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Emergency department triage of patients with nontraumatic chest pain
HEALTH
CARE
DELIVERY
rating and are seen by a physician at a mean time of 14 min after arrival. The ECG is available 7 min (mean) after it is ordered and includes a preliminary, computer-derived interpretation. Once available, the technician gives the ECG directly to the responsible nurse or physician. In the event of evidence of ST segment elevation indicating acute myocardial infarction by ECG in a patient with clear cut symptoms of infarction and no contraindications, the emergency physician has delegated authority to order a thrombolytic drug. The admitting service and primary care physician are contacted concurrently, but infusion of the thrombolytic drug is begun as soon as it is available and is not delayed by these calls. The emergency physician makes decisions that are based on an inclusion and exclusion checklist, an algorithm for administration of the thrombolytic drug as well as other adjunctive and conjunctive drugs (including aspirin, heparin, beta blockers, intravenous nitroglycerin) that reflect findings from clinical trials and are developed and approved by the Division of Cardiology as the standard of practice for the Maine Medical Center. These patients are then admitted to the Cardiac Intensive Care Unit and care is assumed by the cardiologist. Those patients with acute myocardial infarction who are not candidates for thrombolysis or who are hemodynamically unstable are seen immediately in the emergency department by the cardiology staff who assume responsibility for care from the emergency physician. Consideration is given to immediate diagnostic cardiac catheterization and mechanical repertklsion. After initial evaluation, those patients with a known history of heart disease or an abnormal ECG are seen by internists and/or cardiologists for decision and disposition. Those patients who, after initial evaluation and in the presence of a normal ECG, are thought to have chest pain of noncardiac origin, may be discharged from the emergency department by the emergency physician. The primary care provider or clinic is notified of the patient visit and the complaint for the purpose of assuring follow-up. Those patients with normal ECGs or ECG abnormalities with clinical symptoms that are suggestive of cardiac origin, or in whom there is uncertainty as to origin of symptoms, are admitted to a hospital bed for continuous ECG monitoring for arrhythmias, follow-up 12-lead ECG and exclusion of myocardial necrosis through serial enzyme determinations. Patients with positive findings are seen by a cardiologist for further evaluation and treatment; patients with negative findings in need of a stress study are also seen by a cardiologist who is responsible for selecting, conducting and interpreting the study. Protocols for the evaluation of patients with nontraumatic chest pain and the treatment of patients with cardiac isch-
COMMENT: TWO VIEWPOINTS
Emergency Department Triage of Patients With Nontraumatic Chest Pain Costas T. Lambrew, MD, Division of Cardiology, Maine Medical Center, Portland, Maine
he Maine Medical Center is a 598 bed acute care hospital that serves as a primary care facility for a greater Portland population of approximately 200,000 people. It provides tertiary care cardiology services for a large part of the state of Maine and eastern New Hampshire. There are well established residency training programs in all of the clinical specialties and in five internal medicine subspecialties, including cardiovascular disease. It is the major teaching atfiliate of the University of Vermont College of Medicine with 32 third-year clerks in residence at all times. There are 47,000 annual emergency department visits. In a recent study of 800 consecutive patients over the age of 30 with nontraumatic chest pain seen over 6 months, 57% (458) were determined to have chest pain of noncardiac origin. A diagnosis of ST segment elevation indicating acute myocardial infarction was made on 8% (62) of the 800 patients on presentation. Only 40% of the patients arrived for evaluation by ambulance. The emergency department is staffed by full-time, salaried emergency medicine certified physicians. Patients are seen as well by rotating residents. The emergency department staff is supported by specialists from all disciplines, including cardiology, 24 hours each day. Patients arriving by ambulance are generally taken directly to a cubicle or a trauma room, depending on acuteness, and immediately evaluated by a nurse. Patients with nontraumatic chest pain are screened, according to a checklist, by ambulance personnel for symptoms suggestive of acute myocardial infarction and, if present, for possible contraindications to thrombolytic therapy. Those patients with a history suggestive of acute myocardial infarction go directly to the trauma room for evaluation. All patients not arriving by ambulance are seen initially by a registration clerk who is trained to elicit the chief complaint before gathering demographic information. Any patient with nontraumatic chest pain is referred immediately to the triage nurse who has the authority to order a 12-lead ECG in patients with symptoms suggestive of cardiac ischemia. Patients with chest pain automatically receive a high triage
D
AC(Z CURRENT.JOI_]RNALREVIEW May/June 1995
© 1995 by the American (. ollege of C,~.rcliol~gy
