Minimum Standards for Chest Pain Evaluation · management 24/7 • The pathway gives instruction...

Minimum Standards for Chest Pain Evaluation

Implementation Support Guide

Consultation Edition (October 2011)

Contact details NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060

Tel. (02) 9391 9000 Fax. (02) 9391 9101 www.health.nsw.gov.au

Copyright information This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the NSW Department of Health.

© NSW Department of Health 2011

Further copies details

1. For further copies of this document please contact: Better Health Centre – Publications Warehouse Locked Mail Bag 5003 Gladesville 2111 Tel. (02) 9816 0452 Fax. (02) 9816 0492

2. For further copies of this document please contact:

Health Services Performance Improvement Branch Tel. (02) 9391 9823 Email. [email protected]

3. Further copies of this report can be downloaded from the NSW Health website:

www.health.nsw.gov.au

Disclaimer Content within this publication was accurate at the time of publication.

Current Publication Date October 2011

Foreword

The NSW Health system is highly complex, relying on the expertise of 100,000+ employees to provide quality health care services to the citizens of NSW.

A significant wealth of experience exists in specialised management for patients presenting with symptoms of chest pain. A number of chest pain pathways already exist to guide the safety and quality of care provided to patients. However, there is inconsistency in the content and use of these pathways within and between hospitals across NSW.

Root Cause Analysis and Coronial investigations demonstrate that significant adverse events continue to occur, due to inconsistencies in the practice of the minimum standards for chest pain evaluation.

Responding to this need, the State-wide Cardiology Project developed the Chest Pain Pathway working group to work with clinicians and health service teams to redesign better patient journeys for patients presenting to hospitals for chest pain evaluation. The work of this group links into broader improvement strategies for adult patients with Acute Coronary Syndrome.

It is critical to note that these minimum standards have been developed by the working party, comprising multi-disciplinary staff from across NSW health facilities.

The Chest Pain Pathway working group should be acknowledged for their focus on the importance of early and sustained key stakeholder engagement. The minimum standards for chest pain evaluation has included consultation with Local Health District representatives, including Cardiology, Emergency Department, frontline clinicians, Patient Flow Management Team, and Clinical Redesign Unit staff, as well as Ambulance NSW, the Clinical Excellence Commission, the Agency for Clinical Innovation Cardiac Network, the Critical Care Taskforce, Rural Critical Care and consumer representatives.

The minimum standards also align with the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the management of Acute Coronary Syndrome.

The recently issued Policy Directive (CPD2011_037) for the minimum standards for chest pain evaluation will assist clinicians to provide evidence based care to a high risk group of patients who frequently present to our Emergency Departments.

This implementation support guide complements the Policy Directive and aims to assist managers and clinicians to meet the minimum standards outlined in the policy. I commend this resource to you and hope that it assists you and your teams to improve the management of chest pain, every patient, every time.

Mr Mike Wallace A/Deputy Director-General, System Purchasing and Performance Division NSW Health

ContentsExecutive Summary .................................................................................................... 4

Objectives ............................................................................................................ 4

Background ..........................................................................................................4

Mandatory Requirements ..................................................................................... 4

Key questions to guide implementation ............................................................... 5

Key messages for clinicians and managers ......................................................... 5

Ordering the NSW Chest Pain Pathway ............................................................... 7

Case For Change .......................................................................................................... 8

Coroner’s recommendations ................................................................................ 8

Final RCA Report ................................................................................................. 9

Minimum Standards for Chest Pain Evaluation ....................................................... 13

Minimum Standards Explanation ......................................................................... 13

Generic NSW Chest Pain Pathway ...................................................................... 17

Implementation of minimum standards for chest pain evaluation – Making Change ............................................................................................................ 19

1. Getting started ................................................................................................ 20

2. Review before you rebuild ............................................................................. 21

3. Plan the way forward ..................................................................................... 22

4. Making Change .............................................................................................. 24

5. Monitor and evaluate .................................................................................... 24

APPENDIX A — Frequently Asked Questions .......................................................... 27

APPENDIX B — Minimum standards implementation — What’s my role?� ............. 29

APPENDIX C — Self audit of local pathways ............................................................ 31

APPENDIX D ................................................................................................................35

APPENDIX E ................................................................................................................39

APPENDIX F .................................................................................................................41

APPENDIX G — Chest Pain Patient Journey — Working Party ............................... 43

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Executive Summary

ObjectivesTo improve patient safety by implementing minimum standards for chest pain evaluation in NSW Public Hospitals, for every patient, every time.

BackgroundThere is a significant wealth of experience in care for patients presenting with chest pain to hospitals. A number of chest pain pathways already exist; however, there is inconsistency in the use of pathways within and between hospitals across NSW.

The minimum standards for chest pain evaluation and Chest Pain Pathway were developed in response to significant adverse events in NSW that required investigation and attention to preventative measures.

After a review of Incident Information Management System data, the Clinical Excellence Commission prepared two Clinical Focus reports on Acute Coronary Syndrome, delivered to the Clinical Risk Review Committee (CRRC). The CRRC then determined that the Health Services Performance Improvement Branch of the NSW Department of Health be charged with addressing issues identified in the reports.

The Chest Pain Patient Journey Steering Committee (see page 44) began this process and included Senior doctors and nurses representing Emergency and Cardiology Departments, Ambulance Service of NSW, the Australian Heart Foundation, the Agency for Clinical Innovation, Clinical Safety, Quality and Governance, rural and metropolitan stakeholders.

After significant consultation and discussion the steering committee endorsed a chest pain pathway that is applicable to both Primary Percutaneous Coronary Intervention (PCI) sites and non-Primary PCI sites.

Mandatory Requirements1. All facilities with Emergency Departments must have and use a

pathway that meets the following minimum standards for chest pain patients:

• Assigns triage category 2

• ECGs are taken and reviewed by someone competent in ECG interpretation

• Includes risk stratification

• Troponin levels are taken and reviewed

• Vital signs are taken and documented

• Critical times are documented (symptom onset, presentation)

• Aspirin is given, unless contraindicated

• A Senior Medical Officer is assigned to provide advice and support on chest pain assessment and initial management, 24/7

• A nominated Cardiologist is assigned to provide advice on further management 24/7

• The pathway gives instruction regarding atypical chest pain presentations

• High risk alternate diagnosis listed for consideration e.g. Aortic Dissection, Pulmonary Embolism & Pericarditis.

Incident Information Management System data

Clinical Excellence Commission

Clinical Focus Report

Clinical Focus Report

Clinical Risk Review Committee

NSW Dept of Health

Chest Pain Steering Committee

Minimum Standards

For further explanation of the minimum standards, see page 14 in this guide.

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• Sites that do not have 24/7 PCI capability must have Thrombolysis as the default STEMI management strategy unless there is an existing documented system for transfer.

2. All facilities that do not have, or do not use, an existing Chest Pain Pathway that meets the minimum standards must implement the standard NSW Chest Pain Pathway that matches their facility (i.e. only sites that can provide 24/7 Primary PCI are able to use the Primary PCI site Pathway) as the minimum standard.

