Rural accelerated chest pain pathway signals the future for primary care

Ongoing use of the Pinnacle rural accelerated chest pain pathway by general practices in Te Manawa Taki (Midlands region) has highlighted how point of care (POC) testing in primary care can improve health equity in rural communities, and reduce hospital referrals to overloaded emergency departments.  

Developed during a Pinnacle-led research trial in 2018, the implementation of the pathway is an international first for POC cardiac testing.   

Using an ECG test and an i-STAT machine – a diagnostic POC troponin tool that produces cardiac enzyme results in 10-20 minutes, general practitioners can safely identify low-risk patients who can then be assessed and managed in their practice, instead of having to travel significant distances to hospital. That means considerable savings in time, stress and financial cost for patients, and the health system as a whole. 

The 2018 research, recently published in the British Medical Journal, showed use of the rural accelerated chest pain pathway assessment tool prevents unnecessary hospital referrals for 50 per cent of patients who present to rural practices with chest pain.  

Pinnacle medical director, Dr Jo Scott-Jones, says it’s a great example of what POC testing can do, and of the expanding role and responsibilities of general practice.   

“POC testing is going to grow more and more, and this is a good early illustration of that,” says Dr Jo. “The publication of the research confirms the significant benefits of general practices being able to provide a wider range of services to the community, and highlights the value of investment in those programmes.”  

Recognising those benefits and wanting to support continued implementation of the pathway, the Pinnacle Midlands Health Network (MHN) rural advisory group has recently purchased i-STAT POC testing machines for all practices involved in the original trial.   

Further support for the programme has also come from Te Whatu Ora Waikato, with a commitment to fund clinical time for cardiac POC testing in rural practices through the primary options programme. 

Coromandel GP, Dr Bryan MacLeod, welcomes the ongoing support for the pathway and recognition of the importance of POC testing services in primary care.  

Bryan operates the Coromandel Family Health Centre with his wife, Dr Sandy MacLeod, also a GP. It’s a small practice in the remote Coromandel Township where the nearest rural hospital is a hour-long hilly, winding drive away in Thames. The closest tertiary hospital, Waikato, requires a two and a half hour drive.   

The practice was part of the 2018 Pinnacle rural chest pain pathway research trial, and the team has continued to use the tool ever since. Bryan says it’s something that has been really valuable to the practice and their community.  

“It needs to be understood that there are significant barriers [for our patients] to get to an urban centre and the free public health services provided at a hospital,” says Bryan.   

“We are remote, and our community isn’t a high-income area – some people don’t have cars, or they aren’t able to drive. Travelling to hospital for investigation of chest pain ties up an already overburdened ambulance, and then there is the issue of getting home, which can be at all hours.”  

“Being able to offer as many services as we can here helps us as a practice to counteract that inequity.”  

He says the commitment Pinnacle MHN has shown to support the rural chest pain pathway project has been an important part of providing those much-needed services.   

“The amount of energy and resources Pinnacle has put towards it, along with the research to demonstrate this is a safe and effective pathway, is really valuable. It’s good medicine.” 

Dr Jo Scott-Jones says he wouldn’t be surprised if the pathway was funded at a national level in the future, especially given the changes to the health system and focus on equity.  

“Primary care in New Zealand is in a phase where things are changing quite rapidly in terms of the ‘tools of the trade’ and the need to provide more services than ever before,” says Jo.  

“The growth of POC testing means practices in the future will need to be trained in the use and interpretation of a lot more tests, and this is one of them.”   

He points to the recent point of care ultrasound (POCUS) initiative in Pinnacle rural practices, which has provided similar benefits to rural communities.  

“We’re trailblazing a bit now, but there’s no doubt these are the services we need to provide to improve health equity in rural areas and help ensure people are getting the same care across the country.”  

“Being able to do more for patients is really satisfying work, and keeping people out of hospital is a joy. Practices just need the system to recognise what they can do and to provide them with the resources to do it.”