6 1
1062 1458/95/$950 5SD1 1062 1458(95)00061-N
HEALTH
CARE D E L I V E R Y
Chest Pain Management at the Portland, Oregon Veterans Affairs Medical Center Emergency Department
emia and infarction remain the responsibility of the cardiologist, but are widely discussed with and accepted by the emergency medicine, internal medicine and family practice medical staff. The compelling relationship between early reperfusion in patients with ST segment elevation indicating acute myocardial infarction and outcome has resulted in delegation of authority for decision making and implementation of treatment in these patients to the emergency physician through the protocols developed by the cardiologists. This has resulted in a reduction of mean doorto-drug time from 69 rain to 20.7 min in patients with clear-cut ECG findings and no contraindications. There is, however, continuing review of all acute cardiac patients admitted through the emergency department each month by a heart team, which includes a cardiologist, emergency physician, cardiology fellow, emergency nurse, medical resident and pharmacist. This review includes assessment of indications for treatment, accuracy of ECG interpretation, appropriateness of drug use and non-use and outcome of emergency department treatment. Thus, the medical stag at large and the cardiology staff in particular are assured of accountability of the emergency physician for the purpose of continuing confidence in the delegation of authority for decision making under the established protocol. Whereas evaluation of patients with nontraumatic chest pain with suspected ischemia who do not have evidence of ST segment elevation indicating myocardial infarction by ECG may be accomplished by an abbreviated protocol of serial enzyme determination and follow-up to 12 lead ECG, the selection of studies to identify ischemia and assess risk, their conduct and interpretation will still be the responsibility of the cardiologist in a protocol for evaluation of such patients that is now being developed. The evaluation of these patients will be a collaborative effort as it has been for identification, treatment and review of all patients with acute myocardial infarction treated in the emergency department. This mechanism would assure the community that patients with chest pain and acute ischemic syndromes are being treated according to currently accepted standards of care, consistently, and at a high level of quality. Because there is no evidence that a separate Chest Pain Emergency Department/Evaluation Center yields better results than a well-organized interdisciplinary protocol in terms of outcomes or cost, it is not our intention to pursue this course at the present time.
Richard J, Harper, MD and Greg C. Laden, MD,* Emergency Medicine SeNce and *Cardiology Section, Portland Veterans Affairs Medical Center, Portland, Oregon R
he Portland Veterans Affairs Medical Center is a 379 bed regional referral hospital that has an average daily census of 220 patients and an average intensive care unit census of 24. The emergency department has eight monitored beds with 21,000 annual visits. The department is staged by board-certified or board-eligible emergency medicine physicians who also supervise both internal medicine and emergency medicine residents. Admissions for chest pain of possible cardiac etiology average 85 per month. Approximately 41% of these patients are admitted to the coronary care unit (CCU) with the rest admitted to other monitored beds. An analysis of admissions over a 2-momh period showed a myocardial infarction rate of 18% and an additional 9% of patients requiring corona~" arte U bypass grafting or angioplasty during their initial hospitalization. The cardiac catheteriflation laboratory is fully staffed from 7:00 AM tO 3:30 PM. Urgent catheterizations are performed after hours, but response times are well over 1 hour. Thus, primary angioplasty as a therapeutic option for patients with acute myocardial infarction is not available during much of each 24 h day; thrombolytic therapy is the most common treatment used for such patients. Patients presenting to the emergency department with chest pain are immediately triaged to a monitored bed. Management is consistent with the protocol of Moses et al. (1), which expedites lab testing and gives emergency decision-making authority to the emergency department physician. Standing orders call for the immediate placement of intravenous access with blood drawn to await physician orders. A 12-lead electrocardiogram (ECG) is obtained. Patients are usually seen by a physician within 5 min of presentation. Unstable patients or those with ongoing chest pain receive immediate attention. A history is obtained and a focused physical examination performed. Algorithms for triage of patients with chest pain are not currently in use in the emergency department because data suggest they do little to improve the triage decisions of experienced practitioners (2). Patients with history suggesting acute myocardial infarction and qualifying ECG changes (3) are treated with thrombolyric therapy according to a departmental protocol developed with the cardiology' section (Tables 1 and 2). Departmental standards call for the initiation of thrombolytic therapy
Address correspondence and reprint requests to Costas T. Lambrew, MD, Division qf Cardiologv, Marne Medical Center, 22 B~arahall Street, Portland. ME 04102.