Key questions to guide implementationMonitoring the minimum standards for chest pain evaluation should form an ongoing part of the local quality and safety program. There are three basic questions to answer to determine the current state of your hospital against the minimum standards and guide your implementation focus:

1. Does our hospital have a Chest Pain Pathway?�If no – implement the generic NSW Chest Pain Pathway appropriate to your hospital → Then – monitor the pathway to ensure that it is used (every patient, every time)

2. Does our existing pathway meet the minimum standards?�If no – either amend the existing pathway to meet the minimum standards or implement the appropriate generic pathway. → Then – monitor the pathway to ensure that it is used (every patient, every time)

3. Is our existing pathway used (every patient, every time)?�If no – understand why the existing pathway is not being used consistently and develop a plan to improve compliance → Then – monitor the pathway to ensure that it is used (every patient, every time)

Key messages for clinicians and managersPatients presenting with chest pain for evaluation in NSW EDs are suffering significant adverse events due to inconsistencies in the practice of minimum standards for chest pain evaluation.

The mandated minimum standards for chest pain evaluation must be implemented to ensure consistency of practice for every patient, every time.

The take-home message from this implementation support guide is slightly different depending on who you are. Consider the following questions:

Clinicians in Emergency Departments (doctors and nurses)

• Do we have a local chest pain pathway?

• Do I know what is on it and how to use it?

• Do I use this pathway for every patient every time?

For more information on the differences between Primary and non-Primary PCI sites, see: page 18

A template is available to evaluate your current position and guide implementation: page 32

For more information on roles, see: page 30

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Cardiology and Emergency Department Directors

• Do we have a local chest pain pathway that meets the minimum standards?

• Have we trained our clinicians in how to use the pathway?

• Do we monitor compliance with the local pathway and feed back to staff?

Hospital and Local Health District Executive (particularly Directors of Clinical Governance)

• Is there Hospital/District sponsorship for a chest pain pathway?

• Does our Hospital/District meet all requirements of the mandated minimum standards for chest pain evaluation (PD2011_037)?

• Do our clinicians have the training and resources required to use the chest pain pathway for every patient, every time?

Safety and Quality Departments

• Do we monitor patient safety against the performance of existing local chest pain pathways?

• How can we integrate monitoring of the minimum standards for chest pain evaluation into ongoing quality and safety improvement?

Common issues with Chest Pain Pathway compliance

In May 2006 the Chest Pain Evaluation Area Toolkit was released by the Health Services Performance Improvement Branch. Research relating to the use of existing pathways and in conjunction with the repeated findings of Root Cause Analyses and Coronial investigations, highlights some common issues to be:

Category IssuesGeneral Issues • Varying degree of use of chest pain pathways

leading to differences in clinician practices

• Cultural aversion to pathways, despite evidence-based good practice.

• Implementation of pathways have not always followed procedural ‘good practice’ – change management principles need to be followed (e.g. sponsorship, use of a “process owner” at each site, etc).

Process Issues • Delayed or lack of access to stress test inhibits the use of pathway.

• Inconsistencies with acquisition and accurate interpretation of ECGs

• Inconsistencies with acquisition and interpretation of Troponins

People Issues • Insufficient leadership and Executive agreement - Variations in ED and cardiology buy-in.

• Insufficient training for ED clinicians in local pathways – rotation of staff accentuates this problem. A key cause of this problem is a lack of ownership of pathways at each location to help educate staff in its use.

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This confirms that the issue with existing Chest Pain Pathways in NSW is not the level of sophistication of the pathway, but the implementation of minimum standards of chest pain evaluation into core practice.

Ordering the NSW Chest Pain PathwayThere are 2 generic NSW Chest Pain Pathway forms to select from:

• PCI Hospital Pathway

• Non PCI Hospital Pathway

These forms are now available for order from Salmat:

Chest Pain Pathway PCI SiteStockcode NH606600

Chest Pain Pathway Non PCI Site Stockcode NH606601

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Case For ChangeSignificant adverse events continue to occur where patients presenting to NSW Emergency Departments experience inconsistencies in the minimum standards for chest pain evaluation.

The high rate of chest pain presentations, coupled with the potentially catastrophic outcomes when inconsistencies lead to suboptimal care, demands a strategic response.

The NSW State Coroner and Root Cause Analysis (RCA) Committees have called for the use of minimum standards of chest pain evaluation for every patient, every time.

Real life examples below highlight the need to ensure that the minimum standards are implemented and actively used consistently in all NSW Public Hospitals.

NOTE: the causes identified in Coronial and Root Cause Analysis investigations frequently relate to lapses in the basic fundamentals of care for chest pain patients, rather than the use of sophisticated treatment protocols.

Coroner’s recommendationsThe NSW State Coroner’s recommendations arising from investigation of recent deaths include the need to:

• Consider Chest Pain as the cause of other related symptoms presented

• Consider the different causes of Chest Pain

• Follow a Chest Pain pathway in its entirety

• Train all staff in any chest pain treatment protocol

• Stratify the risk of a patient’s condition deteriorating

Excerpts from the Coronial Inquest into the death of a 61 year-old man at a metropolitan hospital in 2006:

… Acute Chest Pain Protocol should be reviewed and amended as appropriate to emphasise the necessity to consider and exclude life-threatening conditions other than cardiac ischaemia, specifically aortic dissection, coronary artery occlusion and pulmonary embolism, in all presentations of acute chest pain.

The … Acute Chest Pain Protocol should be reviewed and amended as appropriate to emphasise that all sections of the Chest Pain Evaluation ED Management Form are to be completed …Specifically, the person filling in the form must note the likelihood of ischaemic heart disease, the risk stratification, the preliminary diagnosis and the action to be taken.

… an exercise stress test is not to be carried out in any case where the patient is experiencing any form of chest pain at the time of the proposed test. … an induction program presented by a senior cardiologist to ensure that all residents and interns caring for cardiac patients are familiar with relevant protocol …

“every patient, every time.”

Implementing standardised protocols of care has been shown to significantly improve patient outcomes.

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Death of a 51 y-o male (rural district hospital) Contributing factor:

The network specific- chest pain/ ACS pathway was not initiated for an atypical acute coronary syndrome presentation resulting in a missed opportunity for further assessment and acute coronary syndrome risk stratification and subsequent management which may have reduced the likelihood of cardiac arrest resulting in death.

Recommendation:

“…the RCA team recommend that all patients presenting to the emergency department with both typical and atypical chest discomfort/tightness or symptoms suggestive of ACS be triaged category 2 and have a chest pain /ACS pathway initiated and followed according to ACS stratification.”

Contributing Factor:

Lack of timely Troponin T analysis resulted in missed opportunity for early recognition and management of acute coronary syndrome which may have prevented cardiac arrest and death.

Recommendation:

“If Troponin T analysis is clinically indicated it should be processed immediately and results known before patients leave the department.”

Root Cause Analysis Report FindingsThe following factors have been consistently identified through the RCA process as contributing to Acute Coronary Syndrome incidents:

• Failure to undertake appropriate investigations, e.g. ECG, Troponin testing

• Failure to interpret ECGs correctly

• No formal system for obtaining senior clinician review of the ECG

• Delay or failure to notify the consultant on call / consultant responsible for the patient

• Failure to review results prior to patient transfer or discharge

• Failure to have a chest pain pathway in place for the management of patients with cardiac / possible cardiac pain

These are illustrated by factors and recommendations highlighted in the following real-life RCA investigations.

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Death of a 76 year old female, district hospital Contributing factor:

A delay in seeking specialist advice … may have contributed to further myocardial ischaemia and the patient’s deterioration which contributed to the patient’s death.

Recommendation:

“… ensure the emphasis on the use of the Chest Pain Pathway and ensure knowledge of the process for obtaining specialist medical advice and support 24 hours a day.”


A chest pain pathway was not initiated and the recommended treatment was not followed.

