If successful and cost-effective, this project will define a new paradigm for assessment and management of acute coronary syndromes (ACS) in rural settings utilising a central clinical decision support service. It can rapidly be scaled up to be applied across NSW.
One third of patients presenting to Australian hospitals with ST-segment-Elevation Myocardial Infarction (STEMI) do not receive primary reperfusion treatment, which is the standard of care. In rural and regional Australia, primary reperfusion treatment involves thrombolysis which, if delivered in a timely fashion, provides outcomes similar to primary percutaneous coronary intervention (PCI). Failure to provide reperfusion doubles mortality, increases length of stay and increases readmission rates. A high level of clinical variation, due to misdiagnosis or treatment of ACS, has been found in NSW. Our research in Hunter New England Local Health District shows that missed acute myocardial infarction (MI) from failure to correctly interpret electrocardiogram (ECG) and serum markers is common, leading to increased mortality and morbidity, and is overrepresented in rural hospitals that are maintained by general practitioners. This proposal will randomize small rural hospitals to either usual care or a mandated transmission of ECG and troponin from spoke (rural) hospitals to a central hub service. Protocol directed advice will be given to the randomized rural hospital clinicians and will channel patients into the existing ACS management structures: The State Cardiac Reperfusion Strategy for STEMI patients, and the NSW Chest Pain Pathway for non-STEMI patients. The primary outcome will be the difference in identification of STEMI in patients who present to rural hospitals across two local health districts, Hunter New England and South Western Sydney.
A cost-effectiveness evaluation will report the resources required to increase STEMI identification. Secondary outcomes include major adverse cardiac events and outcomes in non-STEMI. Hunter New England Local Health District has a proven track record in innovation in rural cardiology. The NSW Health Minister’s award for translational research was won by Hunter New England in 2016 for pioneering the state reperfusion strategy.
Collaborators: Agency for Clinical Innovation, NSW Ambulance, John Hunter Hospital, Monash University