ACC CURRENTJOU RNAL REVIEW May/June 1995
62
CARE
DELIVERY
rating and are seen by a physician at a mean time of 14 min after arrival. The ECG is available 7 min (mean) after it is ordered and includes a preliminary, computer-derived interpretation. Once available, the technician gives the ECG directly to the responsible nurse or physician. In the event of evidence of ST segment elevation indicating acute myocardial infarction by ECG in a patient with clear cut symptoms of infarction and no contraindications, the emergency physician has delegated authority to order a thrombolytic drug. The admitting service and primary care physician are contacted concurrently, but infusion of the thrombolytic drug is begun as soon as it is available and is not delayed by these calls. The emergency physician makes decisions that are based on an inclusion and exclusion checklist, an algorithm for administration of the thrombolytic drug as well as other adjunctive and conjunctive drugs (including aspirin, heparin, beta blockers, intravenous nitroglycerin) that reflect findings from clinical trials and are developed and approved by the Division of Cardiology as the standard of practice for the Maine Medical Center. These patients are then admitted to the Cardiac Intensive Care Unit and care is assumed by the cardiologist. Those patients with acute myocardial infarction who are not candidates for thrombolysis or who are hemodynamically unstable are seen immediately in the emergency department by the cardiology staff who assume responsibility for care from the emergency physician. Consideration is given to immediate diagnostic cardiac catheterization and mechanical repertklsion. After initial evaluation, those patients with a known history of heart disease or an abnormal ECG are seen by internists and/or cardiologists for decision and disposition. Those patients who, after initial evaluation and in the presence of a normal ECG, are thought to have chest pain of noncardiac origin, may be discharged from the emergency department by the emergency physician. The primary care provider or clinic is notified of the patient visit and the complaint for the purpose of assuring follow-up. Those patients with normal ECGs or ECG abnormalities with clinical symptoms that are suggestive of cardiac origin, or in whom there is uncertainty as to origin of symptoms, are admitted to a hospital bed for continuous ECG monitoring for arrhythmias, follow-up 12-lead ECG and exclusion of myocardial necrosis through serial enzyme determinations. Patients with positive findings are seen by a cardiologist for further evaluation and treatment; patients with negative findings in need of a stress study are also seen by a cardiologist who is responsible for selecting, conducting and interpreting the study. Protocols for the evaluation of patients with nontraumatic chest pain and the treatment of patients with cardiac isch-
COMMENT: TWO VIEWPOINTS
Emergency Department Triage of Patients With Nontraumatic Chest Pain Costas T. Lambrew, MD, Division of Cardiology, Maine Medical Center, Portland, Maine
he Maine Medical Center is a 598 bed acute care hospital that serves as a primary care facility for a greater Portland population of approximately 200,000 people. It provides tertiary care cardiology services for a large part of the state of Maine and eastern New Hampshire. There are well established residency training programs in all of the clinical specialties and in five internal medicine subspecialties, including cardiovascular disease. It is the major teaching atfiliate of the University of Vermont College of Medicine with 32 third-year clerks in residence at all times. There are 47,000 annual emergency department visits. In a recent study of 800 consecutive patients over the age of 30 with nontraumatic chest pain seen over 6 months, 57% (458) were determined to have chest pain of noncardiac origin. A diagnosis of ST segment elevation indicating acute myocardial infarction was made on 8% (62) of the 800 patients on presentation. Only 40% of the patients arrived for evaluation by ambulance. The emergency department is staffed by full-time, salaried emergency medicine certified physicians. Patients are seen as well by rotating residents. The emergency department staff is supported by specialists from all disciplines, including cardiology, 24 hours each day. Patients arriving by ambulance are generally taken directly to a cubicle or a trauma room, depending on acuteness, and immediately evaluated by a nurse. Patients with nontraumatic chest pain are screened, according to a checklist, by ambulance personnel for symptoms suggestive of acute myocardial infarction and, if present, for possible contraindications to thrombolytic therapy. Those patients with a history suggestive of acute myocardial infarction go directly to the trauma room for evaluation. All patients not arriving by ambulance are seen initially by a registration clerk who is trained to elicit the chief complaint before gathering demographic information. Any patient with nontraumatic chest pain is referred immediately to the triage nurse who has the authority to order a 12-lead ECG in patients with symptoms suggestive of cardiac ischemia. Patients with chest pain automatically receive a high triage
D
AC(Z CURRENT.JOI_]RNALREVIEW May/June 1995
© 1995 by the American (. ollege of C,~.rcliol~gy
6 1
1062 1458/95/$950 5SD1 1062 1458(95)00061-N