Recommendation:

“ … a chest pain pathway is initiated at triage for patients with chest pain regardless of the cause of the pain.”

Death of 52 year old female, rural referral hospital and tertiary hospitalContributing Factor:

Failure to review the patient’s pathology results prior to discharge meant that a patient with a positive Troponin was discharged home with an incorrect diagnosis. As a consequence the patient experienced an acute cardiac event at home resulting in cardiac arrest from which they did not survive.

Recommendation:

“Patients who have test results pending, specifically Troponin results, are not to be discharged from hospital until the results have been reviewed, documented in the notes and appropriate actions have been undertaken to address the findings.”


Chest Pain Pathway … was not used. These tools are designed to assist clinicians to recognise acute cardiac events and to reduce the possibility of a missed diagnosis.

Recommendation:

“Patients presenting to the Emergency Department with cardiac/possible cardiac pain are to be commenced in the NSW Health state-wide Chest Pain Pathway documentation…”

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Incident involving 70 year old female, metropolitan hospitalContributing Factor:

There are gaps in competence of ECG analysis and/or interpretation skills among medical and nursing staff in ED. This led to an inability to identify ST elevation on ECG and resulted in delay in diagnosing an acute STEMI that required an urgent coronary angioplasty.

Recommendation:

“Implementation of a formal education program on ECGs for both medical and nursing staff and a competency assessment according to the expected standard for each.”

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Minimum Standards ExplanationThe minimum standards for chest pain evaluation must be implemented in all NSW hospitals. They aim to ensure that the fundamentals of care are delivered, every patient, every time.

The following explains some basic detail for each of the minimum standards and the generic NSW Chest Pain Pathway.

1. Assigns triage category 2

All patients who present to an Emergency Department with chest pain or other symptoms of myocardial ischaemia, (eg. sweating, sudden orthopnea, dyspnea, syncope, epigastric discomfort, jaw pain or arm pain) within the last 48hrs MUST be assigned triage category 2.

Where the patient’s clinical situation demands it, these patients could also be assigned triage category 1.

2. ECGs are taken and reviewed

Within 10 minutes of starting on the Chest Pain Pathway, all patients are to have a 12 Lead ECG taken, reviewed and interpreted by a professional who is accredited to interpret the ECG.

A formal process to document that the review has occurred should be in place.

3. Includes risk stratification

All Chest Pain pathways must contain a process for risk stratification that assigns either:

• High Risk

• Intermediate Risk, or

• Low Risk

This risk stratification must be in line with the NHF/CSANZ guidelines for the management of Acute Coronary Syndromes.

4. Troponin levels are taken and reviewed

All patients MUST have a blood sample collected for testing that includes Troponin (or equivalent cardiac biomarker) level on arrival. Once the sample is collected, it must be labelled “urgent” and sent for processing immediately.

The staff member who ordered the Troponin (or equivalent cardiac biomarker) test must actively seek the results to ensure that they are reviewed in a timely fashion.

National Heart Foundation of Australia Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006, MJA, 184:8

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NO patient is to be discharged prior to the review of a Troponin (or equivalent cardiac biomarker) test that has been ordered.

Sites that are able to conduct high sensitivity Troponin assay are encouraged to do so providing that the timeframes meet the recommendations in the 2011 addendum to the NHF/CSANZ guidelines for the management of Acute Coronary Syndromes.

It is recommended that the laboratory reports elevated Troponin levels to the ordering physician as soon as possible.

5. Vital signs are taken and documented

Vital signs (Blood Pressure, Temperature, Pulse, Respiratory Rate and Pain) must be taken and documented in the patient notes at the time that they are taken. If any of the results are outside the acceptable parameters then they must be acted upon, in line with the recognition and management of a deteriorating patient.

If it is not possible to obtain a pain score, a description of the pain is also very useful. A report of ongoing, unresolved pain requires a repeat ECG to be taken and reviewed.

6. Critical times are documented (symptom onset, presentation)

All patients must have critical times documented. These include, but are not limited to, symptom onset and time of presentation.

Other important times to document are:

• Diagnostic (or “trigger”) ECG

• Thrombolytic administration

• Cath Lab arrival

• On table time

• First device use

• TIMI 3 flow

• Discussion with Cardiologist.

7. Aspirin is given, unless contraindicated

Aspirin use is recommended as per the NHF/CSANZ guidelines

If patients present via Ambulance, ensure that Aspirin administered by Paramedics is recorded in the patient record.

This should already be documented in the paramedics' notes. A reference to the advice provided by the paramedics should subsequently be sufficient.

8. A Senior Medical Officer is assigned to provide advice and support on chest pain assessment and initial management, 24/7

Identifying Senior Medical Officers should be considered based on the local staff base and could be defined as:

• Consultants

• Visiting Medical Officers

• Staff Specialists


Recognition and management of a patient who is clinically deteriorating: PD2010_026


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• Career Medical Officers

• Registrars

• Senior Nurses (as a first line of assistance where a senior doctor is not immediately available)

Consideration should be given to strengthening networking linkages through local referral networks and centralised ECG reading services.

9. A nominated Cardiologist is assigned to provide advice on further management 24/7

All Emergency Departments MUST have a defined and documented process that ensures that a nominated Cardiologist is contacted to provide further management advice for the following patient groups:

• STEMI

• High Risk ACS

• Intermediate Risk ACS who are being discharged without access to stress testing within 72hrs

Consideration should be given to strengthening networking linkages through local referral networks and centralised ECG reading services.

10. The pathway gives instruction regarding atypical chest pain presentations

Most chest pain presentations are 'typical' with symptoms, such as: sweating, orthopnea, syncope, dyspnoea, epigastric discomfort, jaw pain and arm pain. There are, however, occasions when chest pain presentations are 'atypical'.

Pathways must contain a listing of common high risk atypical presentations eg. diabetes, renal failure, female, elderly or aboriginal.

Some populations require additional considerations/awareness of the presence of Acute Coronary Syndrome due to the nature of atypical presentations for chest pain and other symptoms of myocardial ischaemia or for the increased prevalence of cardiovascular disease.

These populations are patients with diabetes or renal failure, age>65yrs, chronic renal failure or aboriginal.

11. High risk alternative diagnosis listed for consideration e.g. Aortic Dissection, Pulmonary Embolism & Pericarditis.

Following advice from the Coroner the alternate High Risk diagnoses MUST be included on the pathway to ensure consideration during the initial diagnostic process.

Chest discomfort is a common challenge for clinicians in the emergency department. The differential diagnosis includes conditions affecting organs throughout the thorax and abdomen, with prognostic implications that vary from benign to life-threatening. Failure to recognize potentially serious conditions such as acute ischaemic heart disease, aortic dissection, tension pneumothorax, or pulmonary embolism can lead to serious complications, including death. Conversely, overly conservative management of low-risk patients leads to unnecessary hospital admissions, tests, procedures, and anxiety.

Review the Generic NSW Chest Pain Pathway for an example of atypical chest pain: APPENDIX E

Source: Expert opinion of Chest Pain Patient Journey Working Group

Review the Generic NSW Chest Pain Pathway for an example of high risk alternative diagnoses being integrated into the pathway: APPENDIX E

Reference :Harrison’s Principles of Internal Medicine, Seventeenth Edition (2008) Chapter 12:1

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Aortic dissection, pulmonary embolus, expanding pneumothorax, pericarditis with impending tamponade or serious gastrointestinal pathology are all potentially life threatening and may closely mimic presentations of an acute coronary syndrome. Further, the presence or absence of reproducible chest wall pain does not preclude the possibility of a more serious underlying cause.

