Download 09/27/16 - Lincoln Medical and Mental Health Center

Department of Emergency Medicine
Division of ED Critical Care
Pathway for the Screening and Care of Chest Pain Patients
Purpose: To help guide healthcare providers decision to appropriately screen, identify and
initiate early treatment of patients presenting to the Emergency Department for chest pain.
*This pathway was developed by the Department of Emergency Medicine and Division of Cardiology.
Process:
I.
Initial screening
a. Patients presenting to the Emergency Department with complaints of chest pain
will have an EKG performed at triage.
b. If the patient presents to external triage, the EKG will be presented to the provider
in triage (PIT)- during operating hours- or to the Blue or Green Team Attending
(in an alternating fashion) when PIT is not operating.
c. If the patient presents by EMS to internal triage, the EKG will be presented to the
Red Team ED Attending or the Senior Resident.
d. The EKG should be signed, timed and dated by the ED Attending Physician or
Senior Resident.
II.
ACS Level 1a (PCI indicated)
a. For patients found to have an STEMI on initial EKG screening, Team STEMI
should be called overhead.
b. The patient should be brought into the Medical Resuscitation Room and 3 IV
lines should be placed.
c. The transfer process should be initiated immediately by having one of the
Residents assigned to call the transfer center (844-HHC-Beds).
d. The EKG should be transmitted to the corresponding Cardiology Service and case
discussed for treatment recommendations.
e. At 25 minutes, if the patient is still in the ED, initiate thrombolysis if no contraindications. If on repeat EKG after TNK the STEMI not resolving after bolus,
continue with transfer.
f. Complete transfer form (attached) and send patient to designated PCI center for
rescue PCI.
III.
ACS Level 1b (PCI is contra-indicated)
a. For patients found to have an STEMI on initial EKG screening, Team STEMI
should be called overhead.
b. The patient should be brought into the Medical Resuscitation Room and 3 IV
lines should be placed.
c. The EKG should be transmitted to the Lincoln Cardiology Service and case
discussed for treatment recommendations.
d. Initiate thrombolysis if no contra-indications before 30 minutes with TNK.
e. Patients should be admitted to the CCU.
IV.
ACS Level 1c (Non-emergent transfers)
a. For patients found to have an STEMI on initial EKG screening, Team STEMI
should be called overhead.
b. The patient should be brought into the Medical Resuscitation Room and 3 IV
lines should be placed.
c. The transfer process should be initiated immediately by having one of the
Residents assigned to call the transfer center (844-HHC-Beds).
d. The EKG should be transmitted to the corresponding Cardiology Service and case
discussed for treatment recommendations.
e. At 25 minutes, if the patient is still in the ED, initiate thrombolysis if no contraindications. If STEMI is resolving, the patient may not need to be transferred
emergently.
f. Patient should be admitted to the CCU for transfer at 24-48 hours for nonemergent PCI.
V.
ACS Level 2
a. For patients found to have Non-STEMI or unstable angina (UA), these patients
should be risked stratified by “Thrombolysis In Myocardial Infarction” (TIMI)
score (see attachment 1).
b. Patients with a TIMI score > 4 are classified as ACS Level 2a and should receive
an ICU consult, admitted and considered for non-emergent transfer. If transferred
the admitting team will perform the necessary call and paperwork.
c. Patients with a TIMI score <4 will be classified as ACS Level 2b and should be
admitted to the telemetry service.
d. All ACS 2 patients should receive:
i. In the ED:
1. Aspirin 325 mg
2. Plavix 600 mg
3. Lovenox (weight based)-unless patient is a candidate for PCI
4. Nitrates (SL or Nitropaste)- if non-inferior wall MI
5. Morphine
6. Oxygen in the setting of hypoxia
ii. In the Unit/floors within 24 hours:
1. Beta-blocker
2. Oral ACE-inhibitor (if not hypotensive)
3. HMG-coA reductase inhibitor
e. **Patients may be considered for emergent transfer if they meet one of the
following AHA-ACC criteria for emergent transfer (within 2 hours of arrival):
i. Signs or symptoms of heart failure or new or worsening mitral
regurgitation on initial presentation
ii. Hemodynamic instability at initial presentation
iii. Sustained VT or VF at initial presentation
VI.
