Title: Document Number: Document Type: Affected Departments: Review Bodies: Revision/(Review) Dates: (Dates that included only a review, but no content 07/14 revision, are in parentheses) Effective Date: 08/14 Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department NURS-ED-53 Policy, Procedure Emergency Department (ED), Catheterization Lab (Cath Lab) Position or Committee BHS Regional Chest Pain Steering Committee (Owning body) Date Review Completed 08/14 BHS Cardiovascular Service Line 09/14 BHS ED Service Line 08/14 SUMMARY OF ATTACHMENTS: Associated Policies/Procedures: Nursing Care Protocols Guidelines for the Emergency Department, NURS-ED-23 Patient Transfer, RM-EMTALA-01 Other Associated Document(s): Heart Alert Audit Tool, Attachment A IMPACT Protocol, Attachment B STEMI Walk-In/EMS Pathway, Attachment C Transfer Process for MTB, Attachment D Risk Stratification, Attachment E ACS Clinical Pathways, Attachment F Associated Form(s): EMS Prehospital ECG/Rhythm Strip, BHS-MR 90508802 Thrombolytic Orders for STEMI, BHS Orders Set #CA-CL08 CDU: Chest Pain Possible ACS, BHS-CD-CA03 AMI Admission Orders, CM-BH01 APPROVED BY: Approval Body Name Authentication Date (Position or Committee) Quality & Patient Safety Steering Meeting Minutes & 08/14 Committee Digital Signatures Medical Executive Board Meeting Minutes 09/14 Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 1 of 14
I. PURPOSE II. To define and outline the process of an Emergency Department (ED) ACS and Heart Alert patient from first medical contact to percutaneous coronary intervention (PCI). DEFINITION(S) A. Heart Alert Heart Alert is the notification process that triggers a rapid chain of events leading to the activation of the Cardiac Catheterization Lab (Cath Lab) team and the interventional cardiologist on-call to the Cath Lab for acute treatment of a patient with symptoms of an ST-segment elevation myocardial infarction (STEMI) or new left bundle branch block (LBBB). The treating Cardiologist will determine the appropriate treatment of patients with new or presumed new LBBB and possible Acute Coronary Syndrome. Heart Alert is designed to shorten the door to PCI times (D2B) and heighten awareness using a single paging system and calling Interventional Cardiology. B. ST-segment Elevation Myocardial Infarction (STEMI) STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic (ECG) diagnostic ST elevation (at the J point in at least 2 contiguous leads of _2 mm (0.2 mv) in men or _1.5 mm (0.15 mv) in women in leads V2 V3 and/or of _1 mm (0.1 mv) in other contiguous chest leads or the limb leads) and subsequent release of biomarkers of myocardial necrosis. New or presumably new Left Bundle Branch Block (LBBB) has been considered a STEMI equivalent (ACCF/AHA, 2013). C. Percutaneous Coronary Intervention (PCI) Percutaneous Coronary Intervention (PCI) is a non-surgical, minimally invasive procedure that uses a catheter (a thin flexible tube) inserted into a blood vessel either in the leg or arm to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup, a condition known as atherosclerosis. D. Early Risk Assessment For admitted patients, risk stratification is done after exclusion of STEMI/New LBBB and other non-cardiac diagnoses. Stratification is based on history, physical exam, ECG, lab and x-ray as determined by the treating physician. A variety of tools such as TIMI, Braunwald, and Grace criteria have been used to measure risk of mortality and recurrent cardiac events. However, in the Emergency Department the decision to admit or discharge a patient should be based on clinical judgment since these criteria have not been shown to be superior to physician judgment. Risk stratification of admitted patients may guide additional therapies as an inpatient. E. First Medical Contact The point at which the patient is either initially assessed by EMS or other medical personnel in the pre-hospital setting or the patient arrives at the hospital s emergency department. Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 2 of 14
III. IV. POLICY The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) Task Force on Practice Guidelines recommend a Regional Systems of STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals to enable rapid recognition and timely reperfusion of patients with STEMI. System delays to reperfusion are correlated with higher rates of mortality and morbidity. The Southwest Regional Advisory Council (STRAC) formed a Regional Cardiac Systems Committee in January 2008 to develop a cooperative and regional approach to STEMI care. The Baptist Health System worked with other members of the healthcare community to develop the HEART ALERT activation system to enable rapid recognition and timely reperfusion of patients with STEMI. PROCEDURE A. EMS Pre-hospital to Cath Lab Patients arriving to the ED via EMS. 1. Pre-hospital Work Up a. EMS completes a 12-lead ECG in the field to identify a STEMI or new LBBB. 2. ED Notification a. After a STEMI or new LBBB is identified, the 12-lead ECG is transmitted to the ED s ECG receiving station where it is reviewed by the ED physician and/or ED nurse. b. If EMS is unable to transmit the ECG or the ECG receiving station is inoperable, EMS will relay his/her findings to ED staff via the EMS phone or radio. Additionally EMS will provide a detailed assessment of the 12-lead ECG to include the computer derived interpretation and a description of the leads with ST segment elevation. 