12. Sites that do not have 24/7 PCI capability must have Thrombolysis as the default STEMI management strategy unless there is an existing documented system for transfer.

Sites that do not have 24/7 PCI capability (referred to in the Chest Pain Pathway as Non Primary PCI Sites) must have Thrombolysis as the default STEMI management strategy. The only exceptions to this directive are sites that have a predetermined and documented process for the emergency transfer of patients to a defined Primary PCI site that is able to deliver this service 24/7. The documented system for transfer MUST ensure that the maximum acceptable delay from First Medical Contact (FMC) to percutaneous intervention is not exceeded.

Maximum Acceptable Delay from First Medical Contact (FMC)Time since symptom onset Acceptable delay from FMC to

percutaneous intervention< 1hours 60 minutes1-3 hours 90 minutes3-12 hours 120 minutes>12hours Not routinely recommendedfrom NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006

Reference: Institute for Clinical Systems Improvement, Diagnosis and Treatment of Chest Pain and ACS, 2010 pp.26


NB: It is accepted that some non Primary PCI sites have the capability to perform primary PCI during limited hours. However, outside these hours, thrombolysis must be the default strategy unless a documented system for transfer exists.

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THROMBOLYSIS UNLESS

Transfer to PRIMARY PCI SITE if appropriate

5. THROMBOLYSE

PCI HospitalA PCI Hospital is one that does Percutaneous Coronary Intervention, i.e. Coronary Angioplasty.

The PCI site pathway provides users with opportunity to perform primary angioplasty or thrombolysis depending on the clinical situation of the patient.

Non-PCI HospitalA non-PCI Hospital is one that does not have access to a Cardiac Catheter Laboratory to perform Percutaneous Coronary Interventions, i.e. Coronary Angioplasty.

The non-PCI site pathway directs users to perform thrombolysis on patients unless contraindicated.

Non-PCI sites may also choose to transfer the patient directly to a PCI site for Coronary Angioplasty, as long as the referral network is established and can meet the timeframes identified on the pathway.

A copy of the generic PCI Hospital pathway can be found at APPENDIX E

A copy of the non-PCI Hospital pathway can be found at APPENDIX F

Generic NSW Chest Pain PathwayIf your hospital does not have an existing chest pain pathway, you must implement the generic NSW Chest Pain Pathway to ensure compliance against the minimum standards.

There are two versions of the generic NSW Chest Pain Pathway that are applicable to two different hospital types:

PRIMARY PCI UNLESS

5. TRANSFER TO CATH LABTHROMBOLYSE if appropriate

Implementation of minimum standards for chest pain evaluation – Making Change

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Implementation of minimum standards for chest pain evaluation – Making Change The policy mandates the implementation of the minimum standards for chest pain evaluation, as described in the previous chapter.

The good news is that if your hospital already has a functioning chest pain pathway, you can continue to use it, as long as:

1. It meets all of the minimum standards

2. Your hospital can demonstrate that it is used completely and consistently.

Even if your hospital cannot answer ‘yes’ to the two points above, it does not mean that you have to implement an entirely new pathway. You may choose to review an existing pathway and see where it meets the minimum standards and where it does not. You must also check if the pathway is used or not.

Implementing any change requires a planned approach. Resistance to change is perfectly normal and expected. Managing this resistance well will aid the sustainability of the change.

The following section is a helpful guide to identify and make the necessary changes to implement the minimum standards for chest pain evaluation.

A resource aimed at facilitating effective local change projects has been developed and is available for review (http://www.archi.net.au/resources/moc/making-change).

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1. Getting started1.1 Minimum standards for chest pain evaluation

Review the minimum standards and the two default pathways.

1.2 Case for Change

Read the compelling case for change and consider what it means for your facility. Being able to relate this rationale to the clinicians and managers at your facility is crucial in generating momentum.

The underlying message is simple: people presenting to hospitals with chest pain are experiencing unexpected significant adverse incidents and the root cause is often due to inconsistency in the minimum standards.

1.3 Sponsorship

Who has the authority to make change count? There may be a need to identify a sponsor for Cardiology, a sponsor for Emergency and an overarching sponsor to link the two together. At the facility level, this may be the General Manager or the Director of Medical Services. Implementation at the LHD level should sit under the Director of Clinical Governance.

Minimum Standards: page 14

Primary PCI Site Pathway: APPENDIX E

Non-Primary PCI Site Pathway: APPENDIX F

Case for Change: page 9

LHD Director of Corporate Governance

General Manager

ED DirectorHead

Cardiology

Chest Pain Pathway Consistency:“every patient, every time”

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1.4 Engagement, and involving the right people

Think carefully about who needs to be involved and when, so that any changes to the local Chest Pain Pathway include collaboration from all who are impacted, e.g. (but not limited to):

• Senior doctors

• Junior doctors

• Nursing (particularly Triage)

• Cardiology and Emergency Departments

• Pathology

• Cardiac Catheter Laboratories

• Hospital executive

• Patient Flow Managers

2. Review before you rebuild Understand your local starting point. At the highest level there are 3 questions that every facility must ask itself when considering implementation of the minimum standards for chest pain evaluation:

1. Do we have an existing Chest Pain Pathway?

2. Does our pathway meet the minimum standards in the new policy directive?

3. Do clinicians in our facility consistently use the pathway from start to finish?

There are a number of ways to source information that will help you to get a full understanding of the starting position of your facility against the minimum standards.

2.1 The facts:

• Paper audit of the minimum standards – use the Self Audit of Existing Local Pathways Template to review the elements of any existing local pathway against the mandated minimum standards.

• File audit of local pathway use – undertake a sample file audit of patients presenting with chest pain. Using the Self Audit of Existing Local Pathways Template review the files to record which elements of the minimum standards were completed for each patient.

Tabulate the compliance rate for each of the minimum standards and look for trends.

• Observation / tagalong – observe the journey of patients presenting in the Emergency Department with chest pain. Look for successes, barriers and opportunities to successful implementation of the mandated minimum standards.

• Incident review of patients presenting with chest pain – review a series of local incidents that relate to patients presenting with chest pain. What are the patterns? Where are the barriers, risks and opportunities?

Self Audit of Existing Local Pathways Template: APPENDIX C

An example data analysis spreadsheet is available to download on the ARCHI Cardiology Model of Care web page: www.archi.net.au/resources/moc/cardio

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2.2 The experience and perceptions of clinicians:

Talk to frontline clinicians to give context to the factual information. Some options to consider are:

• One on one interviews – booking time for conversations with a number of different types of clinicians can help to generate a deeper understanding of why the existing pathway works as it does and the potential impact of any change.

• Focus groups – Focus groups are great for bouncing ideas off one another and to generate some respectful, but challenging discussion. Make sure that all those participating in a focus group have a clear understanding of what is in and out of scope.

• Surveys – Surveys are another option for gathering information, as not everyone feels comfortable speaking out in a group scenario.

Questions that are rated on numerical scales are easier to compare and generally have higher completion rates. However, open ended questions can deliver some valuable detail.

Consider the question types carefully in any survey.

2.3 The facts and the experience – prioritise the issues

The risk of any investigation is that you get lost in the detail.

Compare the facts of your local Chest Pain Pathway structure and compliance with completion with the experience of what clinicians are telling you.

