Nurse-led chest pain hot clinics: improving patient flow in the emergency department

2020 ◽  
Vol 15 (5) ◽  
pp. 1-11
Author(s):  
Jon Taylor ◽  
Agnieszka Kopanska ◽  
Tessa Cobb
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Length Of Stay ◽  
Troponin I ◽  
Patient Flow ◽  
Low Risk ◽  
Heart Score ◽  
Ensure Patient Safety ◽  
Number Of Patients ◽  
Risk Patients

This article describes the authors' experiences of a specialist pathway for low-risk patients with chest pain admitted to the emergency department. This pathway uses a modified HEART score and highly sensitive troponin I testing to categorise patients. This was introduced to facilitate safe and speedy discharge of these patients within the 4-hour target. The aim was to demonstrate a reduction in length of stay and a reduction in overcrowding in the emergency department. This also included the introduction of a new nurse-led chest pain hot clinic to provide a specialist cardiology review within 72 hours of discharge. This clinic enabled more appropriate targeted investigation and treatment for patients. As a new initiative, it was important to ensure patient safety with a <1% incidence of major adverse cardiac event at 30 days, which was achieved. The modified HEART score also enabled more low-risk patients to be rapidly discharged from the emergency department. The chest pain hot clinics ensure patients are appropriately assessed and investigated for coronary artery disease reducing the number of unnecessary investigations. It also demonstrated a reduction in the number of computerised tomography coronary angiogram requests enabling more appropriate and timely investigations. In addition, there was a reduction in medical admissions and emergency department overcrowding. These initiatives also reduced the overall length of stay and increased the number of patients discharged within the 4-hour target from the emergency department.

scholarly journals Low-Risk Patients With Chest Pain in the Emergency Department: Negative 64-MDCT Coronary Angiography May Reduce Length of Stay and Hospital Charges

2009 ◽  
Vol 193 (1) ◽  
pp. 150-154 ◽  
Author(s):  
Janet M. May ◽  
William P. Shuman ◽  
Jared N. Strote ◽  
Kelley R. Branch ◽  
Lee M. Mitsumori ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Coronary Angiography ◽  
Length Of Stay ◽  
Low Risk ◽  
Hospital Charges ◽  
Risk Patients ◽  
Mdct Coronary Angiography

scholarly journals P124: The Ottawa Chest Pain Rule would increase stretcher capacity if implemented for cardiac chest pain patients

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S119-S119 ◽  
Author(s):  
M. Sonntag ◽  
E. Lang
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Patient Flow ◽  
System Capacity ◽  
Cardiac Monitoring ◽  
Convenience Sample ◽  
Heart Score ◽  
Number Of Patients ◽  
The Impact ◽  
Pain Patients

Introduction: Reducing the number of patients requiring cardiac monitoring would increase system capacity and improve emergency department (ED) patient flow. The Ottawa Chest Pain Rule helps physicians identify chest pain patients who do not require cardiac monitoring and is based on a ‘normal or non-specific’ ECG and being pain-free on initial physician assessment. Our objective was to measure the impact that the implementation of this decision rule would have on cardiac monitoring bed utilization in adult EDs in Calgary. Methods: A convenience sample of patients was prospectively obtained at each of the four Calgary adult emergency sites. All patients presenting with the Canadian Triage Acuity Scale chief complaint of “cardiac pain”, or “chest pain with cardiac features” were captured for inclusion in the study. Real time interviews and survey assessments were conducted with the primary nurse and physician involved in each patient’s care. Results: A total of 61 patients were captured by the study. Physicians identified cardiac as the primary rule-out pathology in 51% of these patients. The average Heart Score of all study patients was 4.2, and 30% of patients were ultimately admitted. Physicians believed that 39% of the 61 patients needed cardiac monitoring, while primary nurses believed that 59% needed monitoring. Of the 61 patients, 59% were triaged to areas providing cardiac monitoring. The application of the Ottawa Rule would have allowed 47% of patients triaged to cardiac monitoring to be taken off cardiac monitoring. This would translate to a total of greater than 74 hours saved or a reduction of 30% of the total cardiac monitored patient time. Conclusion: The Ottawa rule appears to be a low-risk emergency department flow intervention that has the potential to help reduce resource utilization in emergency departments. This change may result in increased emergency department capacity and improved overall patient flow. This simple rule based only on ECG findings and absence of chest pain can easily be applied and implemented without increasing physician workload or increasing risk to patients.

