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7th January 2022
A telephone triage study has identified a number of potentially life-threatening conditions associated with chest pain that ought to require a high priority ambulance response according to researchers from the Division of Cardiovascular Sciences, Core Technology Facility, University of Manchester, UK.
Chest pain is a common reason for ambulance transport with one study finding that it accounted for 16.4% of acute ambulance transports. However, although the majority of patients with chest pain are admitted to hospital, one study has revealed that only a quarter of those assessed before arriving at hospital had a severe illness. In fact, an audit of patients admitted to hospital with suspected acute coronary syndrome (ACS), who were assessed by telephone triage, found that only 1 in 18 of those with chest pain were diagnosed with ACS.
Although telephone triage systems leading to the dispatch of emergency services are able to accurately identify those who require transport to hospital, a 2018 systemic review concluded that ‘there is a very low to low overall level of evidence for the accuracy of medical dispatching systems.’ Moreover, other research has shown that pre-hospital over triage occurred in more than 70% of cases and for chest pain in particular, this happened in 7.7% of cases but was under triaged in 1.2% of cases. As a result, telephone triage systems need to be able to define the range of conditions that should be identified to ensure that patients receive appropriate care.
For the present study, the researchers used the Delphi approach, which represents a structured process for collection and extraction of information from experts over a series of 1 to 3 rounds, to achieve consensus on which life-threatening emergencies associated with chest pain require an immediate ambulance response. The researchers defined consensus as > 70% agreement. The team defined priority 1 as a life-threatening and time-critical condition that required immediate intervention or resuscitation and priority 2 which was an emergency that might require urgent assessment, intervention or transport.
A total of 15 participants including emergency doctors, nurses and paramedics completed the first round and 10 the third round. A total of 10 conditions met the consensus for requiring a priority 1 response after telephone triage which were: oesophageal perforation/rupture; ST elevation myocardial infarction; non-ST elevation myocardial infarction with clinical compromise; acute heart failure; cardiac tamponade; life-threatening asthma; cardiac arrest; tension pneumothorax and massive pulmonary embolism.
An additional six conditions, acute coronary syndrome, supra-ventricular tachycardia, abdominal aortic aneurysm, lower respiratory tract infection with respiratory compromise, pneumothorax, ventricular tachycardia with pulse, met the criteria for priority 2.
The authors concluded that based on these findings, the conditions could be used as a composite primary outcome in future research to derive and validate clinical prediction models to optimise telephone triage for patients with chest pain.
Alotaibi A et al. Towards enhanced telephone triage for chest pain: a Delphi study to define life-threatening conditions that must be identified BMC Emerg Med 2021