To create some sense of the list of issues, barriers and opportunities keep bringing your thinking back to the key message: Minimum standards for chest pain evaluation: every patient, every time.

Create the priority list that will help your facility to first meet the mandated minimum standards for every patient, every time, before becoming more sophisticated.

3. Plan the way forwardThere are most likely a number of different ways that you can successfully move from your current state to your desired state – having a fully-compliant pathway.

Your job now is to plan the most effective way to shift your current practice to a compliant pathway while maintaining focus and motivation.

START

Current State Compliant Pathway

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Try and learn from the successes and challenges of others. There is a high probability that another hospital has faced, or is facing the same issue that you are now and has implemented a useful solution.

• Brainstorm and develop solutions to the issues you have identified. It is very important to maintain good engagement with the different clinical and non-clinical groups that will be affected.

These stakeholders understand the existing local practices, so it is important to make use of their knowledge to help design the relevant solutions.

Consider mechanisms that will ensure the local Chest Pain Pathway both meets the minimum standards and is consistently used, e.g.:

o Senior leadership involvement

o Governance, policy, evaluation and monitoring

o Pathway awareness and communications

o Education and training

• Prioritise the solutions to meet all of the minimum standards, before going beyond specific minimum standards. Further prioritise against the Pathway to see if implementing one solution is dependent on another already being in place. For example, ensure Troponin testing is in place before implementing a solution that expands to high sensitivity assays.

• Plan the sequence of work, including a description of the work to be undertaken at each stage, timeframes and who is responsible for each section of work.

• Communicate throughout change. Plan the important key messages that may include: what will change? when? and, what is everybody’s role?

START


First — Minimum Standards

Later — Go beyond the Minimum Standards

START


Which changes can be done together, and which must follow on from each other?

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4. Making ChangeNewton’s third law says that for every action there is an equal and opposite reaction. Therefore you should expect some resistance if you make any change to the existing local Chest Pain Pathway.

If you’ve planned well to this point it is not hard, just hard work. You need to stick to your communication plan and actively manage timeframes, risks and issues.

Pay now or pay later

The faster you expect a change in process to include the minimum standards for chest pain evaluation the greater the effort will be to monitor and evaluate compliance with the change.

The concept is that you can either pay now by building early commitment and engagement to design a change, or pay later, by having to enforce compliance with the pre-determined changes. Neither of these options is incorrect, you just need to decide on the approach that is appropriate for the local context for change:

1. There is a serious deficiency against the minimum standards that is a risk to patient care = Enforce the change and “pay later”

2. There is some minor tweaking to be done that will set up the local Chest Pain Pathway to go beyond the minimum standards = Design and build the change with clinicians, “pay now”

5. Monitor and evaluate Evaluating change is essential. Without a regular monitoring and evaluation strategy your change is likely to slip back down the hill to where it began.

The work that you and your facility undertook in section 2 (Review before you rebuild) will give you an excellent baseline to continue monitoring and evaluation.

Monitoring compliance against consistent completion of the minimum standards on every chest pain pathway should start with:

• high frequency (monthly audit of X% of chest pain files), and;

• high profile (direct feedback to key stakeholder groups).

Feeding back to stakeholder groups means both up and down the chain. When providing the feedback, consider the type of feedback that resonates best with the group it is being provided to (e.g. formal report, newsletter, one on one briefing, staff meeting, focus groups etc).

Wherever possible, try to include opportunities for a feedback loop in the opposite direction so that there is a continual dialogue about the process, results and the context of potential barriers and opportunities.

As the implementation of the minimum standards for chest pain evaluation settle towards core business then the monitoring plan can reduce in frequency to quarterly, half-yearly and then annually.

It is important that if you detect deterioration in performance the high profile and frequency of monitoring is returned immediately.

Increasing monitoring is not just to check up on people, but to understand why there has been a change in performance. By understanding the facts and the clinician context for change, there is a greater chance of taking corrective and sustainable action.

A resource aimed at facilitating effective local change projects has been developed and is available for review: http://www.archi.net.au/resources/moc/making-change

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Appendices

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1. What is a pathway?�

A pathway provides the standard map of care for all patients presenting to hospital with a particular clinical condition or set of symptoms.

The generic NSW Chest Pain Pathway is targeted at all patients presenting with symptoms of chest pain or symptoms suggestive of myocardial ischaemia and directs their care to achieve definitive diagnosis of Acute Coronary Syndrome or not and their subsequent management.

2. Why have a Chest Pain Pathway?�

Acute Coronary Syndrome is a time-critical and potentially life-threatening condition. Using an evidence-based, standardised protocol of care for every patient, every time, will help to quickly identify the patients with the greatest clinical need.

3. We have a pathway already. Why change?�

If you have an existing pathway, it meets the minimum standards and you can demonstrate that the pathway is actively and consistently used in your facility, then you do not need to change a thing.

However, if your facility does not have a pathway, or has one that does not meet the minimum standards or your facility has a low compliance rate with an existing pathway, then you need to make change. The Implementation Support Guide is designed to help.

4. How do I utilise the Chest Pain Pathway in a facility using an electronic Medical Record for patients?�

The Chest Pain Pathway is flagged as a high priority to be integrated into the State Based Build for EMR. However (as at June 2011), it does not currently exist in the integrated electronic form.

Unless facilities have existing Chest Pain Pathways (meeting the minimum standards) integrated into their local EMR, paper based forms must continue to be used.

5. How do the minimum standards apply to rural and regional NSW?�

The policy (PD2011_037) mandates that the minimum standards are implemented and that all hospitals have a Chest Pain Pathway for patients presenting to Emergency Departments.

Frequently Asked Questions

APPENDIX A

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Rural and regional hospitals are advised to implement the minimum standards in a locally appropriate way, by exploring linkages with rural referral networks and centralised ECG reading services.

6. What are ‘the basics’?�

The minimum standards are defined in this toolkit, however, there is also a list of considered ‘basics’ with respect to care for patients presenting with symptoms of chest pain. It is these ‘basics’ that are often found to have been suboptimal in the root cause analyses of critical adverse events. ‘The basics’ include:

• Triage category 2 being assigned

• ECG being taken

• ECG being reviewed (accurately)

• Troponins being taken

• Troponins being reviewed (accurately)

• Lack of senior leadership being available or sought

7. Do the minimum standards apply to children?�

The minimum standards for chest pain evaluation have been developed in response to critical adverse events occurring in the adult population presenting with symptoms of chest pain.

It is very rare that children with presenting with symptoms of chest pain or associated symptoms are in fact experiencing Acute Coronary Syndrome (ACS). It is therefore considered that the minimum standards for chest pain evaluation do not apply as a value-add to the existing specialised care of paediatric patients.

8. Do the minimum standards for chest pain evaluation apply to inpatients on wards?�

The minimum standards and associated generic NSW Chest Pain Pathway have been designed for patients presenting to Emergency Departments (e.g. Assigns triage category 2).

Hospitals are recommended to focus their implementation on the Emergency Department initially. However, the minimum standards should be considered transferable to tailored implementation for patients who experience chest pain or associated symptoms on inpatient wards. The Emergency Department pathway would need to be altered, but the bulk of the minimum standards remain highly relevant to safe clinical care.

9. If a patient is part of a clinical trial, do they still use the pathway?�

Clinical trials are highly important for researching treatment regimes that lead to improvement of the way we deliver healthcare. This however must not stop a patient presenting with chest pain commencing on a chest pain pathway that meets the minimum standards when they present to hospitals.

