Implementation of a remote rapid access chest pain service during the COVID-19 pandemic

Background

Rapid Access Chest Pain Clinic (RACPC) is a vital service in many hospitals in the UK, providing early specialist input for patients with suspected coronary artery disease referred via the Emergency Department (ED) or primary care (1). When the COVID-19 pandemic forced hospitals to refine their outpatient systems (2), our Trust continued the RACPC service remotely via telephone consultations.

Purpose

To examine the long-term viability of this service, we designed a study to compare the outcomes of patients seen remotely during the pandemic to patients seen face to face.

Methods

We performed a retrospective cohort study. The remote group (n=217) were patients seen over 4 weeks in April 2020, all having telephone consultations. The control group (n=368) were patients assessed face to face in the same 4-week period in 2019. Outcomes being analysed included: mode of investigation; interventions performed; and a 12 month combined safety endpoint of ED attendance with chest pain, re-referral to cardiology and hospitalisation for cardiac issue. Subgroup analysis was performed based on typicality of symptoms defined by NICE (3).

Results

Baseline characteristics were similar between groups. In both 2019 and 2020, the largest subgroup of patients were those with non-anginal chest pain (64%, 71%). There were significant differences in investigation and management between the two cohorts (Figure 1). In 2020, a higher proportion of patients were discharged with no investigation (57% vs 23%, p<0.0001). This was driven primarily by changes in management of patients with non-anginal chest pain. There were significantly higher rates of investigation of this subgroup in 2019 by either CT Coronary Angiography (25% versus 4.5%, p<0.001) or functional testing (25% versus 6.5%, p<0.001), with a much higher rate of reassurance and discharge in 2020 (81% versus 36%, p<0.0001). More patients received coronary intervention in 2019 than in 2020 (2.4% vs 0%, p=0.02). In 2020, higher proportions of patients were commenced on medical therapy without further investigation when presenting with atypical (28% versus 1%, p<0.0001) or typical angina (63% versus 11.4%, p<0.0001) (Figure 2). There was no significant difference in the 12 month combined safety endpoint (1.3% in 2019 versus 2.3% in 2020, p=0.39), and no reported cardiac deaths.

Conclusions

During the pandemic, as expected, fewer patients were investigated for coronary artery disease, with the preference being to commence medical therapy initially. This did not have a significant effect on safety endpoints. Importantly, clinicians felt comfortable with assessing and discharging patients with non-anginal chest pain remotely in 2020. This is key to the viability of a remote RACPC model, as this subgroup forms the majority of the referrals. We suggest that RACPC is appropriate for a remote model in the long term, in view of the relatively low-risk population and clear management guidelines.

Funding Acknowledgement

Type of funding sources: None.

80 Improving Documentation of DNAR Decisions on the Acute Medical Take

Introduction

The BMA, Resuscitation Council and Royal College of Nursing have set out clear guidelines on documentation of Resuscitation discussions and decisions.1 On the acute medical take documentation of these discussions and decisions can be unclear despite use of an electronic patient record (EPR). The aim of this audit was to improve documentation of Do Not Attempt Resuscitation (DNAR) decisions in EPR.

Methods

We listed patients admitted on the medical take over 1-week, looking at resuscitation status and the documentation of the DNAR decision. We then implemented a change to the format of the EPR treatment escalation plan (TEP) form. Prior to the change the DNAR form was behind the TEP form which had to be clicked on separately and was not mandatory to complete. After the intervention the DNAR decision was placed in a box on the front page of the TEP form to ensure that it was clear and accessible.

Results

Pre-intervention we reviewed 114 patients notes of which 94 were DNAR. Of these 94 only 17 (18%) had correctly documented DNAR decisions in EPR. Following the intervention we again looked at all admissions to the medical take over a 1-week period, out of 151 patients 75 were DNAR and of these 75 patients 29 had correctly documented DNAR forms. This shows an increase in the percentage of the DNAR decisions filled in from 18% to 39%.

Conclusion

The results show that although there has been an improvement in the number of DNAR decisions being documented there are still a large percentage of patients who do not have this correctly documented. We are designing further interventions to ensure that the DNAR documentation is marked as a mandatory part of the TEP form as well as educating around the importance of this documentation.