3. Activation of Heart Alert a. Based on the pre-hospital 12-Lead ECG and the EMS report of Heart Alert, the ED Physician and/or ED nurse will activate a Heart Alert prior to the patient s arrival using a single paging system and calling Interventional Cardiology (see below and STEMI Walk-In/EMS Pathway Flowchart (Attachment C)). b. Initiating a BHS Heart Alert includes calling the on-call Interventionalist and activating the Cath Lab team using a single page system. Nursing directors, house officer, and administration will also be notified with paging system. c. The pre-hospital ECG s are mounted on BHS Pre-Hospital ECG/Rhythm Strip mounting sheet. The pre-hospital ECG is given to the ED physician (goal less than 10 minutes) who will generate a written record of their interpretation and place in patient s permanent medical record. d. Reference to STEMI Walk-In/EMS Pathway Flowchart (Attachment C). 4. Patient Preparation a. The ED staff will initiate the IMPACT protocol (Attachment B). Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 3 of 14
5. Transport to the Cath Lab a. Once the Cath Lab team arrives the patient is transported to the Cath Lab by ED personnel and/or Cath Lab team. b. Verbal report providing pertinent information and the ED chart; medication reconciliation, heart alert audit tool, original ECG, ED nursing documentation, ED physician documentation is given to the Cath Lab team. B. ED Walk-in to Cath Lab Patients presenting to the ED with signs or symptoms of acute coronary syndrome, not arriving by EMS. 1. Triage a. The patient is initially greeted by a Registered Nurse or an employee who has had annual formal training in ACS signs and symptoms. 2. ED Work-up a. The triage nurse will ensure a 12-lead ECG is completed as soon as possible upon identifying the chief complaint of Chest Pain or ACS symptoms. (Goal: less than five minutes from time of arrival). b. The ED Physician will review the ECG for evidence of STEMI and sign the ECG. The triage nurse triages the patient based on standard Emergency Severity Index (ESI) guidelines. (Goal: less than 10 minutes) c. After the ECG is performed, patient will be transferred from triage to an Emergency Department room if bed available. If no bed available chest pain protocols will be initiated per BHS Nursing Care Protocols Guidelines for the Emergency Department, NURS-ED-23. 3. Activation of Heart Alert a. Based on the 12-lead ECG, the ED physician will activate a Heart Alert using a single paging system and calling Interventional Cardiology for a STEMI or presumed new LBBB. b. Initiating a BHS Heart Alert includes calling the on-call Interventionalist and activating the Cath Lab team using a single page system. Nursing directors, house officer, and administration will also be notified with paging system. 4. Patient Preparation a. The ED staff will initiate the IMPACT protocol (Attachment B). 5. Transport to the Cath Lab a. Once the Cath Lab team arrives the patient is transported to the Cath Lab by ED personnel and/or Cath Lab team. b. Verbal report providing pertinent information and the ED chart; medication reconciliation, heart alert audit tool, original ECG, ED nursing documentation, ED physician documentation is given to the Cath Lab team. 6. Reference STEMI Walk-In/EMS Pathway Flowchart (Attachment C). Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 4 of 14
C. Thrombolytic Therapy 1. In some patients with identified STEMI the ED physician may decide the patient would benefit from Thrombolytic therapy if PCI will be delayed. For example, a patient in the first 120 minutes of symptoms where there will be greater than a 90 minute delay in PCI may do better if given thrombolytic. Refer to BHS Thrombolytic Orders for STEMI. D. Mission Trail Baptist Hospital Transfer Process 1. Mission Trails Baptist hospital does not perform heart catheterizations for acute treatment. If the patient presents with STEMI or presumed new LBBB, a heart alert is paged alerting Baptist Medical Center Cath Lab and the interventional cardiologist is notified. 2. Following the BHS Patient Transfer Policy, RM-EMTALA-01, the patient is transferred to Baptist Medical Center Cath Lab by EMS (Attachment D). 3. See Attachment D for transfer process flowchart. E. Risk Stratification Guide 1. Risk stratification is done for admitted patients using the guide after exclusion of STEMI/New LBBB and other non-cardiac diagnoses (Attachment E). Consider utilization of the BHS Low Risk Chest Pain Orders (order number) for low risk patients or BHS Admission Orders Acute MI (order number) for non-low risk patients. 