The Accelerated Chest Pain Risk Evaluation (ACRE) Project Is a Statewide Clinical Redesign

The Accelerated Chest pain Risk Evaluation (ACRE) project is a statewide clinical redesign initiative supported by theHealthcare Improvement Unit of the Queensland Health Clinical Excellence Division. The aim of ACRE is to rapidly translate recent research into clinical practice, to enable safe, evidence based care of patients presenting to Queensland Health Emergency Departments (EDs) with chest pain. The intention is to improve patient care through shorter lengths of stay, and to create hospital capacity by improving patient flow.

Many Primary Health Clinicians may be familiar with stage I of ACRE, which rolled out across Queensland between 2014 and 2016. It involved implementation of anAccelerated Diagnostic Protocol (ADP) described in the ADAPT Trial1 which enables fast-tracked care ofaround 20%of patients presenting to ED with possible cardiac chest pain. These patients had accelerated ECG and Biomarker testing (0 and 2 hours), and were able to be discharged for outpatient objective testing (usually EST). ACRE I reported significant patient flow and economic outcomes across the 19 hospitals that implemented the ADP2 and has since been incorporated into the National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand Guidelines3.()

Stage II of the ACRE Projecthas commenced implementation of the latest research from theteam behind ADAPT.The Improved Assessment of Chest pain Trial (ImpACT)3 protocol describes an ADP that safely accelerates up to 70% of ED chest pain presentations by identifying:

1)A very low risk groupof patients (18%) who following normal 0 and 2 hour ECG and laboratory based Troponin I testing, do not require further objective testing

2)A group of intermediate risk patients (58%) who can have 0 and 2 hour ECG and laboratory based Troponin I tests, followed by early inpatient objective testing(usually EST)

Both these groups of patients are discharged with instruction to consult their General Practitioner for risk factor modification, with letters for GPs explaining the protocol.

The ACRE Project has been funded to roll out the ImpACT protocol across Queensland Health Hospitals and many Primary Health Clinicians will likely encounter patients who have been treated on this pathway. It is currently in use at the following hospitals:

• Royal Brisbane and Women’s Hospital
• Cairns Hospital
• Ipswich Hospital
• Sunshine Coast University Hospital
• Nambour Hospital

And the ACRE Team is currently engaged with the following hospitals that are planning to implement:

• The Townsville Hospital
• Rockhampton Hospital
• Gladstone Hospital
• Bundaberg Hospital

The Clinical Leads for the ACRE Project are Dr Louise Cullen (Emergency physician) and Dr Louise McCormack (Cardiologist), based at the Royal Brisbane and Women’s and Ipswich Hospitals.

For further information:
Phone: 07 36465891

Email:

Web:

References:

1. Than M, Cullen L, Aldous S, Parsonage WA, Reid CM, Greenslade J, et al. 2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker: The ADAPT Trial. Journal of the American College of Cardiology. 2012;59(23):2091-8.
2. Parsonage WA, Milburn T, Ashover S, Skoien W, Greenslade JH, McCormack L, et al. Implementing change: Evaluating the accelerated chest pain risk evaluation (ACRE) project. Medical Journal of Australia. 2017;207(5):201-5.
3. Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart, Lung and Circulation.25(9):895-951.
4. Cullen L, Parsonage WA, Greenslade JH, Hawkins T, Hammett C, O’Kane S, et al. Improved assessment of chest pain trial (IMPACT): Assessing patients with possible acute coronary syndromes. Medical Journal of Australia. 2017;207(5):195-200.