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The Chest Pain Observation Unit

Acute, undifferentiated chest pain. Normal or nondiagnostic ECGNo evidence of co-morbidity (e.g. CCF)No evidence of alternative serious cause (e.g. PE, aortic dissection)Not clinically obvious unstable anginaNot obviously non-cardiac (e.g. reproduced by chest wall palpation). Acute undifferentiated chest pain.

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The Chest Pain Observation Unit

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    1. The Chest Pain Observation Unit Steve Goodacre & Jane Arnold University of Sheffield s.goodacre@sheffield.ac.uk j.a.arnold@sheffield.ac.uk http://www.shef.ac.uk/scharr/escape/

    2. Acute, undifferentiated chest pain Normal or nondiagnostic ECG No evidence of co-morbidity (e.g. CCF) No evidence of alternative serious cause (e.g. PE, aortic dissection) Not clinically obvious unstable angina Not obviously non-cardiac (e.g. reproduced by chest wall palpation)

    3. Acute undifferentiated chest pain Diagnostic ECG changes – 11% Clinically obvious unstable angina – 34% Serious alternative or co-morbidity – 13% Negligible risk of ACS – 18% Acute undifferentiated chest pain – 24%

    4. Management issues Rule out AMI Stratify risk of adverse outcome Hospital admission is wasteful Discharge home is risky

    5. Current practice B J Cardiol 2003;10:50-4 Very variable Admission rates vary from <20% to >80% Most hospitals do not use short stay facilities, troponin testing or exercise testing in A&E Most guidelines refer to diagnosed ACS 7% of patients discharged home have evidence of ACS (Collinson et al)

    6. The Chest Pain Observation Unit Nurse-led, A&E based, protocol-driven care Clinical predictors to select patients Period of observation & cardiac biochemical testing Exercise treadmill test Admit with diagnosis if positive Safe to discharge if tests negative

    7. The Sheffield CPOU Established 1999 Initially 2 CP Nurses – open 9-9, Mon-Fri Now 4 CP Nurses – open 9-9, every day 2-6 bays in A&E trolley area Treadmill machine in A&E

    8. Patient Selection Low risk group Normal ECG Chest pain of unknown origin No co-morbidity

    9. The Sheffield CPOU Protocol ECG analysis CK-MB(mass) on arrival & at least 2 hours later Troponin T at least 6 hours after worst pain Followed by immediate exercise treadmill test Discharged home if tests negative

    10. The Chest Pain Observation Unit

    11. The Chest Pain Observation Unit

    12. CPOU – the literature J Accid Emerg Med 2000;17:1-6. Mostly from US CPOU care is safe – few missed AMI CPOU care is practical – most patients discharged after assessment CPOU is cost-saving in US Little robust evaluation of outcomes

    13. The Sheffield CPOU Emerg Med J 2002;19:117-121 534 patients over one year 23 AMI (4.3%) – by old definition 461 (86.3%) discharged after assessment 357 (66.9%) avoided admission entirely No AMI discharged 89% of discharged followed-up 3 days later - one case with elevated troponin T

    14. Randomised controlled trial BMJ 2004;328:254-7 442 days randomised to CPU or routine care All patients attending with chest pain were screened for eligibility Those with AUCP selected and invited to participate Follow-up at 2 days, one month, and six months

    15. Outcome measures Proportion admitted Proportion with ACS who were discharged (troponin T > 0.03ng/ml at follow-up) Major adverse cardiac event rate Health related quality of life Reattendance and readmission Health service costs

    16. Results CPU reduced admissions (37% v 54%, p<0.001) Fewer discharged with ACS (6% v 14%, p=0.264) One cardiac death in each group MACE rate: 3.8% versus 3.4% (p=0.796) ED reattendance: 12.7% versus 17.2% (p=0.05) Hospital (re)admission: 7.7% versus 10.5% (p=0.122)

    17. Quality of life over six months

    18. Costs over six months

    19. Total costs over six months CPU: £478 per patient Routine care: £556 per patient Difference: £78 95% CI: -56 to 210 P=0.252

    20. Single centre study Cost savings uncertain and may not generalise to other hospitals Insufficient statistical power for cardiac event rates Health outcomes may be influenced by patient awareness that they were in a trial

    21. Setting up a Chest Pain Unit Location Chest Pain Nurse Biochemical Markers Treadmill testing facilities

    22. The ESCAPE Multicentre Trial Effectiveness & Safety of Chest pain Assessment to Prevent Emergency Admissions Can CPOU care be established in a variety of NHS hospitals? Is CPOU care effective throughout the NHS? Is CPOU care cost-effective? How & where are the cost savings realised?

    23. Methodology 18 hospitals willing to participate 9 randomised to set up a CPU in 2004 9 randomised to delay setting up any CPU until at least 2005 Measure costs and outcomes at all hospitals, before and after CPU set-up

    24. Intervention Sites DoH CTSG will reimburse £106 per patient in the first year Estimated 500 patients per year receive CPOU care UP to £50,000

    25. Summary – low risk chest pain Current practice is very variable Discharge home is risky Hospital admission is wasteful CPU offers improved care at lower cost CPU needs up-front investment The ESCAPE trial is the next logical step

    26. Any Questions? s.goodacre@sheffield.ac.uk j.a.arnold@sheffield.ac.uk http://www.shef.ac.uk/scharr/escape

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