There is no reason why patients on a Chest Pain Pathway cannot be enrolled in a clinical trial, as the pathway mandates the minimum standards only.

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Implementation of the minimum standards is of critical importance and requires that all of the necessary clinicians and managers understand and perform their necessary roles.

LHD Chief Executives • Direct a LHD gap analysis against the chest pain evaluation minimum

standards

• Assign LHD sponsorship to the appropriate Executive figure to implement the minimum standards for chest pain evaluation (likely Director of Clinical Governance)

• Report minimum standards for chest pain evaluation implementation to the LHD Governing Board

• Report Chest Pain Pathway implementation and performance against the minimum standards to NSW Department of Health as requested

LHD Directors of Clinical Governance • Provide Hospitals direction and lead the LHD initial gap analysis of compliance

against the minimum standards for chest pain evaluation

• Ensure data from current information systems is accessible

• Develop and sponsor the implementation strategy to ensure LHD compliance with the minimum standards

• Coordinate appropriate educational resources for clinicians

• Evaluate LHD momentum and performance against the local implementation strategy to meet the minimum standards

• Investigate RCA incidents relating to the minimum standards for chest pain evaluation

Facility General Managers and Heads of Cardiology and Emergency Departments• Undertake the local gap analysis against the minimum standards for chest

pain evaluation – 1) Do we have a pathway; 2) Does it meet the minimum standards, and; 3) Do we actively and consistently use our local pathway?

• Involve clerical and medical records staff as appropriate to access date from existing information systems

• Communicate a united message that patients presenting with symptoms of chest pain must commence and complete a chest pain pathway that meets the minimum standards – every patient, every time.

• Lead local implementation of the chest pain evaluation minimum standards

• Engage junior and senior clinicians to get feedback on current barriers, risks and opportunities relating to any existing chest pain pathway and the implementation of the minimum standards.

• Engage junior and senior clinicians in implementation.

Minimum standards implementation — What’s my role?�

APPENDIX B

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• Engage Imaging, Pathology and Cardiac Catheter Laboratory teams to ensure that each understand the needs of the minimum standards as they relate to them and can be involved in implementation.

• Evaluate and monitor local implementation momentum and performance

• Determine requirements and provide local education for clinicians

• Coordinate local rostering to ensure that a senior clinician is available to assist 24/7 as per the chest pain evaluation minimum standards or utilise documented referral networks

Clinicians• Triage nurses will be the first point to initiate the use of a local chest pain

pathway that meets the minimum standards and hand over to subsequent clinicians that the patient is on the chest pain pathway.

• Junior doctors should provide feedback to senior clinicians regarding the challenges and opportunities relating to the use of any current chest pain pathway.

• Senior clinicians need to be available and place a high value on providing clinical advice to more junior colleagues with regards to questions relating to chest pain evaluation.

• Junior clinicians need to proactively seek out the advice of more senior colleagues when they are concerned about any aspect of management for patients presenting with symptoms of chest pain.

• All clinicians should seek opportunities to engage in implementation of the minimum standards for chest pain evaluation.

• All clinicians must comply with the minimum standards of chest pain evaluation.

• All clinicians need to provide Safe Clinical Handover when there is a transfer of accountability and responsibility for patient care (e.g. shift change, when seeking advice from senior colleagues or when a patient transfers for a test).

• Escalate management of deteriorating patients as per Between the Flags (PD2010_026).

• In Emergency Departments that do not have a medical officer accessible 24/7, it will be necessary to implement processes where the nurse in charge of the ED signs the Chest Pain Pathway form in place of the medical officer. Where the nurse in charge of the ED is not accredited or competent and active in interpreting ECGs, a process must also be implemented to engage suitably accredited practitioners through ECG reading networks with coronary care or other facilities.

• Clerical data and medical records staff have a role in accessing data during implementation and ongoing monitoring.

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Self audit of local pathways

APPENDIX C

PD2011_037 mandates the implementation of a set of minimum standards for chest pain evaluation for patients presenting to Emergency Departments in all NSW public hospitals.

Hospitals are advised that they may continue to use any existing pathway, as long as it complies with the minimum standards and they can demonstrate that it is actively used.

The following tool is designed to facilitate hospitals to review any existing local pathways with the mandated minimum standards.

Evaluating a local pathway has 3 steps:Step 1: Does your hospital have an existing local pathway?

Step 2: Does the existing local pathway meet the mandated minimum standards for chest pain evaluation?

Step 3: Is the existing pathway actively used – every patient, every time?

Hospital: _______________________________________

Date local pathway reviewed: _____________________________________

Name of person reviewing local Chest Pain Pathway: ______________________________

Position of person reviewing local Chest Pain Pathway: ____________________________

Step 1Does your hospital have an existing local pathway?�Answer Secondary question/instruction Secondary answer(s)Yes What is the name of the local

pathway?Is the pathway formal, or informal (i.e. backed by a local policy or guideline?, if so, what is the Policy reference)Who owns the pathway? (e.g. content, usage, education, monitoring and evaluation)Who knows about the local pathway?Who is expected to fill out the local pathway?Please progress to Step 2 of the self audit

No If no existing local pathway, you do not need to complete the rest of this self audit, and must implement the generic NSW Chest Pain Pathway to meet the minimum standards for chest pain evaluation

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Step 2

Does the existing local pathway meet the mandated minimum standards for chest pain evaluation?�

Further explanation on the minimum standards for chest pain evaluation will assist with completion of the audit tool. This information is available from the Minimum Standards for Chest Pain Evaluation Implementation Support Guide (www.archi.net.au/resources/moc/cardio)

Minimum standard Local compliance (Y/N)If no, add item to the mal-compliance list at the end of the audit

Exceeds minimum standard(detail if appropriate)

Assigns triage category 2

Document when ECGs have been taken

Document when ECGs have been reviewed

Stratify risk into high, intermediate or low risk patient groups (in alignment with the NHF/CSANZ guidelines)

Document when Troponin levels have been taken

Document with Troponin levels have been reviewed

Document when vital signs are taken

Direct action to be taken if vital signs move outside of acceptable ranges (as per Between the Flags PD2010_026)

Document critical times within the patient journey, specifically:

Symptom onset

Presentation

Time of diagnostic ECG

Time of Thrombolytic administration, if given

Catheter Laboratory arrival time (if applicable)

□ On table time

□ First device used

□ TIMI 3 flow time

Discussion with cardiologist

Direct that Aspirin is given, unless contraindicated

Direct that a Senior Medical Officer is assigned to provide advice and support on chest pain evaluation and initial management, 24/7 (an SMO could include consultant or VMO ED Physician, Cardiologist, General Physician, Career Medical Officer, Cardiac or Emergency Registrars)

Direct that a nominated cardiologist is assigned to provide advice on further management, 24/7

Give instruction regarding atypical chest pain presentations

List high risk alternate diagnoses for consideration

Indicate the process to initiate either Thrombolysis or PCI as the default management strategy for STEMI

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Local pathway mal-compliance list – list each of the minimum standards that are not met by the local pathway.

If choosing to amend an existing pathway, instead of implementing the generic NSW Chest Pain Pathway, these are the items that must be addressed prior to plans to exceed the minimum standards in any other item.

#1

#2

#3

#4

#5

Please progress to Step 3 of the self audit

Step 3

Is the existing pathway actively used – every patient, every time?�

Perform a sample file audit of patients presenting to your hospital with Chest Pain over the past 3 months. A helpful automated data analysis tool is available for download (www… ARCHI Cardiology page)

Transcribe results below.

