Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 1 of 14 NURS-ED-53 Approval Date: 08/14 Title: Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Document Number: NURS-ED-53 Document Type: Policy, Procedure Affected Departments: Emergency Department (ED), Catheterization Lab (Cath Lab) Review Bodies: Position or Committee Date Review Completed BHS Regional Chest Pain Steering Committee (Owning body) 08/14 BHS Cardiovascular Service Line 09/14 BHS ED Service Line 08/14 Revision/(Review) Dates: (Dates that included only a review, but no content revision, are in parentheses) 07/14 Effective Date: 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 (Position or Committee) Name Authentication Date Quality & Patient Safety Steering Committee Meeting Minutes & Digital Signatures 08/14 Medical Executive Board Meeting Minutes 09/14
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Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 1 of 14
NURS-ED-53 Approval Date: 08/14
Title: Acute Coronary Syndrome (ACS) and Heart Alert
in the Emergency Department
Document Number: NURS-ED-53
Document Type: Policy, Procedure
Affected Departments: Emergency Department (ED), Catheterization Lab
(Cath Lab)
Review Bodies:
Position or Committee Date Review
Completed
BHS Regional Chest Pain Steering
Committee
(Owning body)
08/14
BHS Cardiovascular Service Line 09/14
BHS ED Service Line 08/14
Revision/(Review) Dates: (Dates that included only a review, but no content
revision, are in parentheses)
07/14
Effective Date: 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
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 9 of 14
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YES
NO
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.
RN Triage
Signs & Symptoms
of Acute Coronary
Syndrome
Perform ECG
Interpret for STEMI, signed &
placed on chart with Goal within
10 minutes.
STEMI
Initiate BHS Nursing Care Protocols
Guidelines for the Emergency
Department, NURS-ED-23.
Initiate HEART ALERT
utilizing one-call system
ED physician calls report to
Interventional Cardiologist
IMPACT
PROTOCOL
To Cath Lab for
Invasive Intervention
ED Physician Evaluation
RISK STRATIFICATION
(ACS Clinical Pathways, Attachment F)
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.
Walk-in
Baptist Health System
STEMI WALK-IN/EMS PATHWAY
Attachment C
Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department Page 10 of 14
NURS-ED-53 Approval Date: 08/14
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 11 of 14
NURS-ED-53 Approval Date: 08/14
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
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NURS-ED-53 Approval Date: 08/14
Baptist Health System ACS Clinical Pathways
Attachment F
Diagnosis STEMI Angioplasty STEMI Thrombolysis
Probable NSTEMI Possible ACS Non-ACS
Clinical Evaluation/Symptoms
Based on ED Physician evaluation
Consistent with ACS Consistent with ACS Consistent with ACS Consistent with ACS or atypical Not consistent with ACS
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 13 of 14
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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
(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)
Discharged Instructions based on determined etiology including specific information that includes risk and lifestyle modifications as indicated. Follow-up instructions provided.
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 follow-up. If Stress Test not done during initial visit, discharge instructions should include a follow up plan with physician.
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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.