CPCs serve to streamline chest pain evaluation

Usage, availability of cost-effective centers grows

It’s a scene that’s been repeated countless times. A middle-aged individual (usually male) has been brought into your emergency department (ED). He’s complaining of chest discomfort. He also may be nauseous and/or dizzy. He’s often anxious and "sweating bullets." And he should be — because he may be in the early stages of a heart attack or, then again, perhaps he only has indigestion, or maybe he’s just going through a panic attack.

Whatever the case, Raymond D. Bahr, MD, medical director of the Paul Dudley White Coronary Care System at St. Agnes Healthcare in Baltimore, wants this patient checked out thoroughly. Bahr has spent most of the past 30-odd years working to reduce deaths from heart attacks, "which now total nearly 600,000 per year in the United States — more than all the soldiers killed in past American wars combined," he says.

His approach to the problem revolves around a prompt, appropriate, and cost-effective medical response to what is often the early sign of a heart attack (e.g., chest discomfort that often gets ignored because it falls short of what an individual perceives as pain). Bahr says his delivery system for this response is a chest pain center (CPC). Introduced in 1981 at St. Agnes, the CPC is a readily accessible, often ED-based facility that provides immediate evaluation of chest pain, accurate diagnosis of myocardial infarction (MI) with protocols for rapid treatment, and definitive ruleout of MI for all but the lowest-risk patients.

Basically, the CPC represents another step in the evolution of the medical community’s response to chest pain, lawsuits, and cost constraints. "Historically, about half of the patients coming into an ED with chest discomfort have been sent home, where about 5% turned out to have had an MI, which has caused a lot of malpractice lawsuits," says Bahr. In a costly and inefficient response to this, he notes, "For a while, everybody with a suspected MI was getting admitted to the coronary care unit (CCU) for a two- to three-day stay."

The CPC, in a sense, stakes out a "middle ground." It is a facility specifically dedicated to quickly evaluating patients complaining of chest pain. Often located inside or next to EDs, it brings together the necessary staff, equipment, and treatment protocols to deliver quick, efficient care to potential heart attack victims, while allowing other patients to be safely discharged and sent home.

The hallmark of the CPC is its emphasis on streamlined procedures that triage patients into one of five clinical pathways or tracks, according to Bahr. These pathways include:

Track I. Patients are crashing with an acute MI and need prompt thrombolytic therapy or primary angioplasty. These patients are sent rapidly to the CCU after initiating thrombolytic therapy in the ED or moving to the catheterization area for percutaneous transluminal coronary angioplasty.

Track II. Patients have non-Q wave infarction or severe, progressive unstable angina, and also need admission to the CCU for stabilization, with decisions regarding cardiac catheterization to be made any time.

Track III. Patients have myocardial ischemia that has quieted down upon arrival. In most cases, these patients need to be admitted to the hospital either to the "high-rent" CCU district for heparin, nitroglycerine, and cardiac catheterization the next day, or the "low-rent" telemetry district where stress testing can be promptly carried out.

Track IV. These patients may have an atypical presentation with a normal or nondiagnostic EKG, but a certain amount of indecision prevails that needs to be resolved prior to discharge.

Track V. These patients are considered strictly to be noncardiac (e.g., elbow in the chest playing basketball) and are sent home.

Slashing chest pain hospitalization costs

Since its introduction some 18 years ago, the CPC approach has taken hold nationwide. "They are growing on an exponential basis," says Bahr, and currently number some 1,200.

Chest pain centers have become recognized as a means of reducing what has been estimated as the $3 billion spent annually on patients hospitalized in the United States for chest pain, but found free of acute disease.1 In a 1995-97 study involving patients coming to the Mayo Clinic in Rochester, MN, with acute chest pain that met the criteria of unstable angina, researchers concluded that "A [chest pain unit] located in the emergency department can be a safe, effective and cost-saving means of ensuring that patients with unstable angina who are considered to be at intermediate risk of cardiovascular events receive appropriate care."2

In a paper presented at the Third National Congress of Chest Pain Centers in Emergency Departments, Robert J. Stomel, DO, FACOI, FACC, reported on the impact of a chest pain center at Botsford General Hospital in Farmington Hills, MI. Botsford established a chest pain center in 1993. By 1996, the number of patients admitted to the hospital for angina pectoris and chest pain (DRGs 140 and 143) had been cut from 591 to 470, a 20.5% decrease, Stomel states. Meanwhile, patient days dropped some 51.5%, from 2,024 days to 1,043 days; average length of stay decreased from 3.4 to 2.1 days, or 39.1%.

Understandably, in today’s environment, much of the research concerning chest pain centers focuses on the potential economic benefits. "Yet, decision makers should resist placing too much emphasis on studying dollars and cents," according to a recent statement from James L. Field, MBA, DBA, managing director of the Washington, DC-based Cardiology Preeminence Roundtable.

"The chest pain center concept, stripped to its core, is about expert patient triage, smart and efficient management of a critical subset of the ED population," says Field.

"To invest in a chest pain center, or to embrace its principles, is a commitment to providing the highest levels of cardiac care. It is this sort of institutional competence," he notes, "that engenders public and payer confidence, leading to economic well-being over time." In today’s payer environment, managed care companies want what Field calls "discriminating medicine — assurances that money is appropriately spent; the chest pain center can be one powerful means to this end."

[For more information, contact:

• Raymond D. Bahr, MD, FACP, FACC, Medical Director, The Paul Dudley White Coronary Care System, St. Agnes Healthcare, 900 Caton Ave., Baltimore MD 21229. Telephone: (410) 368-3200. Fax: (410) 368-2273. E-mail: rbahr@ehac.org.

• The Society of Chest Pain Centers and Providers. Web site: www.chestpaincenters.org.

• Early Heart Attack Care (EHAC). Web site: www.ehac.org.]

References

1. Roberts R, Zalenski R, Mensah E, et al. Costs of an emergency department-based accelerated diagnostic protocol vs. hospitalization in patients with chest pain. JAMA 1997; 278:1,670-1,676.

2. Farkouh M, Smars P, Reeder G, et al. A clinical trial of a chest-pain observation unit for patients with unstable angina. N Engl J Med 1998; 339:1,882-1,888.