VCU HEALTH SYSTEM EMERGENCY DEPARTMENT GUIDELINE SUBJECT: Care of the Chest Pain Patient in the Emergency Department FILE SECTION: VCUHS/ED Section: Please note: Clinical Practice Guideline Evidence-based interventions related to a patient s diagnosis or condition that provides the basis for patient care. Clinical Practice Guidelines may be general or specialty-specific e.g. as generated by specialty organizations. REVIEWED/REVISED (HISTORICAL): Original date: 11/15 Last Date Reviewed: 1/16 PURPOSE: To establish a clinical guideline for the care of patients in the Emergency Department that present with chest pain or equivalent symptoms consistent with Acute Coronary Syndrome. DEFINITION(S): A. VCU HEART Score (Appendix B) Tool used to determine risk stratification of patient that presents with chest pain or symptoms consistent with Acute Coronary Syndrome. B. STEMI ST Elevated Myocardial Infarction. C. NSTEMI Non-ST Elevated Myocardial Infarction. D. Shared Decision Making (Appendix D) Tool designed to share the decisionmaking tasks about care between the patient and the medical provider. WHO CAN PERFORM: Physicians, Residents, Nurse Practitioner, Physicians Assistants, Nurses. GUIDELINE: A. Nurse Initiated Interventions: 1. Any patient that meets VCU Health MCV ECG Screening Guideline (Appendix A) criteria will have an ECG within 10 minutes of arrival. 2. Any patient that has an ECG performed in Triage based on VCU Health MCV Screening Guidelines that is interpreted as non-ischemic and patient Page 1 of 8
is not placed immediately in a treatment area, will have a Troponin I, CBC w/diff, and BMP drawn in triage per Triage Standing Protocol orders. (Appendix B) B. Risk Stratification 1. All patients that meet ACS Screening Guideline criteria will be assessed and have a VCU HEART score (Appendix C) calculated by the Physician, Nurse Practitioner, or Physician Assistant. 2. The calculated VCU HEART score will assign the patient into one of the following risk categories: Low Risk (VCU HEART 0-3), Moderate Risk (VCU HEART 4-6), or High Risk (VCU HEART 7-10). 3. When appropriate, the medical provider will follow the established guidelines for each risk category. C. Guideline for Risk Stratification Care 1. Low Risk Cardiopulmonary Chest Pain (VCU HEART Score 0-3) a. If the patient is experiencing chest pain that could be consistent with a cardiopulmonary process a screening ECG should be performed and a baseline Troponin I performed. If there is any change in clinical condition a repeat ECG should be performed immediately. b. Patients <40y old should receive a 3-hour repeat ECG and Troponin I. Those with a non-ischemic ECG, normal second Troponin I (both values 0.06 ng/ml), and VCU HEART score 3 can safely be discharged home. 1.) If the patient <40y old and the second Troponin I is >0.06ng/ml but the delta value Troponin I <0.05ng/ml the patient should have shared decision making (Appendix D). c. Patients >40y old should receive a 3-hour repeat ECG and Troponin I. Those with a normal, non-specific or unchanged from prior ECG and Delta Troponin is <0.05ng/ml, they then should have shared decision making offering close follow up as outpatient versus CDU for stress. d. Prescribing of Aspirin on discharge should be considered for patients that have a VCU HEART score of > 3. 2. Moderate Risk Cardiopulmonary Chest Pain (VCU HEART Score 4-6) a. Patients with moderate risk should receive a screening ECG and baseline Troponin I. If the ECG is non-ischemic and Troponin I is
<0.06 ng/ml, the patient should be admitted to the CDU for serial testing and same day stress. 1.) If the patients baseline trop >0.06ng/ml then a delta troponin should be performed. If the Delta Troponin <0.05ng/ml, patient should be observed in the CDU. If the Delta Troponin >0.05ng/ml patient should be admitted to the hospital for further management. 2.) In the CDU a 6-hr Troponin I should be performed, and Cardiology consult and stress testing should be considered. 3. High Risk Cardiopulmonary Chest Pain (VCU HEART Score 7-10) a. Patients at high risk should receive a screening ECG and Troponin I. If the ECG is non-ischemic and Delta Troponin is < 0.05 ng/ml, the patient should be admitted for further management. 4. NSTEMI 5. STEMI a. Patient with ischemic ST depression and ongoing symptoms should be admitted to CICU. b. Patient with non-ischemic ECG and an increasing Troponin I (>0.05ng/ml) should be evaluated for admission to CICU versus Cardiology service. c. Patient with clearly elevated Troponin I (>0.2ng/ml) and recent or ongoing chest pain should be evaluated for admission to CICU versus Cardiology service. a. Patient with STEMI should be Alpha alerted immediately upon recognition. GUIDELINE AUTHOR(S): Emergency Department Leadership/Operations Emergency Department Nurse Practice Council Director of Emergent Cardiac Care STAKEHOLDER REVIEWERS and APPROVAL: Authors, Chief of Emergency Medicine, Operations, Director of Emergency Nursing, Nurse Practice Procedure Council [NPPC]. RESPONSIBILITY: It is the responsibility of Authors, Stakeholders, QA Coordinator and Practice Council members, to implement, maintain, evaluate, review and revise this policy.
SIGNATURES: Chief of Emergency Medicine, Operations Director of Emergency Nursing Nurse Clinician, Emergency Department Division Practice Committee Chair Adult Date Date Date Date
Appendix A ECG Screening Guidelines for Emergency Department Clinical Staff
Appendix B
Appendix C VCU HEART SCORE History Highly Suspicious 2 Moderately Suspicious 1 Low Suspicion 0 ECG Abnormal** 2 Nonspecific Changes 1 Normal* 0 AGE >65 2 40-65 1 <40 0 Risk Factors >3 risk factors or known CAD 2 1-2 risk factors 1 No risk factors 0 Troponin > 0.15 2 0.07-0.14 1 0.06 0 * ECG unchanged from previous ECG should be score as Normal **Abnormal ECG paced, bundle branch block, LVH with ST, T changes
Appendix D Shared Decision Making Tool