Date range of files audited

Number of files audited

Number of Chest Pain presentations during the audit date range (best approximate from HIE – variability due to coding and potential multiple co-morbidities of patient cohort)

% of chest pain presentation files audited (#files audited / # of Chest Pain presentations)

Overall compliance (% compliance of total positive responses across all files audited) Xx%

Minimum standard evaluated (in the file there is documented evidence of…)

Activity compliance (% compliance of total positive responses across all files audited)

Triage category 2 assigned

ECG taken

ECG reviewed

risk stratified

Troponin level taken

Troponin level reviewed

Vital signs taken at regular intervals as appropriate

Vital signs documented at same time as being taken

Escalation of care when vital signs move outside acceptable parameters (BTF indicators)

Time symptom onset documented

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Time of presentation documented

Time of ECG documented

Time of thrombolytic administered documented (if applicable)

Cath Lab arrival time documented (if applicable)

On table time documented (if applicable)

First device used documented (if applicable)

TIMI 3 flow time documented (if applicable)

Discussion with Senior Medical Officer documented (if required)

Discussion with Cardiologist documented (if required)

Aspirin given unless contraindication recorded

High risk alternate diagnoses are considered and clinical reasoning documented

Where suboptimal compliance is found through this activity audit, the answers obtained in Step 1 should be reviewed and considered to give insight into the potential causes/solutions, specifically:

• Is the pathway formal, or informal?

• Who owns the pathway? (e.g. content, usage, education, monitoring and evaluation)

• Who knows about the local pathway?

• Who is expected to fill out the local pathway?

What do we do now?�1. If necessary, undertake further diagnostic review to understand why an existing pathway does not

already meet the minimum standards, or why it is not actively used (further advice on understanding the ‘as is’ state can be found in the Minimum Standards for chest Pain Evaluation Implementation Support Guide)

2. Create a plan that is designed to:

a. Ensure the local pathway meets the minimum standards

b. Ensure the local pathway is actively used – every patient, every time

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APPENDIX D

Policy Directive

Department of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

spacespace

Chest Pain Evaluation (NSW Chest Pain Pathway)space

Document Number PD2011_037

Publication date 09-Jun-2011

Functional Sub group Clinical/ Patient Services - Governance and Service DeliveryClinical/ Patient Services - Medical Treatment

Summary The Policy outlines the minimum standards for the management ofpatients presenting with Chest Pain or other symptoms of myocardialischaemia.

NOTE: This Policy also applies to Local Health Networks until LocalHealth Districts commence on 1 July 2011.

Author Branch Health Services Performance Improvement Branch

Branch contact James Dunne 9391 9555

Applies to Local Health Networks, Board Governed Statutory Health Corporations,Network Governed Statutory Health Corporations, NSW AmbulanceService, Public Hospitals

Audience All staff involved in the management and risk stratification of patients whopresent with chest pain

Distributed to Public Health System, Divisions of General Practice, GovernmentMedical Officers, Health Associations Unions, NSW Ambulance Service,NSW Department of Health, Tertiary Education Institutes

Review date 09-Jun-2016

Policy Manual Patient Matters

File No.

Status Active

Director-GeneralspaceThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatoryfor NSW Health and is a condition of subsidy for public health organisations.

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POLICY STATEMENT

PD2010_037 Issue date: June 2011 Page 1 of 3

IMPLEMENTATION OF MINIMUM STANDARDS FOR CHEST PAIN EVALUATION (NSW CHEST PAIN PATHWAY)

PURPOSEThe policy mandates the implementation of minimum standards for chest pain evaluation, by all hospitals in the NSW Health system for patients presenting to Emergency Departments with chest pain. Compliance with these minimum standards for chest pain evaluation will improve the management of patients by guiding clinicians through risk stratification and outlining the best practice management. Facilities may continue to use existing local Pathways provided that they meet all of the minimum standards and are in active use in emergency departments.Facilities who do not use an existing Chest Pain Pathway that meets the minimum standards must implement the standard NSW Chest Pain Pathway. The NSW Chest Pain Pathway aligns with the National Heart Foundation/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes.

MANDATORY REQUIREMENTS

1. All facilities with Emergency Departments must have and use a pathway that meets the following minimum standards for chest pain patients:

• Assigns triage category 2• Includes risk stratification• ECGs are taken and reviewed• Troponin levels are taken and reviewed • Vital signs are taken and documented• Critical times are documented (symptom onset, presentation)• Aspirin is given, unless contraindicated• A Senior Medical Officer is assigned to provide advice and support on

chest pain assessment and initial management, 24/7• A nominated Cardiologist is assigned to provide advice on further

management 24/7• The pathway gives instruction regarding atypical chest pain presentations• High risk alternate diagnosis listed for consideration e.g. Aortic Dissection,

Pulmonary Embolism & Pericarditis.• Sites that do not have 24/7 PCI capability must have Thrombolysis as the

default STEMI management strategy unless there is an existingdocumented system for transfer.

2. All facilities who do not use an existing Chest Pain Pathway that meets the minimum standards must implement the standard NSW Chest Pain Pathway that matches their facility (i.e. only sites that can provide 24/7 Primary PCI are able to use the Primary PCI site Pathway) as the minimum standard.

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POLICY STATEMENT


IMPLEMENTATIONROLES AND RESPONSIBILITIES

• Review the minimum standards of a Chest Pain Pathway in line with relevant national guidelines and best practice evidence.

NSW Department of Health:

• Develop and make accessible implementation support tools.• Evaluate Chest Pain Pathway implementation and performance against the

minimum standards across the NSW Health system.

• Ensure effective implementation of the minimum standards for chest pain evaluation in all LHN Emergency Departments

LHN Chief Executives:

• Report minimum standards for chest pain evaluation implementation to the LHN Governing Council

• Report Chest Pain Pathway implementation and performance against the minimum standards to NSW Department of Health as requested

• Direct a LHN gap analysis against the chest pain evaluation minimum standardsLHN Directors of Clinical Governance:

• Develop and lead implementation strategy• Coordinate appropriate educational resources for clinicians• Evaluate LHN Chest Pain Pathway implementation and performance against the

minimum standards• Investigate RCA incidents relating to the minimum standards for chest pain

evaluation

• Direct a local gap analysis against the chest pain evaluation minimum standardsFacility General Managers and Heads of Cardiology and Emergency Departments:

• Implement the chest pain evaluation minimum standards locally• Evaluate and monitor local implementation and performance against the chest

pain evaluation minimum standards• Coordinate local education requirements for clinicians• Coordinate local rostering to ensure that a senior clinician is available to assist

24/7 as per the chest pain evaluation minimum standards or utilise documented referral network

• Comply with the minimum standards of chest pain evaluationClinicians:

• Escalate management of deteriorating patients as per Between the Flags (PD2010_026)

• In Emergency Departments that do not have a medical officer accessible 24/7, it will be necessary to implement processes where the nurse in charge of the ED signs the Chest Pain Pathway form in place of the medical officer.