P6135Improving detection of AF: insights from real world screening programme

Background

AF related stroke places a significant burden on individuals, carers and health and social care systems. The observed prevalence of AF in populations is often lower than expected and this results in high rates of AF diagnosis at the time of the stroke event. Opportunistic screening for AF in at risk populations is recommended by ESC, however, is often missed due to time constraints and lack of expertise. Technological advancements such as m-health ECG monitors can aid in the diagnosis of AF with improvements in timely risk assessment and initiation of protective anticoagulation.

Purpose

The purpose of this study was to determine whether introduction of a suite of m-health tools including electronic patient record based tools and smart phone based ECG recording could improve the rates of AF detection and subsequently reduce the rate of AF related strokes.

Methods

The study was conducted in a city region with a population of around 300 000, served by 48 primary care practices. The project involved a three staged approach; education and support for primary care staff, creating an “at-risk” register on primary care electronic patient record for those over 60 or with relevant co-morbidities associated with electronic prompts for screening and a standardized assessment template and the roll-out of smart phone based single-lead ECG monitors to facilitate rhythm checks. The population was followed over a 4 year period to monitor rates of AF diagnosis, anticoagulation and stroke rates.

Results

The study population were male (53%), aged between 30–39 (22.4%) and were of white ethnicity (40%). At baseline, in 2014, the prevalence of AF was 0.89% (2492 individuals). By 2018, this had increased to 1.1% (3328 individuals) with on average 40 new diagnoses of AF compared to 26 in the baseline period (see figure).Anticoagulation prescription within 30 days of diagnosis increased from 29.80% to 50.00% whilst prescription of antiplatelet monotherapy within same time period decreased from 12.73% to 6.4%. This was also associated with a reduction in the proportion of strokes seen in the population secondary to AF with 35% (n=143) of strokes secondary to AF in 2014 and 25% (n=127) secondary to AF in 2017.

Conclusion

The study found that implementation of a screening programme across a wide range of primary care practices led to an improvement in AF diagnosis, management and timeliness of care. This highlights the benefit of using simple methods such as GP educations in conjunction with new technology device to detect AF more effectively and subsequently treat in an appropriate and time-effective fashion. In our population this appears to be associated with real reductions in AF related strokes

Acknowledgement/Funding

CLAHRC NWL, NHS Hounslow CCG, Pfizer

The microbiology of glue ear in Australian Aboriginal children

OBJECTIVE

To study the bacterial cultures of middle ear aspirates from 27 Aboriginal children with otitis media with effusion.

METHODS

Standard bacteriological techniques were used to analyse the middle-ear aspirates collected during surgery to insert grommets in 27 Aboriginal children. Swabs of the tympanic membrane were taken for comparison.

RESULTS

Forty-five aspirates were collected from 59 myringotomies. Positive cultures were obtained from 19 of these (13 children) with potentially pathogenic organisms identified in 11 children including Staphylococcus, Pseudomonas, Haemophilus influenzae, Moraxella, Achromobacter, Enterobacter and Corynebacterium.

CONCLUSION

This is only the second study to look at the bacteria in middle ear effusions in Aboriginal children. Streptococcus pneumoniae was notable in its absence as was found in a previous study.

A biochemical analysis of people with chronic fatigue who have Irlen Syndrome: speculation concerning immune system dysfunction

This study investigated the biological basis of visual processing disabilities in adults with Chronic Fatigue Syndrome. The study involved 61 adults with symptoms of Chronic Fatigue Syndrome who were screened for visual processing problems (Irlen Syndrome) and divided into two groups according to the severity of symptoms of Irlen Syndrome. Significant variations were identified in blood lipids and urine amino and organic acids of the two groups, which may be indicative of activation of the immune system due to some infective agent. It was suggested that metabolic profiling may help the development of more valid diagnostic categories and allow more investigation of immune system dysfunction as a possible causal factor in a range of learning and behaviour disorders.

Chronic orofacial muscle pain: a new approach to diagnosis and management

The initial data from this study indicate that there are clearly identifiable chronic muscle pain conditions in the form of localized pain; myofascial pain or regional pain conditions; and fibromyalgia or generalized pain conditions. A clear difference exists between the prevalence of these conditions in male and female patients, with a higher percentage of female patients suffering generalized pain problems and temporomandibular problems. Generalized or localized pain appears to be an individual variant of a similar problem and pain patients may have a genetically determined vulnerability associated with bacterial toxins, particularly within the genitourinary tract. It appears that in fibromyalgia there is an underlying genetic factor that causes abnormalities in the muscle metabolic cycle, and preliminary data suggest that lipid anomalies predispose to fibromyalgia and possibly chronic fatigue syndrome. Patients report infectious events at/or around onset in more than 60 percent of cases. Seventy percent of fibromyalgic cases report orofacial pain.

