inspiration in luscii's world
‘‘Thousands of people end up in the emergency room, when a visit to the doctor is more appropriate”

Hospitals are full, emergency services are overrun and the ageing population has not yet reached its peak. How can we keep healthcare future-proof? Luscii lets the healthcare professionals who are part of the solution have their say. Today, we spoke to Rudolf Tolsma, a nurse specialist in emergency care. He is currently investigating whether the triage of people with chest pain can be moved from the emergency room to the home.

What is triage and why is it so important?

‘Chest pain is a very common reason for calling an ambulance. They are afraid of having a heart attack, but there is often another explanation, such as stress or muscle pain. On a yearly basis, thousands of people end up in the emergency room, when a visit to the doctor is more appropriate. This is frightening and stressful for patients. But emergency doctors and nurses are investing their precious time in those who don’t actually need their help. Triage means making distinctions, in this case between pain caused by heart damage and pain arising from a less serious origin. That is important for everyone involved’.

Is the triage complicated?

‘Not really. Many years ago, doctors in the Utrecht region developed an instrument, the HEART score, with which you can easily and reliably predict the likelihood that chest pain is caused by a heart condition. This involves listening to the complaints, assessing the heart recording, and we also take into account the patient’s age and risk factors, such as diabetes, obesity or a previous attack. Finally, we take blood samples and assess Troponin levels. Troponin is an enzyme that is released into the blood if there is oxygen damage to the heart’.

Then what is the problem? 

‘The HEART score works great in practice as a triage instrument. Only now, it happens at the emergency room because of the blood test. If there is a low risk, people can go home without a follow-up appointment. With a high risk, patients are admitted. In either case, everyone is taken to the emergency department. These days, the technology is so advanced that the blood test can be performed in the ambulance. Therefore, we are investigating whether ambulance paramedics can safely perform the triage at home with the help of the HEART score. Which would mean that a large group of people with a low risk would no longer need to go to the hospital’.

How are patients reacting? 

‘You have to be able to explain everything well as a paramedic. And I believe it is actually quite easy to do so. Remember that we used to leave people at home, but we did so based on clinical insight or feeling. The blood test is an additional means of proof. People are often terrified by the pain in their chest, but breathe a sigh of relief when the heart recording shows no abnormalities and the blood test is clear. Incidentally, during the study, we return three hours later to repeat the blood test for every patient. We are investigating whether there is a possibility that the troponin continues to increase after the first visit’.

What happens if the score indicates a low risk, but the paramedic does not trust it? 

‘The HEART score helps, but it is certainly not definitive. If you have a feeling that something is not quite right, then you should take the patient to the hospital to be sure. But paramedics are wise enough to make those decisions’. 

What are your plans after the study is completed?

‘After having worked for a while at the emergency department at Isala Hospital, I plan to return to the ambulance service. I have realised that my heart leans more towards pre-hospital care. The sector is changing enormously and I am involved in interesting research studies and projects. Although the challenges are great, I see beautiful things happening. In the control room, for example, previous choices were restricted to police, fire brigade or ambulance. Now there are projects where more is being done to improve care coordination. For example, there is also a doctor and someone from home care present within the control room. We are looking much more specifically at what is actually needed: an ambulance? A doctor? A district nurse? This is how we can hope to achieve the right care in the right place. The patient is always the main focus, and that is ultimately why we do what we do!’ 

Do you think that you, as a healthcare professional, are part of the solution, too? Then contact us and share your story on Luscii.com!