2. Patient s being admitted will be admitted to a cardiac monitoring unit. 3. Nursing handoff per BHS Hand-Off Communication, RM-PS-04, with original ECG accompanying the patient and an additional copy scanned into the medical record. 4. Reference BHS ACS Clinical Pathways flowchart (Attachment F). V. REFERENCES American Heart Association. (2013). ACCF/AHA practice guideline. Circulation, 127, e663-e828. doi: 10.1161/CIR.0b013e31828478ac. Retrieved from: http://circ.ahajournals.org/content/127/23/e663.full Hess, E. (2012). Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: A meta-analysis. Canadian Medical Association Journal, 182(10), 1039-1044. doi: 10.1503/cmaj.092119 Manini, A., Dannemann, N., Brown D., Butler, J., Nagurney, J., et al. (2009). Limitations of risk score models in patients with acute chest pain. American Journal of Emergency Medicine, 27(1), 42-48. doi: 10.1016/j.ajem/2008.01.022 Meyer, M., Mooney, R., & Sekera, A. (2006). A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: Role of outpatient stress testing. Annals of Emergency Medicine, 47(5). doi: 10.1016/j.annemergmed.2005.10.010 Norekyl, T., Lindahl, B., Hasin, Y., McLean, S., Tubaro, M., & et al. (2012). Pre-hospital treatment of STEMI patients: A scientific statement of the working group acute care of the European society of cardiology. Acute Cardiology Care, 13, 56-67. Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 5 of 14
O Gara, P., Kushner, F., Ascheim, D., Casey, D., Chung, M., & et al. (2013). 2013 ACCF/AHA Guideline for the management of ST-evelation myocardial infarction: Executive summary. Journal of the American College of Cardiology, 61(4), 485-510. doi: 10.1016/j.jacc.2012.11.018 Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 6 of 14
Heart Alert Audit Tool Attachment A Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 7 of 14
IMPACT Protocol Attachment B The IMPACT protocol was designed to expedite STEMI care in the ED while the Heart Alert team is in route to the facility. IMPACT is an acronym for the following: 1. Identify and consent the patient (if applicable) 2. Medicate the patient. Communicate with the physician(s) regarding the patient s medication needs (example: ASA, pain medication, heparin, beta blockers, etc.). Remember, the key is good communication 3. Pads. Use radiolucent defibrillator pads (white leads). Place one pad on the right back and the other on the left side. 4. Access X 2. Please provide two (2) IV access points. Draw labs/cardiac biomarkers. 5. Clip (both sides of groin). Trim from the groin to just above the knee. Electric clipper only. 6. Transport on monitor with defibrillator/external pacing capability. Assist Cath Lab staff with transporting the patient to the Cath lab and transferring the patient to the procedure table. Assist with lead, BP monitor, O2, and SPO2 placement. When applicable, assist family members to the waiting area. Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 8 of 14
Baptist Health System STEMI WALK-IN/EMS PATHWAY Attachment C Walk-in RN Triage EMS- transmits ECG via LifeNet - call ED to activate Heart Alert. If unable to transmit ECG- call ED & activate Heart Alert identified by EMS provider. Signs & Symptoms of Acute Coronary Syndrome Perform ECG Interpret for STEMI, signed & placed on chart with Goal within 10 minutes. STEMI YES Initiate HEART ALERT utilizing one-call system ED physician calls report to Interventional Cardiologist NO Initiate BHS Nursing Care Protocols Guidelines for the Emergency Department, NURS-ED-23. IMPACT PROTOCOL ED Physician Evaluation RISK STRATIFICATION (ACS Clinical Pathways, Attachment F) To Cath Lab for Invasive Intervention Clinical pathways never replace judgment. Care outlines in the pathway must be altered if it is not clinically appropriate for the individual patient. Timing of referral to cardiology/medical may vary for local circumstances. Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 9 of 14
Transfer Process for Mission Trails Baptist Attachment D ED Physician decides Thrombolysis may be preferable to transport in select patients Thrombolysis Order Set Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 10 of 14
Risk Stratification Attachment E Risk Stratification for Likelihood of Acute Coronary Syndrome and Short Term morbidity/mortality For Admitted patients after exclusion of STEMI/New LBBB and other non-cardiac diagnoses. Stratification based on history, physical exam, ECG, lab and x-ray as determined by the treating physician. This is a guide, but not a substitute for clinical judgment, which in multiple studies has been found to be equivalent or better than scoring tools. High Risk any of the following (suggest use of appropriate ACS physician order set) Known Medical history of Coronary Artery Disease, MI, or Revascularization. Chest or Left arm pain similar to prior symptom of angina or MI Elevated cardiac troponin Hypotension OR pulmonary edema on presentation New (or presumed new) ST deviation ( 0.5 mm) New (or presumed new) T-wave inversion (>1mm or in multiple precordial leads) New RBBB Ventricular tachycardia Moderate Risk (suggest use of appropriate ACS physician order set) Chest or Left arm pain or discomfort as chief symptom (do not mark if clearly chest wall pain, GERD or pleuritic in nature) Diabetes Extracardiac vascular disease (CVA, PVD, AAA) Pathologic Q waves Age >70 2-3 risk factors for CAD Low Risk (suggest use of appropriate ACS physician order set) Absence of STEMI/New LBBB, High Risk Criteria or Moderate risk Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 11 of 14
