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Chest Pain Units: The Diagnostic Testing

Literature Review

Chest Pain Units (CPUs) are the innovative systems of monitoring and treatment of patients with undifferentiated acute chest pain. Along with the opportunities of cutting the testing costs and earlier diagnosing of the cardiac diseases, the CPU approach presupposes difficulties of organization of a separate unit in the hospital setting and training of the dedicated personnel. A number of empirical studies have proven that the CPU approach allows avoiding wrong diagnosing, distributing the health care resources more reasonably and increasing the clients’ satisfaction with the services, thus, is worth of costs required for reorganization of the hospital setting.

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Though early diagnosing is significant for all types of diseases, the undifferentiated patient population with symptoms which can be consistent with acute coronary syndrome (ACS) increase the potential risks of the physicians and clients themselves. The consequences of wrong diagnosing and premature discharge of these patients can be dreadful, and this group of clients requires a systematic approach to testing and specific hospital resources for avoiding the inadmissible medical mistakes.

The traditional hospital setting does not allow devoting enough time and resources to monitoring these patients, and organization of a specialized CPU with dedicated space and trained personnel may be a way out for increasing the effectiveness of monitoring and ensuring the informed decision making as to the following intervention. Blomkalns and Gibler (2005) noted that “the evaluation of patients who exhibit symptoms consistent with ACS requires a protocol that includes testing for myocardial necrosis, rest ischemia, and exercise-induced ischemia” (p. 411). At the same time, organization of these units presupposes a number of difficulties related to dedication of place and training the personnel. Lacking the resources for start-up of a separate CPU, the same protocols are often used in a standard emergency department (ED).

On the one hand, organization of the CPU requires additional costs for providing the patients with additional comforts such as beds, TV sets, and telephones, not to mention the equipment required for monitoring. On the other hand, for conducting all the necessary tests and evaluating all the measurements, a patient will need to stay at the department for not less than 6 hours, and it might cause the client’s dissatisfaction. For these reasons, the effectiveness of the CPUs as compared to the traditional EDs needs to be evaluated critically with the aim of deciding on the cost-effective monitoring and improving the clients’ outcomes.

Blomkalns and Gibler (2005) shed light upon the economical benefits of the CPUs along with their practical value: “admissions for ultimately diagnosed ‘noncardiac’ chest pain cost our society billions of dollars annually. The CPU has allowed physicians to condense a hospital admission into a 6- to 12-hour evaluation, risk stratification, and observation period” (p. 418). The funds that have been economized by testing the patients with symptoms which can be consistent or not with ACS at CPUs can be used more effectively for the purpose of increasing the quality of the health care services.

The time-consuming and expensive traditional approach to monitoring the symptoms appears to be ineffective. The problem with the correct monitoring and assessment at EDs is caused by the diagnostic limitations of electrocardiography (ECG) which is not always able to detect acute myocardial infarction, not to mention unstable angina. Serum markers which are used for detection of myocardial necrosis are not always effective as well.

All these limitations can result in misdiagnosing, premature discharge of the patients and even more serious consequences. Quin (2000) noted that “faced with these diagnostic difficulties, and the consequences of misdiagnosis, ED physicians have a low threshold for admitting patients with chest pain in whom the diagnosis is not immediately clear” (p. 404). For the purpose of more effective utilization of the hospital resources, the personnel should use serial testing of patients with symptoms which may be consistent with cardiac diseases.

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Looking for the alternatives to the traditional approach to monitoring the chest pain symptoms, hospitals organized the CPUs with specialized protocols, laboratories and qualified staff. Quin (2000) noted that “the available evidence suggests that chest pain evaluation units deliver what they promise, providing equivalent clinical outcomes to inpatient management, in a shorter time and for lower cost” (p. 406). Using the evidence based approach to decision making, contemporary hospitals and EDs start the CPUs for the purpose of using their resources more effectively and reducing the physicians’ risks of misdiagnosing and increasing the patients’ safety and satisfaction.

Patients’ perception and evaluation of the health care services has a significant impact on the effectiveness of the procedures. Along with all the economical and practical benefits of the CPU approach, the patients’ attitude towards the new method should be taken into consideration as well. Cross and Goodacre (2010) conducted a survey of the patients’ opinion as to introduction of the CPUs and their effectiveness. They selected 5584 patients at 18 hospitals and asked them to participate in the research by answering the questionnaire concerning the quality of the health care services they had received at a CPU and their effectiveness.

The results of the study did not come up to the researchers’ expectations and contradicted the data of the previous researches in the same field. Cross and Goodacre (2010) noted that “the ESCAPE study found no evidence that patient satisfaction was improved by the introduction of CPU and, if anything, the trend was towards reduced satisfaction” (p. 775). The main limitations of the study were its quantitative measures, which cannot reflect the whole range of changes in people’s attitudes and feelings. For instance, previously when the CPU approach was considered as innovative, patients demonstrated higher level of their satisfaction with the services. At present, the majority of them take the admission to a CPU for granted and do not appreciate its benefits.