An alteration in the host-parasite relationship in subjects with chronic bronchitis prone to recurrent episodes of acute bronchitis

Acute episodes of bronchitis have been shown to be unequally distributed within a population of subjects with chronic bronchitis. Two groups were identified based on incidence of acute bronchitis--subjects who were 'infection-prone' (2-5 infections per year) and those who were 'non-infection-prone' (0-1 infections per year). Minor differences in clinical parameters existed, except for smoking experience. The non-infection-prone group included more current smokers, and the total smoking experience (in 'pack years') was significantly greater in this group. Between-year analysis demonstrated a stability of classification, established after a minimum of two years' prospective observation. Parameters of the host-parasite relationship were assessed in both groups. A significantly greater polybacterial colonization of the oropharynx was observed for chronic bronchitics, both infection-prone (P < 0.0001) and non-infection-prone (P < 0.001), compared with control subjects. Infection-prone chronic bronchitics had significantly greater total bacteria cultured from the oropharynx compared to the non-infection-prone group (P < 0.05); adherence of indigenous microflora to buccal epithelial cells, in particular Gram-positive cocci (P < 0.01) and in vitro adherence of non-serotypable Haemophilus influenzae to buccal cells (P < 0.05) compared with the control and non-infection-prone groups. These studies suggest that an important variation in subjects with chronic bronchitis is the binding capacity of epithelial cells for bacteria, which when increased enhances susceptibility to colonization and clinical infection.

Detection of antigen-antibody interactions by surface plasmon resonance. Application to epitope mapping

Surface plasmon resonance (SPR) detection requires no labeling of antigen or antibodies and allows quantification of two or more interacting molecular species. The automated SPR instrument used here consists of an optical detection unit, an integrated liquid handling unit, and an autosampler. A first molecule is immobilized to the dextran modified surface of the sensor chip. By sequential introduction, the stepwise formation of multimolecular complexes can then be monitored. A two-site binding assay which allows characterization of MoAb epitope specificities is described. A polyclonal rabbit anti-mouse IgG1 (RAMG1) immobilized to the dextran surface is used to capture the first MoAb from unprocessed hybridoma culture supernatants. After introducing the antigen, the ability of a second MoAb to bind to the antigen is tested. The analysis cycle which is fully automated can be performed more than 100 times using the same RAMG1 surface. Since the detection principle allows monitoring of each reactant in the consecutive formation of a multimolecular complex, multi-site binding experiments can be performed. Five MoAbs recognizing different epitopes on an antigen were shown to bind sequentially, forming a hexamolecular complex. MoAbs were further characterized by inhibition analysis using synthetic peptides derived from the primary structure of their antigen. As a model system MoAbs against recombinant HIV-1 core protein p24 were used in all experiments.

[Endomyocardiopathy and eosinophilia (author's transl)]

Clinical, laboratory, and necropsy findings in a male patient with marked eosinophilia and fatal cardiac failure are reported. Necropsy revealed an obliteration of the left ventricle caused by endomyocardial fibrosis, left ventricle hypertrophy, and white thrombus. There was also found endomyocardial fibrosis and hypertrophy of the right ventricle. Pathogenesis and treatment of endomyocardiopathies are discussed.

[Lactic acidosis after administration of guanidine derivatives (buformine, phenformine) (author's transl)]

Three patients are reported on, who at the time of admittance showed a decompensated metabolic acidosis, elevated concentrations of serum lactate and a reduced kidney funktion. All the patients had taken guanidine derivates (phenformine, buformine) because of diabetes mellitus. The serum biguanid concentrations, however, were elevated in only two cases. Therapy of the lactic acidosis has to be directed at the underlying disease. In biguanid incluced acidosis, haemodialysis with simultaneous administration of sodium bicarbonate is indicated.

[Syndrom of hypercalcemia in a case of hyperthyroidism, primary hyperparathyroidism and cancer of the gall-bladder (author's transl)]

A hypercalcemia syndrom in the case of a 63 year old female patient is reported on, who simultaneously suffered from hyperthyroidism and suspected primary hyperparathyroidism. During autopsy an ectopic (ventral mediastinum) parathyroid adenoma and a gall bladder carcinoma were discovered. Each of these three diseases can induce hypercalcemia by themselves.