ACS Level 3
a. For patients with normal or non-diagnostic EKG and/or atypical chest pain
without alternative explanation, these patients should be risked stratified by the
HEART score (see attachment 2) and have 4 hour repeat troponins.
b. Patients classified as high risk should be treated as ACS level 2, risk stratified by
TIMI, admitted based on stratification and started in the ED on:
1. Aspirin 325 mg
2. Nitrates (SL or NTP) or Morphine for pain
3. Oxygen in the setting of hypoxia
c. Patients classified as moderate risk should be scheduled for an ED exercise
stress test (Tests times Monday- Friday 9AM to 3 PM). Please see appendix for
ED Stress test Process. **Note: The ED provider should call the Cards PA PRIOR
to ordering the test to confirm a testing spot is open and the case is appropriate.
i. Stress test positive- admit to telemetry and started on:
1. Aspirin 325 mg
2. Nitrates (SL or NTP) or Morphine for pain
3. Oxygen in the setting of hypoxia
ii. If unable to perform ED exercise stress test the patient should be admitted
and started on:
1. Aspirin 325 mg
2. Nitrates (SL or NTP) or Morphine for pain
3. Oxygen in the setting of hypoxia
iii. If ED exercise stress test is negative the patient can be discharged with 4
week Medicine follow up.
d. Patients classified as low risk should have a repeat troponin at 4 hours.
i. If repeat Troponin is positive, follow ACS level 2 pathway
ii. If repeat Troponin is negative, the patient may be discharged home with
4 week Medicine follow up.
Attachment 1: TIMI score for 30 day mortality in patients with NSTEMI/UA
TIMI Risk Score for UA/NSTEMI
Age > 65
1
> 3 CAD Risk Factors
(FH, HTN, HLD, DM, active smoker)
1
Known CAD (stenosis > 50%)
1
ASA use in the past 7 days
1
Recent (< 24 hr) severe angina
1
Elevated cardiac markers
1
ST deviation > 0.5 mm
1
Attachment 2: HEART Score for major adverse cardiac events (within 6 weeks of ED visit)
History
ECG
Age
Highly suspicious
2
Moderately suspicious
1
Slightly suspicious
0
Significant ST-depression
2
Non specific repolarisation disturbance
1
Normal
0
≥ 65 years
2
45 – 65 years
1
≤ 45 years
0
≥ 3 risk factors or history of atherosclerotic disease 2
Risk Factors 1 or 2 risk factors
Troponin
1
No risk factors known
0
≥ 3x normal limit
2
1 – 3x normal limit
1
New York City STEMI Transfer Form
From: __________________________________ To: ___________________________________
(Non-PCI Hospital)
(PCI Hospital)
This document provides a framework for care and triage of patients from non-PCI hospitals to PCI hospitals.
It represents recommendations and each facility may individualize to optimize patient care.
Patient Information and Times
*Door-In-Door Out Goal is less than 30 minutes. Do not sacrifice DIDO for paperwork!*
Date (mm/dd/yy): __________________________
Symptom onset time (hh:mm):
_________________
ED Arrival Date & Time: _____________________
Mode of Arrival to ED:
________________________
*If Mode of Arrival = EMS, Mobile, ICU, or Air
* FMC Date & Time: ________________________
Call for Transport
Date & Time: _______________
ECG Date & Time:
____________________________
Transport Arrival
Transport Departure
Date & Time:
Date & Time: ____________
_________________
Pertinent Medical History: □ Previous Stent □ CABG Other:___________________ Allergies:
_____________________
Vital Signs (at FMC):
BP
HR
SaO2
Patient Wt (llbs):
__________
__________
____________
_____________
Did patient suffer any of the following?
