Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations
Rory Miller 1 12 , Joanna Young 1 , Garry Nixon 2 , John W. Pickering 3 , Tim Stokes 1 , Robin Turner 4 , Gerard Devlin 5 , Antony Watson 6 , Marc Gutenstein 1 7 , Tim Norman 8 , Peter Myles George 9 , Stephen Du Toit 10 , Martin Than 111 Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
2 Cardiology, Canterbury DHB, Christchurch Hospital, Christchurch and Department of Medicine, University of Otago – Christchurch, Christchurch, New Zealand
3 Medicine, University of Otago – Christchurch and Emergency Department, Christchurch Hospital and Department of Medicine, University of Otago, Christchurch, New Zealand
4 Centre for Biostatistics, Division of Health Sciences, University of Otago, Dunedin, New Zealand
5 Tairawhiti DHB, Gisborne, New Zealand
6 Emergency Care Foundation, St Albans, Christchurch, New Zealand
7 Rural Health Academic Centre Ashburton, University of Otago and Christchurch and Emergency Department, Nelson Hospital, Nelson, New Zealand
8 Project Office, Midlands Regional Health Network Charitable Trust, Hamilton, New Zealand
9 Chemical pathology, PathoGene, Merivale, Christchurch, New Zealand
10 Biochemistry, Waikato DHB. Biochemistry Department, Waikato Hospital, Hamilton, New Zealand
11 Emergency Department, Canterbury DHB, Christchurch Hospital, Christchurch, New Zealand
12 Corresponding author. Email: Rory.miller@otago.ac.nz
Journal of Primary Health Care 12(2) 129-138 https://doi.org/10.1071/HC19059
Published: 20 May 2020
Journal Compilation © Royal New Zealand College of General Practitioners 2020 This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License
Abstract
INTRODUCTION: Accelerated diagnostic chest pain pathways are used widely in urban New Zealand hospitals. These pathways use laboratory-based troponin assays with good analytical precision. Widespread implementation has not occurred in many of New Zealand’s rural hospitals and general practices as they are reliant on point-of-care troponin assays, which are less sensitive and precise. An accelerated chest pain pathway using point-of-care troponin has been adapted for use in rural settings. A pilot study in a low-risk rural population showed no major adverse cardiac events at 30 days. A larger study is required to be confident that the pathway is safe.
AIMS: To assess the safety and effectiveness of an accelerated chest pain pathway adapted for rural settings and general practice using point-of-care troponin to identify low-risk patients and allow early discharge.
METHODS: This is a prospective observational study of an accelerated chest pain pathway using point-of-care troponin in rural hospitals and general practices in New Zealand. A total of 1000 patients, of whom we estimate 400 will be low risk, will be enrolled in the study.
OUTCOME MEASURES: The primary outcome is the proportion of patients identified by the pathway as low risk for a 30-day major adverse cardiac event. Secondary outcomes include the proportion of low-risk patients who were discharged directly from general practice or rural hospitals, the proportion of patients reclassified as having acute myocardial infarction by the pathway and the proportion of patients with low and intermediate risk safely managed in the rural hospital.
KEYwords: Rural health; Chest pain; Primary Care; rural hospitals; point-of-care troponin
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