Forging a New Pathway for Chest Pain Patients

A clinical trial supported by Sydney Health Partners has been reducing unnecessary hospital admissions by pioneering a new way to assess the large numbers of patients who present to emergency departments (EDs) with chest pain.

An alternative clinical pathway, dubbed Rapid Access Cardiology Clinics (RACCs), has been successfully established at three major Sydney hospitals to manage low-to-intermediate risk chest pain patients.

“Chest pain is a very common and its one of the leading causes of presentation to our EDs, but after investigation, it turns out that 90 per cent of these patients do not have an acute coronary syndrome,” said chief investigator, university of Sydney Professor Clara Chow.

“Nonetheless, these patients are commonly admitted for a short stay in hospital under observation when they could be equally well investigated and managed in an Outpatients clinic. We wanted to know whether RACCs could reduce unnecessary hospital admissions without any harm to patients.”

Following an initial trial at Westmead in 2016, the Sydney Health Partners grant allowed the research to be continued at Westmead and extended to Concord and Royal North Shore hospitals. Significantly it also allowed de-identified information about thousands of chest pain patients from the three sites to be combined into a common data set.

This core data is used to calculate the risk of each patient developing coronary disease in the short to medium term, and is used by cardiologists to motivate the patients to make diet and lifestyle changes to prevent disease.

Cardiology departments at the hospitals are also using the data at weekly team meetings to compare treatments at different locations and reduce clinical variation.

Early analysis of Westmead data indicates that, following the establishment of the first RACC, the proportion of chest pain emergency presentations admitted to hospital fell significantly, from 71 per cent in 2014 to 52 per cent in 2018.

Such has been the effectiveness of the alternative pathway, General Practitioners have begun bypassing EDs altogether and referring their patients directly to a RACC via a telephone hotline.

“The RACCs have been adopted more quickly and demand has been greater than we expected. We’ve asked referring doctors what they would have done if these rapid access clinics hadn’t existed, and a substantial number said they would have felt obliged to admit the patient to hospital.”

“In addition, patient surveys indicate that they really prefer to be treated in a clinic that be hospitalised.”

Professor Chow says the RACC trial has also spurred other, complimentary, research projects.

“The work funded by SHP has led to an expansion of the project in new directions, which is exactly what we hoped it would do.”

“We received a grant to establish a digital health test bed and another grant to trial preventative health management through new digital education methods.”

“Despite all our efforts cardiovascular disease remains Australia’s number one killer and we need new approaches to preventing it and better ways of treating it.”