Heart Failure? □ Yes □ No
Cocaine Use? □ Yes □ No
If yes, Date & Time_________________________
If yes, Date & Time: ________________________
Cardiogenic Shock? □ Yes □ No
Cardiac Arrest req. Defib? □ Yes □ No
If yes, Date & Time: _______________________
If yes, Date & Time: ________________________
Is the patient taking/receiving any of the following:
□ Apixaban (Eliquis) □ Dabigatran (Pradaxe) □ Rivaroxaban (Xarelto) □ Warfarin (Coumadin)
□ Prasugrel (Effient) □ Clopidogrel (Plavix) □ Ticagrelor (Brillinta)
Medication and Times Administered
□ ASA 325mg PO ( __________mg, if different)
Date/Time: ____________________________
□ Heparin IV Bolus 5000U, no max ( __________U,
if different) Date/Time: _______________
Prepare Patient For Rapid Transfer
□ Avoid or minimize any continuous IV infusions
□ Remove clothing, place patient in gown
□ Prep patient & family for rapid handoff to
transfer staff
□ Clopidogrel 600mg PO ( __________mg, if
different) Date/Time: ______________________
Have paperwork ready for transfer:
□ Copy of Diagnostic EKG □ STEMI Transfer Sheet
□ EMTALA or other Transportation Forms
To Be Completed by Interfacility Transfer Agency
Transfer Agency: _____________________________________________________________________
Additional Medications Administered: ___________________________________________________
Major Change in Hemodynamic Status or Arrhythmia: ______________________________________
References:
HEART Score:
1. Backus, B E, A J Six, J C Kelder, M A R Bosschaert, E G Mast, A Mosterd, R F
Veldkamp, et al. 2013. A prospective validation of the HEART score for chest pain
patients at the emergency department. International journal of cardiology, no. 3 (March
7). doi:10.1016/j.ijcard.2013.01.255.
2. Backus, B E, A J Six, J H Kelder, W B Gibler, F L Moll, and P A Doevendans. 2011.
Risk scores for patients with chest pain: evaluation in the emergency department. Current
cardiology reviews, no. 1. doi:10.2174/157340311795677662.
3. Six, A J, B E Backus, and J C Kelder. 2008. Chest pain in the emergency room: value of
the HEART score. Netherlands heart journal : monthly journal of the Netherlands
Society of Cardiology and the Netherlands Heart Foundation, no. 6.
TIMI Score:
1. Antman EM, Cohen M, et. al. The TIMI risk score for unstable angina/non-ST elevation
MI: A method for prognostication and therapeutic decision making. JAMA. 2000 Aug
16;284(7):835-42.
2. Charles V. Pollack Jr., MA, MD, Frank D. Sites, RN, Frances S. Shofer, PhD,
Keara L. Sease, MAEd, Judd E. Hollander, MD. Application of the TIMI Risk Score for
Unstable Angina and Non-ST Elevation Acute Coronary Syndrome to an Unselected
Emergency Department Chest Pain Population. Society of American Emergency
Medicine. doi: 10.1197/j.aem.2005.06.031
Appendix:
Process for ordering an ED Stress Test:
1) Please call ext. 4876 or 4868 to discuss the case with the Cards PA first.
2) If appropriate candidate for ED cardiac stress testing place order by using search term
“cardiac” and selecting Cardiac exercise stress test (see below):
3) Fill out the required fields (please indicate HEART score in indication field).
4) The ED provider will fill out a ED Stress test card (to include date, MRN, HEART
score) and give it to the ED Clerk who will log the case into the ED Stress Test excel
file and whether or not testing is available.
5) The Cardiologist will interpret the findings and a note will be placed in Quadramed
by the interpreting cardiologist with recommendations.