Baptist Health System ACS Clinical Pathways Attachment F Diagnosis STEMI Angioplasty STEMI Thrombolysis Probable NSTEMI Possible ACS Non-ACS Clinical Evaluation/Symptoms Consistent with ACS Consistent with ACS Consistent with ACS Consistent with ACS or atypical Not consistent with ACS Based on ED Physician evaluation ECG (as indicated) Completed in <5 MINUTES ECG given to physician for interpretation. Goal within 10 minutes. Physician records time and interpretation. Findings: ST Elevation/New LBBB ECG given to physician for interpretation. Goal within 10 minutes. Physician records time and interpretation. Findings: ST Elevation/New LBBB ECG given to physician for interpretation. Goal within 10 minutes. Physician records time and interpretation. Findings: Absence of ST Elevation/New LBBB ECG given to physician for interpretation. Goal within 10 minutes. Physician records time and interpretation. Findings: Absence of ST Elevation/New LBBB ECG given to physician for interpretation. Goal within 10 minutes. Physician records time and interpretation. Findings: Not consistent with ACS TESTS Labs/ Cardiac Biomarkers, CXR Findings: Initial labs not a determinant of diagnosis or disposition Labs/ Cardiac Biomarkers, CXR Findings: Initial labs not a determinant of diagnosis or disposition Labs/ Cardiac Biomarkers, CXR Findings: (+) Cardiac Troponin Labs/Cardiac Biomarkers, CXR Screening for non-acs etiology as indicated. Stress Test as indicated Findings: (-) Cardiac Troponin Diagnostic tests determined by ED Physician Evaluation. Screening for non-acs etiology as indicated. Findings: (-) Cardiac Troponin if ordered Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 12 of 14
Diagnosis STEMI Angioplasty STEMI Thrombolysis Probable NSTEMI Possible ACS Non-ACS MEDICATIONS ASA chewed (unless contraindicated) *See IMPACT Protocol #2 ASA chewed (unless contraindicated) *See IMPACT Protocol #2 ASA chewed (unless contraindicated) ASA chewed (unless contraindicated) Medications determined by ED Physician Evaluation, as appropriate for determined etiology DISPOSITION Activate HEART ALERT- CONTACT INTERVENTIONAL CARDIOLOGIST Initiate IMPACT Protocol. TRANSFER TO CATHERIZATION LAB (MTB Only)- Follow MTB to BMC STEMI Transfer Process Activate HEART ALERT- CONTACT INTERVENTIONAL CARDIOLOGIST Initiate IMPACT Protocol. TRANSFER TO CATHERIZATION LAB (MTB Only)- Follow MTB to BMC STEMI Transfer Process In the event of a significant delay in the availability of the Cath lab or interventional cardiologist, consider Thrombolysis. Follow Thrombolytic Policy. Admit to Cardiac Monitoring Unit. Implement AMI Physician Order Set Secondary Risk Stratification Further risk stratification using Risk Stratification tool (Attachment E) Moderate or High Risk Place patient in Observation Status to Cardiac Monitored Unit, use appropriate ACS physician order set. Low Risk Place in Observation Status to Cardiac Monitored Unit, use appropriate ACS Physician order set. May consider discharge from Emergency Department with follow up plan. Discharge patients receive information that includes risk and lifestyle modifications and outpatient followup. If Stress Test not done during initial visit, discharge instructions should include a follow up plan with physician. Discharged Instructions based on determined etiology including specific information that includes risk and lifestyle modifications as indicated. Follow-up instructions provided. Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 13 of 14
1. (-) ECG means normal or unchanged from previous ECG 2. Non-STEMI Definition: Either one of the following criteria satisfies the diagnosis of an acute, evolving or recent MI: a.) Rise and fall of biochemical markers for myocardial necrosis with at least one of the following: ischemic symptoms, development of pathologic Q waves on ECG, and ECG changes indicative of ischemia (ST elevation or depression). b.) Pathologic findings of AMI 3. Risk stratification tool for admitted patients only (Observation/Admit). If the patient's condition changes, patient will be reassigned to the appropriate clinical pathway. CLINICAL PATHWAYS NEVER REPLACE CLINICAL JUDGMENT. CARE OUTLINED IN THE PATHWAY MUST BE ALTERED IF IT IS NOT CLINICALLY APPROPRIATE FOR THE INDIVIDUAL PATIENT. TIMING OF THE REFRERRAL TOO CARDIOLOGY/MEDICAL MAY VARY FOR LOCAL CIRCUMSTANCES. Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 14 of 14