitude of cardiologists to management of such patients in the emergency department. Cardiologists can no longer continue to wait for the problem to come out of the emergency department before getting involved. Critical pathways now demand the cardiologist's participation right from the start. In fact, in most chest pain centers, cardiologists are now working with emergency physicians to help champion the cause of early heart attack intervention. This partnership will enhance and guarantee that optimal heart attack care takes place within the community.
Future heart attack care
The concept of focused managed care (i.e. a critical pathway for the low-probability ischemia patient) opens the door to the development of other critical pathways for both ischemic and non-ischemic patients (Fig. 2). It is obvious that this burden cannot be placed on the shoulders of the emergency department and the emergency physicians alone. |
| Fig. 2.The evolution of chest pain centers. ER, emergency room; ED, emergency department; CHF, congestive heart failure; Fib, fibrillation |
Today's exponential growth in the number of chest pain centers has been fueled by research developments within those centers. The most important development is a cost-effective method of evaluation for patients with ischemia but at low risk of heart attack. This now allows for a more aggressive cardiac outreach program (EHAC strategy) [17,18] that encourages more patients with early symptoms of heart attack to come into chest centers promptly to undergo checks. The shift to earlier heart attack care is no longer just a concept, but a reality with future possibilities and implications (19-23].
This strategy
represents a shifting paradigm, and creative nerve-hitting messages are
very much needed to make this successful. The heart attack problem needs
to be viewed as a process and system failure. The way to solve it may
not be another new thrombolytic agent, but ways to organize more
effectively what we presently have. Wars have generals to do this. The
heart attack problem represents a war in our homes, the evidence being
the 600000 deaths and casualties which occur each year in the United
States. Bringing the effects of the medical services and the public
together in a short period of time is a strategy to win this war.
References
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Minutes to Treatment Working Group: Emergency department: rapid
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treatment centers in the emergency department for patients with
chest pain [abstract]. 65th Annual Scientific Sessions,
American Heart Association 1992.
- Rodriguez S,Cowfer JP, Lyston DJ, et al.: Clinical efficacy and cost
effectiveness of rapid emergency department rule out myocardial
infarction and noninvasive cardiac evaluation in patients with
acute chest pain [abstract]. Abstracts of the American College of
Cardiology Scientific Sessions 1994.
- Lewis WR, Lee TY, Amsterdam EA: Immediate exercise testing in the assessment of low
risk patients presenting to the emergency room with acute chest pain
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Requests for reprints to Dr Raymond D. Bahr, The Paul Dudley White Coronary Care System,
St Agnes Hospital, 900 Caton Avenue, Baltimore, MD 21229, USA.
Date received:12 May 1995; revised: 4 August 1995; accepted: 16 August 1995.
© Growth in chest pain emergency departments Publishers ISSN 0954-6928
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