Previous studies demonstrated the increased satisfaction of the clients with the quality of the health care services along with the reduced costs on their delivery which can be explained with the more reasonable and effective distribution of the hospital resources. Arnold, Goodacre, & Morris (2007) noted that “CPU care reduced hospital admissions, health service costs, and patient anxiety and depression, and improved patient-reported health, quality of life and satisfaction with care” (p. 462). These researchers studied the operation of 7 CPUs during the first year after its establishment, using the descriptive research methods.

They chose 14 hospitals for participating in the project and in 7 of them the CPUs were established soon after the beginning of the study, the rest of them were used as the control group. The researchers estimated that the rate of the adverse events among the patients who were discharged after monitoring at CPUs reached only 1.7 %. Arnold, Goodacre, & Morris (2007) concluded that “CPU care can be instituted in a safe manner in a variety of NHS hospitals, with most patients being discharged after assessment” (p. 466). The evidence retrieved from Arnold, Goodacre, & Morris (2007) report proves the economical and practical benefits of implementation of the CPU approach in diagnosing the patients with acute chest pain which can be consistent with ACS and other cardiac diseases.

A successful start-up of the CPU at the hospital setting or at ED requires the evidence-based approach to decision-making as to the reorganization of the structure of the institution in general and organization of the unit itself in particular. Providing rapid assessment of the symptoms of patients with acute undifferentiated pain, CPUs use the standardized sets of procedures and serial testing. The main components of the monitoring are electrocardiographic recording (ECG) and biochemical markers.

Goodacre et al (2005) conducted a research for the purpose of defining the most valuable testing components and increasing the effectiveness of operations within these units. Identifying the adverse cardiac events among the patients who had been discharged after the diagnostic assessment at CPUs, the research team tried to estimate the sensitivity of each component and evaluate the effectiveness of the method.

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During the study period 706 patients of the Northern General Hospital were asked to return for an additional testing in 72 hours after they had been discharged from CPU. About 86% of the patients returned to have the repeating blood testing and there was the only case of patient with ACS while all the rest cardiac diseases were detected by the CPU protocols. Goodacre et al (2005) noted that “The CPU aims to rapidly diagnose acute coronary syndrome (ACS), providing early access to appropriate care for those with positive test results and discharge home for those who test negative” (Which diagnostic tests are most useful).This data proves the effectiveness of the CPU approach and the importance reorganization of the medical institution for improving the quality of services and outputs of the intervention.

The CPU system of monitoring the patients with acute chest pain which can be consistent with ACS had positive consequences for the hospital settings in which it was introduced. Along with cutting the costs required for monitoring the symptoms in traditional EDs, this approach provides a condensed course of serial testing, improving the effectiveness of diagnosing and increasing the patients’ satisfaction with the services.

Theory

The patient population with acute chest pain may cause particular diagnostic difficulties for the health care practitioners. The results of the initial ECG and cardiac markers testing, not to mention the physical examination may be inconsistent for diagnosing the patients. The CPU approach according to which the patients with acute chest pain are sent to separate units with dedicated beds, laboratories and qualified personnel helped not only to decrease the rate of misdiagnosing, but also to cut costs required for the testing routine of the same patients in traditional hospital setting.

Conclusion

The CPUs with the specialized equipment, dedicated personnel and standardized protocols are aimed at early detection and more effective intervention of the cardiac diseases. At the same time, these units help to decrease the physicians’ risks of wrong diagnosing and discharging a patient who will have adverse cardiac events in the nearest future. Cannon (2003) admitted that “at many sites, the use of Chest Pain Centers or Chest Pain Units has eased the pressure on the ED physician to commit high-cost cardiac care unit resources or release the patient” (p. 200). Compared with conventional in-patient admission, the testing at CPU allows reducing costs for diagnosing the undifferentiated patient population with acute chest pain.

Reference List

Arnold, J., Goodacre, S., & Morris, F. (2007). Structure, process and outcomes of chest pain units established in the ESCAPE Trial. Emergency Medicine Journal, 24(7): 462-466.

Blomkalns, A. & Gibler, W. (2005). Chest pain unit concept: Rationale and diagnostic strategies. Cardiology Clinics, 23: 411-421. Web.

Cannon, C. (ed.) (2003). Management of acute coronary syndromes. Totowa, NJ: Humana Press.

Cross, E. & Goodacre, S. (2010). Patient satisfaction with chest pain unit care: Findings from the Effectiveness and Safety of Chest Pain Assessment to Prevent Emergency Admissions (ESCAPE) cluster randomized trial. Emergency Medicine Journal, 27: 774-778.

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Goodacre, S. et al. (2005). Which diagnostic tests are most useful in a chest pain unit protocol? BMC Emergency Medicine, 5 (6). Web.

Quin, G. (2000). Chest pain evaluation units. Western Journal of Medicine, 173(6): 403-407.

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