P2712Integration of new CENTAUR high-sensitivity Troponin I assay with HEART score chest pain pathway to maximise early discharge from emergency department

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
E M Thet ◽  
J J Murphy ◽  
J G Crilley
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Troponin I ◽  
High Sensitivity ◽  
Early Discharge ◽  
Low Risk ◽  
Acute Pulmonary Oedema ◽  
Original Cohort ◽  
Heart Score ◽  
Coronary Syndrome

Abstract Introduction Chest pain is a common presentation to the emergency department (ED). Differentiating those with an Acute Coronary Syndrome from the majority without, within 4 hours, is a priority. Introduction of high-sensitivity TnI assays has the potential to allow early discharge from ED but at the expense of lower specificity. Given the pressure in ED to identify patients who can safely be discharged we developed an algorithm based on the HEART score. This combines the history, ECG, age, risk factors and hsTnI level and outperforms TIMI and GRACE scores in identifying low-risk patients. Patients with a score of ≥4 have an increased major adverse cardiac event (MACE) rate at 30 days; those with a score of <4 are suitable for early discharge. There are no studies utilising the CENTAUR assay combined with a clinical risk score. Methods An initial algorithm based on the HEART score tool was developed incorporating estimated hsTnI boundaries for the CENTAUR assay to inform the “T” component of the tool. This was tested on a 2 month sample of patients presenting with chest pain to the ED. Following review a revised pathway was developed. Patient outcome was recorded with both pathways including subsequent investigations and MACE at 30 days and compared with historical discharge rates for chest pain from the same ED. Sensitivity, specificity and NPV were calculated. Results There were 478 presentations with chest pain and at least one hsTnI level. Age ranged from 13 to 98 years (median 56); 50% were male. There were 21 (4%) MACE within 30 days of the initial presentation (NSTEMI: 18, STEMI: 1, unstable angina requiring CABG: 1, acute pulmonary oedema: 1). A 2 hour hsTnI ≤8 identified a low-risk group with no MACE <30 days. 30% of patients using the initial pathway had a HEART score of ≥4 (100% sens, 73% spec). 70% were suitable for ED discharge; there were no MACE in this group (100% NPV). A revised pathway was derived incorporating previous cardiac history and modified hsTnI boundaries. Applying this to the original cohort would have increased the proportion suitable for ED discharge to 82%. Both pathways improved the proportion of patients who could be discharged directly from ED from a historical 64%. The revised pathway demonstrated improved specificity for the identification of MACE with no loss of sensitivity and excellent negative predictive value. (100% sens, 86% spec, 100% NPV). Conclusions The CENTAUR hs-TnI assay and HEART score with modifications would facilitate the early discharge of patients with chest pain from ED within 4 hours without missing any MACE at 30 days. This conclusion should be validated in a prospective cohort.

scholarly journals LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S61-S62 ◽  
Author(s):  
J. Andruchow ◽  
A. McRae ◽  
T. Abedin ◽  
D. Wang ◽  
G. Innes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
Moderate Risk ◽  
Heart Score ◽  
High Sensitivity Troponin ◽  
High Sensitivity Troponin T ◽  
Pain Patients

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

A New Improved Accelerated Diagnostic Protocol Safely Identifies Low-risk Patients With Chest Pain in the Emergency Department

2012 ◽  
Vol 19 (5) ◽  
pp. 510-516 ◽  
Author(s):  
Sally J. Aldous ◽  
Mark A. Richards ◽  
Louise Cullen ◽  
Richard Troughton ◽  
Martin Than
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Low Risk ◽  
Diagnostic Protocol ◽  
Risk Patients

Rapid rule out for suspected myocardial infarction: is the algorithm appropriate for all?

2020 ◽  
Vol 6 (3) ◽  
pp. 193-198 ◽  
Author(s):  
Erez Marcusohn ◽  
Danny Epstein ◽  
Ariel Roguin ◽  
Robert Zukermann
Keyword(s):  
Myocardial Infarction ◽  
Chest Pain ◽  
Troponin I ◽  
Low Risk ◽  
Risk Of Death ◽  
Coronary Syndrome ◽  
Risk Patients ◽  
Grace Score ◽  
High Sensitive Troponin ◽  
Rule Out

Abstract Aims Patients presenting to the emergency department (ED) with cardiac chest pain and high-sensitive troponin I (HsTnI) less than 5 ng/L have very good prognosis and low risk for major adverse cardiovascular events. The 2015 European Society of Cardiology (ESC) guidelines for non-ST-elevation myocardial infarction (MI)/acute coronary syndrome (ACS) suggests that patients with normal high-sensitive troponin, which are free of chest pain and have a global registry of acute coronary events (GRACE) score less than 140 are eligible for discharge from the hospital for outpatient workup. Our hypothesis suggests that not all patients with GRACE score under 140 should be discharged for ambulatory tests even with undetectable HsTnI as recommended in the guidelines. Methods and results Population-based retrospective cohort study in a large tertiary care centre. The study population included all patients discharged from the hospital between 1 February 2016 and 28 February 2019 following rule out of MI. During the study period, a total of 13 800 patients were discharged from the hospital after rule out of MI. Among them, 9236 (67%) had HsTnI below 5 ng/L. A total of 7705 patients (83%) met the criteria for low (n = 7162) or moderate (n = 543) GRACE risk score. Moderate-risk patients had significantly more adverse events than low-risk patients (4.6% vs. 2.1%, P &lt; 0.001). They are in higher risk of death (0.5% vs. 0.1%, P = 0.042), revascularization (3.9% vs. 1.8%, P = 0.0047), and readmission due to ACS (1.1% vs. 0.4%, P = 0.031). Conclusion Patients presenting to the ED with chest pain and HsTnI less than 5 ng/L and GRACE score under 140 have 2–4% adverse event in 60 days. The differences between the groups suggest using rapid rule out algorithms for only low-risk patients with GRACE score under 73.

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