HEALTH
CARE D E L I V E R Y
Chest Pain Management at the Portland, Oregon Veterans Affairs Medical Center Emergency Department
emia and infarction remain the responsibility of the cardiologist, but are widely discussed with and accepted by the emergency medicine, internal medicine and family practice medical staff. The compelling relationship between early reperfusion in patients with ST segment elevation indicating acute myocardial infarction and outcome has resulted in delegation of authority for decision making and implementation of treatment in these patients to the emergency physician through the protocols developed by the cardiologists. This has resulted in a reduction of mean doorto-drug time from 69 rain to 20.7 min in patients with clear-cut ECG findings and no contraindications. There is, however, continuing review of all acute cardiac patients admitted through the emergency department each month by a heart team, which includes a cardiologist, emergency physician, cardiology fellow, emergency nurse, medical resident and pharmacist. This review includes assessment of indications for treatment, accuracy of ECG interpretation, appropriateness of drug use and non-use and outcome of emergency department treatment. Thus, the medical stag at large and the cardiology staff in particular are assured of accountability of the emergency physician for the purpose of continuing confidence in the delegation of authority for decision making under the established protocol. Whereas evaluation of patients with nontraumatic chest pain with suspected ischemia who do not have evidence of ST segment elevation indicating myocardial infarction by ECG may be accomplished by an abbreviated protocol of serial enzyme determination and follow-up to 12 lead ECG, the selection of studies to identify ischemia and assess risk, their conduct and interpretation will still be the responsibility of the cardiologist in a protocol for evaluation of such patients that is now being developed. The evaluation of these patients will be a collaborative effort as it has been for identification, treatment and review of all patients with acute myocardial infarction treated in the emergency department. This mechanism would assure the community that patients with chest pain and acute ischemic syndromes are being treated according to currently accepted standards of care, consistently, and at a high level of quality. Because there is no evidence that a separate Chest Pain Emergency Department/Evaluation Center yields better results than a well-organized interdisciplinary protocol in terms of outcomes or cost, it is not our intention to pursue this course at the present time.
Richard J, Harper, MD and Greg C. Laden, MD,* Emergency Medicine SeNce and *Cardiology Section, Portland Veterans Affairs Medical Center, Portland, Oregon R
he Portland Veterans Affairs Medical Center is a 379 bed regional referral hospital that has an average daily census of 220 patients and an average intensive care unit census of 24. The emergency department has eight monitored beds with 21,000 annual visits. The department is staged by board-certified or board-eligible emergency medicine physicians who also supervise both internal medicine and emergency medicine residents. Admissions for chest pain of possible cardiac etiology average 85 per month. Approximately 41% of these patients are admitted to the coronary care unit (CCU) with the rest admitted to other monitored beds. An analysis of admissions over a 2-momh period showed a myocardial infarction rate of 18% and an additional 9% of patients requiring corona~" arte U bypass grafting or angioplasty during their initial hospitalization. The cardiac catheteriflation laboratory is fully staffed from 7:00 AM tO 3:30 PM. Urgent catheterizations are performed after hours, but response times are well over 1 hour. Thus, primary angioplasty as a therapeutic option for patients with acute myocardial infarction is not available during much of each 24 h day; thrombolytic therapy is the most common treatment used for such patients. Patients presenting to the emergency department with chest pain are immediately triaged to a monitored bed. Management is consistent with the protocol of Moses et al. (1), which expedites lab testing and gives emergency decision-making authority to the emergency department physician. Standing orders call for the immediate placement of intravenous access with blood drawn to await physician orders. A 12-lead electrocardiogram (ECG) is obtained. Patients are usually seen by a physician within 5 min of presentation. Unstable patients or those with ongoing chest pain receive immediate attention. A history is obtained and a focused physical examination performed. Algorithms for triage of patients with chest pain are not currently in use in the emergency department because data suggest they do little to improve the triage decisions of experienced practitioners (2). Patients with history suggesting acute myocardial infarction and qualifying ECG changes (3) are treated with thrombolyric therapy according to a departmental protocol developed with the cardiology' section (Tables 1 and 2). Departmental standards call for the initiation of thrombolytic therapy
Address correspondence and reprint requests to Costas T. Lambrew, MD, Division qf Cardiologv, Marne Medical Center, 22 B~arahall Street, Portland. ME 04102.
ACC CURRENTJOU RNAL REVIEW May/June 1995
62