Implementation of Rapid Response Flow Reduces the Waiting Time of Patients with Chest Pain in an Emergency Unit

Chest Pain (CP) corresponds to one of the most frequent symptoms in the emergency units worldwide and represents a great challenge for all the professionals who work in emergency care services, considering the multiplicity of possible diagnoses and the fluctuation between situations of low and high risk, requiring the emergencista an additional ability to diagnose fast and direct a specific and safe therapy for each case [1-6]. The traditional approach to patients in emergency units in Brazil follows the severity screening approach proposed by the Manchester protocol [7] which, in many cases, may underestimate the severity of the patient with CP, a fact due to the variation in intensity of presentation clinic of severe patients as occurs in acute coronary syndrome. The implementation of a flow directed to CP approach allows to identify and optimize care in severe patients in a fast way, making the approach safer for patients and medical staff.


Introduction
Chest Pain (CP) corresponds to one of the most frequent symptoms in the emergency units worldwide and represents a great challenge for all the professionals who work in emergency care services, considering the multiplicity of possible diagnoses and the fluctuation between situations of low and high risk, requiring the emergencista an additional ability to diagnose fast and direct a specific and safe therapy for each case [1][2][3][4][5][6]. The traditional approach to patients in emergency units in Brazil follows the severity screening approach proposed by the Manchester protocol [7] which, in many cases, may underestimate the severity of the patient with CP, a fact due to the variation in intensity of presentation clinic of severe patients as occurs in acute coronary syndrome. The implementation of a flow directed to CP approach allows to identify and optimize care in severe patients in a fast way, making the approach safer for patients and medical staff.
The insertion of protocols and the training process of the team have a direct repercussion in accelerating arrival times, diagnosis, treatment and therefore in reducing the risks of the patient with CP [8,9]. Some indexes guide the measurement of the delay time and, consequently, the efficacy in the evaluation of a patient with CP, among them, door-to-ECG time, a measure that evaluates the time between the patient's arrival at the hospital reception to the filling of the recording protocol until the first electrocardiogram (ECG) was performed [9][10][11][12]. The door-to-ECG time considered ideal is 10 minutes, a real agility challenge for the teams of an emergency unit. [13,14] The objective of the study was to implement a protocol with a rapid care flow at the entrance of patients with CP within the emergency unit.

Method
Place of study -The study was conducted at the Emergency and Cardiology Unit of the University Hospital of Vassouras-RJ, state of Rio de Janeiro, Brazil, approved by the Ethics and Research Committee, under the approval number (1.843.401).Study design -The patient with CP, once identified by the hospital's reception team, did not use the traditional risk screening route according to the Manchester protocol [7], his card received a stamp of Thoracic Pain with the message for rapid care. The nurse responsible for the triage, upon receiving the patient's file at hand, brought by the receptionist, immediately took the patient to the electrocardiogram room. The ECG was then performed by a medical technician or student, who was then delivered immediately to the physician for evaluation of the case, ignoring the natural order of arrival sequence. Purposely, the physician was placed in the last stage of the flow, once belonging to him one of the traditional points of delay resulting from the sequential patient care in order of arrival.
Door-to-ECG time -To measure door-to-ECG time, the hospital electronic cadastre system was used, which provided information about the patient's time of entry into the hospital as well as the time of ECG recording. The times before and after the new flow of care and training of the emergency team were verified.Statistics -Initially the normal distribution of the data was verified through the Kolmogorov-Smirnov test. Afterwards, a possible statistical difference was verified through the paired t-test of Student with post-test of Tukey. Data were expressed as mean ± standard deviation of the mean and a significant p value <0.05 was considered. We analyzed 199 medical newsletters of which 105 patients under the traditional flow and 94 under the rapid flow of care.It was verified that the average time between the arrival of the patient with CP in the emergency of the University Hospital of Vassouras-RJ until being submitted to the ECG was of 63 minutes using the traditional flow, being that in the day period this time was of 65 minutes and in the nocturnal period of 59 minutes, all times above recommended. After the training of the multidisciplinary team, 94 newsletters were checked and a significant reduction in ECG time was observed for 23.31 minutes in all shifts, a general reduction of ( Figure 1) 63% (p <0.001), daytime decreased by 61% (p <0.001) and the nocturnal period decreased by 63% (p <0.001).

Discussion
The door-to-ECG time is responsible for 25% of delays in the institution of fibrinolytic therapy or primary angioplasty in patients with CP due to acute myocardial infarction [15,16] which is why it is considered an important item of qualification and optimization of the teams within the units of emergency; target to be pursued when seeking the excellence in the service of CP. According to Missagliaet al. [17] the application of the flow protocol in the approach of the CP in an emergency unit, streamlines and directs the patient care, shortening the time of recognition of the origin of the CP, optimizing the insertion of a suitable therapy, with consequent immediate impact in the mortality of these patients in the first 12 hours of care.
The traditional inflow of the patient with chest pain: reception, risk screening and waiting for medical attention, according to the Manchester protocol, only to perform the ECG, was changed at the University Hospital of Vassouras-RJ for the use of a protocol with a faster inflow, which resulted in a positive impact on the optimization and search for the reduction of door-to-ECG time, with a mean decrease of 63% in time between hospital admission and the first electrocardiogram (ECG). Phelan MP et al. [18] also observed a decrease in door-to-ECG time in 72 patients with infarction, reduction of 21.3 minutes pre-insertion of rapid protocol to 9.5 minutes in the subsequent phase, 55% decrease in door-to-ECG time obtained with the training of a new patient input flow. Another study documented a drop of 10 to 6.3 minutes, a 63% shortening in door-to-ECG time [19,20]. Therefore, although still far from the ideal goal of 10 minutes according to the protocols of the American College of Cardiology [14], the shortening of the ECG time lag reached in the University Hospital of Vassouras-RJ was the result of the multidisciplinary training of the team in constructing and applying a new path of arrival for the patient with CP, making access, diagnosis and therapy faster, promoting safety and risk minimization to patients and also to the medical team [21][22][23].

Conclusion
The insertion of a rapid inflow into the emergency room resulted in a significant reduction in door-to-ECG time, minimizing the initial delay in the diagnosis and, consequently, optimizing a faster therapeutic approach that mainly benefits CP patients with high risk. New flows with fast input must be tested for optimization in patient approach with CP. The characteristics pertinent to each emergency service and the participation of the multidisciplinary team, should be taken into account in the construction of a new flow design.