Improved prehospital triage for acute cardiac care: results from HART-c, a multicentre prospective study

Cardiac symptoms are one of the most prevalent reasons for emergency department (ED) visits [1]. Interestingly, the vast majority of patients with cardiac symptoms are sent home after acute cardiovascular disease has been ruled out. Previous studies showed that up to 80% of all patients with chest pain do not have an acute coronary syndrome (ACS) [2‐4]. This situation calls for improvement, especially in an era in which the Dutch healthcare system is increasingly under pressure.

Overcrowding of EDs leads to worse patient outcomes, increased healthcare costs and dissatisfied patients and healthcare workers [5‐8]. From a cardiologist’s perspective, previous attempts to reduce overcrowding mostly focused on rapid risk stratification to rule out ACS with the development of risk scores, including the frequently used HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score [9, 10]. These risk scores, however, do not address the root cause of overcrowding, as patients are still required to visit the ED. Accordingly, attention shifted from in-hospital triage towards prehospital triage. The recent FamouS Triage [11] and ARTICA [12] studies focused on prehospital risk stratification. These studies bring progress, but focus only on chest pain patients, whereas patients with other cardiac symptoms also contribute considerably to ED overcrowding. Improved prehospital triage of all cardiac patients could potentially reduce the number of unnecessary ED visits and contribute to effectively combatting overcrowding throughout the Netherlands.

To improve prehospital triage for all patients with cardiac symptoms a comprehensive novel triage method was developed, entitled Hollands-Midden Acute Regional Triage—cardiology (HART-c). This triage method combines prehospital real-time emergency medical services (EMS) data with hospital data and direct consultation of a cardiologist with insight into the triage platform. The primary aim of the HART‑c study was to investigate whether this novel triage method could increase the number of patients who could safely stay at home.

Implementing a novel prehospital triage method for patients visited by the EMS for cardiac symptoms combining live-streamed prehospital data, insight into previous medical history and expert consultation led to a significant increase in the number of patients who could stay at home. The triage method had a MACE rate < 1%; none of these patients died. Furthermore, a decrease in interhospital transfers was achieved. Patients and healthcare workers were very satisfied with the presented triage method. These results may help to relieve the pressure from the currently overcrowded Dutch EDs.

Overcrowding of EDs is a major healthcare challenge [5‐8]. Cardiac patients form a large part of all ED consultations, with more than 10% of all ED consultations involving patients experiencing chest pain [1]. However, over 80% of these patients do not suffer from acute cardiovascular disease. To reduce overcrowding, in-hospital triage for rapid risk stratification of chest pain patients has been in use for several years, employing risk scores [9, 15, 16]. Although these result in accurate and fast risk stratification, patients are still presented to and evaluated at the ED, and thus still contribute to overcrowding. Therefore, scientific focus has shifted to improving prehospital triage.

The ARTICA [12] study assesses whether the addition of point-of-care cardiac troponin T (cTnT) measurement is cost-effective in ruling out ACS and leaving patients at home after EMS consultation. The FamouS Triage [17] investigators concluded that it seems feasible and non-inferior to rule out myocardial infarction in prehospital chest pain patients using a modified HEART score at the patient’s home, incorporating only a single cTnT measurement on intravenously acquired blood samples [18]. The PRESTO [19] study seeks to evaluate the diagnostic accuracy of the validated Troponin-only Manchester Acute Coronary Syndromes decision rule to rule out ACS in the prehospital environment. This could allow paramedics to rule out ACS in chest pain patients in the very low risk group and avoid the need for transport to the ED.

The present HART‑c study differs from the aforementioned studies as regards the patients included, the triage method and its main objective. Firstly and uniquely, the HART‑c study does not limit inclusion to chest pain patients, but also includes patients with other cardiac symptoms. Thus, the HART‑c study could be of benefit to a larger cohort of patients and, for this reason, could be of greater value in preventing overcrowding of EDs and hospitals. Since the method is not solely focused on chest pain patients, it is easier to recreate, adjust and implement for other medical specialties. Second, the HART‑c study is unique in its triage method. The ARTICA, FamouS and PRESTO studies rely solely on prehospital data, whereas the HART‑c study is the first study to combine prehospital and hospital data. Furthermore, the HART‑c study includes expert on-scene consultation by having a cardiologist available for the nurse paramedic. Lastly, this is the first study to publish its results regarding safely leaving cardiac patients at home after EMS assessment. Appropriate selection of patients at (very) low risk for MACE, who could therefore safely stay at home following EMS consultation, could contribute substantially to providing overcrowded EDs and hospitals with much-needed relief. Of utmost importance, patients who can safely stay at home after EMS consultation are spared the (unnecessary) strain and stress of an ED visit.

The HART‑c study has some limitations. First of all, this is not a randomised controlled trial, so selection bias could influence its results and therefore these results should be seen as promising and not definitive. A randomised controlled trial or a study with a stepped wedge design should be conducted in the future to confirm the results presented in the current study. Another limitation is the number of patients lost to follow-up when not transferred to an ED. Unfortunately, not all these patients (or their GPs) could be contacted after 30 days, as some patients (tourists or homeless) did not have a GP or in some cases phone numbers were not noted correctly. Therefore, the true MACE rate could be slightly higher than 1%. Furthermore, the MACE rate might have been this low due to the broad inclusion criteria: ‘symptoms of possible cardiac origin’. Chest pain patients with possible ACS have a higher MACE rate than, for example, patients with palpitations or dyspnoea. The intervention was planned for 1 year. However, in March 2020 COVID-19 struck the Netherlands, which had a huge impact on acute and non-acute (cardiac) care. As patients might have hesitated to contact the GP, EMS or hospitals this would have introduced too much bias in the study, affecting the comparability between the intervention and the (historical) control group. Therefore, the study was closed in March 2020.

In conclusion, the HART‑c study evaluated a novel triage method combining prehospital live-streamed EMS data, insight into previous medical records, real-time hospital admission capacity with consultation of an expert cardiologist. The achieved increase in patients who could safely stay at home after EMS consultation and the reduction in interhospital transfers could help take substantial pressure off the currently overloaded healthcare system. Furthermore, the presented triage method is adjustable and easily implementable for other medical specialties to further reduce overcrowding.