To the Editor:

I read with the interest the editorial by E. Alegría and J. Bayón in the Revista Española de Cardiología1 in which they drew attention to the urgency of the implementation of chest pain units in Spanish hospitals, and I believe that some thoughts on the subject may be in order, before accepting a proposal that comes, once again, from a country that is socioeconomically very different from ours and with a health care organization that has little in common with ours.

In the Getafe University Hospital the coronary care unit is integrated into the cardiology service and a cardiologist on call, supported by a cardiology resident, is in the emergency room 24 hours a day. The service established its priorities so that if there is a reasonable diagnostic doubt, the patient can be admitted and a stress test can by performed within a maximum of 24 to 36 hours, following analysis of serum markers and monitoring if necessary. The transfer of a patient from the emergency room to the coronary care unit and from the latter to a general hospital floor does not require consultation or special transport. In this environment it is possible to establish a diagnosis and prognosis and plot a therapeutic program within a period of 24 to 48 hours. Is a chest pain unit necessary? And this hospital is not unique.

We are all thinking about the organization of many of our hospitals. The emergency room physician is disconnected from the cardiology service and is frequently not a cardiologist but an internist or an intensivist who attends the external emergency room. The transfer of a patient from the coronary care unit is difficult at times when the entire hospital is overloaded and this unit is dependent on a service other than the cardiology service. The performance of tests within the cardiology service is frequently isolated and departmentalized, so that the waiting period for a stress test or an echocardiogram depends on another «group» of cardiologists within the service and sometimes on a different service entirely, who may be occupied with their own their duties and work demands and have little to do with the other groups in the same service. Perhaps here indeed improvement could be made in the attention given to the coronary patient in a specific chest pain unit.

But once again we think of our healthcare history which, due to its recent development, contains lessons of interest. We have seen hospitals with organizational charts in which the hemodynamic laboratory, the coronary care unit, and even the testing groups are all separate services. At one time we looked for efficiency by separating large cardiology services into functional units of this or that type. The inefficacy of this line of thinking seems to have been accepted in light of the current tendency to group not only all the cardiological medical services, including the coronary care unit, but also the surgical units, into the cardiology service. And now we inaugurate a new chest pain unit, with specific ends, which without a doubt will create a group of professionals functioning autonomously. Alegría and Bayón point certainly out that only the enthusiasm of the professionals is behind the development of these units, and we should not forget that we are living out the ideas of other professionals, who are already mature, who initiated other changes, only to find themselves with the passing years frustrated by their isolation and the absence of growth perspectives.

I think that before declaring the creation of chest pain units in our hospitals indispensable, we should reflect on the organization of our cardiology services, analyze them and bravely recognize their defects, where there are defects, and restructure our priorities, centering our attention more on the clinical problems and less on the number of interventions performed or the development of sophisticated technology for its own sake. It would also not be a bad idea to study the hospital models in our country, where what some call a general problem does not seem to exist, in order to look for alternative solution that do not require new organizational complexities. The proper organization of work is a problem of the coordination of cardiologists and nursing staff in the face of real problems, and this is not solved well by the construction of new structures on bad foundations.