Advanced Nurse-Led Referral Versus ED Physician Referral to a Nurse-Led Chest Pain Clinic: Patient Outcomes

Background: The role of registered advanced nurse practitioner (RANP) in Ireland is in its infancy compared to the US. The SCAPE study ¹ recommended that future research focus on capturing specific clinical outcomes related to advanced nursing practice, however identifying the outcomes of advanced nursing practice is complex. Existing evidence shows similar outcomes for nurse practitioners and physician care in the US ² and better RANP radiological diagnostic skills in Ireland ³ yet there is a dearth of literature showing better outcomes of RANP led services to usual physician led care.

Internationally chest pain is a common presentation to Emergency Departments (ED), accounting for 5-10% of ED visits annually and a quarter of hospital admissions ⁴. Over 90% of chest pain presentations are unrelated to acute coronary syndromes (ACS) ⁵ with less standardised protocols and treatment for this group. An alternative nurse led chest pain service was set up to assess non-ACS chest pain patients presenting to the ED for possible stable coronary artery disease (SCAD). The service consists of two components i) advanced nurse-led consultation in the ED and ii) advanced nurse-led chest pain clinic review < 72 hours after discharge. The aim of the study was to compare patient outcomes post chest pain clinic review by referral type; Advanced nurse-led v ED Physician.

Methods: The study took place in a large tertiary level acute urban teaching hospital in Dublin, Ireland as a one site cross sectional study of patients attending the chest pain clinic over two years. Utilising an accelerated diagnostic protocol (ADP), referrals to the clinic were by the advanced cardiology nurse-led service during consult hours and out-of-hours by the ED physicians. Data was extracted from case notes and analysed using SPSS version 20. Ethical approval was given by the local research ethics committee.

Results: 1041 patients were referred to the nurse-led chest pain clinic, 45% by the nurse-led service. The nurse referred statistically significantly more patients who had; pre-existing vascular disease (24% vs 13%), positive exercise stress test (21% vs 12%), a final diagnosis of stable coronary artery disease (19% vs 11%), were older (56.5 yrs. vs 52.3 yrs.); and less patients with final diagnoses of musculoskeletal (5% vs 13%) and other non-cardiac pain (36% vs 45%) when compared to the ED physician referrals. This reflects appropriate patient selection following nursing-led assessment in the ED with a statistically significant diagnosis of coronary heart disease by the nurse-led service.

Conclusions: This study provides evidence of a successful alternate nurse led model utilising a cardiology advanced nurse practitioner-led service for patients who present to the emergency department with chest pain. It fills a gap in the literature regarding patient outcomes, directly comparing advanced nursing practice with the medical model, evidencing the effectiveness and clinical leadership of RANP led care.