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POLICY STATEMENT


REVISION HISTORYVersion Approved by Amendment notesJune 2011(PD2011_037)

Dr Tim Smyth, Deputy Director-General, HSQPID

New Policy

ATTACHMENTS1. NSW Chest Pain Pathway: Primary PCI Site2. NSW Chest Pain Pathway: Non Primary PCI Site

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ctio

n (

back

pai

n, h

yper

tens

ion,

abs

ent

p

ulse

, BP

diffe

renc

e) C

onsi

der P

ulm

onar

y

Em

bolis

m

(se

vere

dys

pnoe

a, re

spira

tory

dist

ress

, low

sub

scrip

t O2 s

atur

atio

n)

Dia

gnos

eN

ON

ST

ELE

VA

TIO

N A

CU

TE

C

OR

ON

AR

Y S

YN

DR

OM

E (

AC

S)

ST

RA

TIF

Y A

CS

RIS

K

Con

side

r Per

icar

ditis

(sha

rp c

hest

pai

n, re

spira

tory

or

pos

ition

al c

ompo

nent

)

Go

imm

edia

tely

to

STEM

I M

AN

AG

EMEN

T (p

age

3)

N N

N

Y

HIG

H R

ISK

Any

of t

he fo

llow

ing

INTE

RM

EDIA

TE R

ISK

Any

of t

he fo

llow

ing

and

no h

igh

risk

feat

ures

LOW

RIS

K

Any

of t

he fo

llow

ing

and

no h

igh

or

inte

rmed

iate

risk

feat

ures

A

CS

sym

ptom

s ar

e re

petit

ive

or

pro

long

ed (>

10

min

) & s

till p

rese

nt.

S

ynco

pe

His

tory

of c

hron

ic le

ft ve

ntric

ular

s

ysto

lic d

ysfu

nctio

n (e

spec

ially

if

kno

wn

LVE

F <

40%

) OR

cur

rent

clin

ical

evi

denc

e of

LV

F.

Pre

viou

s P

CI/C

AB

G <

6 m

onth

s

Dia

bete

s +

typi

cal A

CS

sym

ptom

s

Chr

onic

rena

l fai

lure

+ ty

pica

l AC

S

sym

ptom

s

Hae

mod

ynam

ic c

ompr

omis

e

(sus

tain

ed S

BP

< 90

mm

Hg

and

/ or

n

ew o

nset

mitr

al re

gurg

itatio

n)

E

leva

ted

Trop

onin

(co

nsid

er h

aem

olys

is, r

enal

failu

re)

A

CS

sym

ptom

s w

ithin

48

hrs

that

occ

urre

d at

rest

, or w

ere

repe

titiv

e or

pro

long

ed (b

ut c

urre

ntly

reso

lved

)

Pre

viou

s P

CI/C

AB

G >

6 m

onth

s

Kno

wn

coro

nary

hea

rt di

seas

e-

E

sp if

prio

r AM

I or k

now

n co

rona

ry

l

esio

n >

50%

ste

nosi

s

Tw

o or

mor

e ris

k fa

ctor

s of

:

H

yper

tens

ion,

fam

ily h

isto

ry,

activ

e sm

okin

g or

hyp

erlip

idae

mia

Chr

onic

rena

l fai

lure

(esp

ecia

lly if

kn

own

GFR

< 6

0 m

L/m

in) +

at

ypic

al A

CS

sym

ptom

s

D

iabe

tes

+ at

ypic

al A

CS

sym

ptom

s

A

ge >

65

year

s

P

rese

ntat

ion

with

clin

ical

feat

ures

con

sist

ent w

ith A

CS

with

out

in

term

edia

te- r

isk

or h

igh-

risk

feat

ures

.

P

ersi

sten

t or d

ynam

ic E

CG

cha

nges

of

ST

depr

essi

on ≥

0.5

mm

or

new

T w

ave

inve

rsio

n ≥

2 m

m

T

rans

ient

ST

elev

atio

n (≥

0.5

mm

) in

m

ore

than

two

cont

iguo

us le

ads

S

usta

ined

VT

E

CG

is n

ot n

orm

al a

nd h

as c

hang

ed

f

rom

pre

viou

s pa

in fr

ee E

CG

but

doe

s

not

con

tain

hig

h ris

k ch

ange

s.

E

CG

Nor

mal

or u

ncha

nged

from

pre

viou

s pa

in fr

ee E

CG

All

case

s to

be

disc

usse

d w

ith S

enio

r Med

ical

Of

cer

Rec

omm

ende

d M

anag

emen

t on

page

2

This

tool

is in

tend

ed a

s a

guid

elin

e fo

r clin

icia

ns to

pro

vide

qua

lity

patie

nt c

are.

It is

not

inte

nded

, nor

sho

uld

it re

plac

e, in

divi

dual

clin

ical

judg

emen

t. So

me

patie

nts

with

co-

mor

bidi

ties

or p

atie

nts

not s

uita

ble

for i

nvas

ive

inve

stig

atio

ns m

ay b

e ap

prop

riate

ly m

anag

ed m

edic

ally.

Con

trai

ndic

atio

ns a

nd c

autio

ns fo

r thr

ombo

lysi

s us

e in

STE

MI1

Abs

olut

e co

ntra

indi

catio

ns:

Ris

k of

ble

edin

g- A

ctiv

e bl

eedi

ng o

r ble

edin

g di

athe

sis

(exc

ludi

ng m

ense

s)- S

igni c

ant c

lose

d he

ad o

r fac

ial t

raum

a w

ithin

3 m

onth

s- S

uspe

cted

aor

tic d

isse

ctio

n (in

clud

ing

new

neu

rolo

gica

l sym

ptom

s)R

isk

of in

trac

rani

al h

aem

orrh

age

- Any

prio

r int

racr

ania

l hae

mor

rhag

e- I

scha

emic

stro

ke w

ithin

3 m

onth

s- K

now

n st

ruct

ural

cer

ebra

l vas

cula

r les

ion

(eg,

arte

riove

nous

mal

form

atio

n)- K

now

n m

alig

nant

intra

cran

ial n

eopl

asm

(prim

ary

or m

etas

tatic

)R

elat

ive

cont

rain

dica

tions

:R

isk

of b

leed

ing

- Cur

rent

use

of a

ntic

oagu

lant

s: th

e hi

gher

the

inte

rnat

iona

l nor

mal

ised

ratio

(IN

R),

the

high

er th

e ris

k of

ble

edin

g- N

on-c

ompr

essi

ble

vasc

ular

pun

ctur

es- R

ecen

t maj

or s

urge

ry (<

3 w

eeks

)- T

raum

atic

or p

rolo

nged

(> 1

0 m

inut

es) c

ardi

opul

mon

ary

resu

scita

tion

- Rec

ent (

with

in 4

wee

ks) i

nter

nal b

leed

ing

(eg,

gas

troin

test

inal

or u

rinar

y tra

ct h

aem

orrh

age)

- Act

ive

pept

ic u

lcer

Ris

k of

intr

acra

nial

hae

mor

rhag

e- H

isto

ry o

f chr

onic

, sev

ere,

poo

rly c

ontro

lled

hype

rtens

ion

- Sev

ere

unco

ntro

lled

hype

rtens

ion

on p

rese

ntat

ion

(> 1

80 m

mH

g sy

stol

ic o

r > 1

10 m

mH

g di

asto

lic)

- Isc

haem

ic s

troke

mor

e th

an 3

mon

ths

ago,

dem

entia

, or k

now

n in

tracr

ania

l abn

orm

ality

not

cov

ered

in c

ontra

indi

catio

nsO

ther

- Pre

gnan

cy1 A

dapt

ed fr

om N

HF/

CS

AN

Z G

uide

lines

for t

he m

anag

emen

t of a

cute

cor

onar

y sy

ndro

mes

200

6

Con

trai

ndic

atio

ns to

Exe

rcis

e Te

stin

g (A

CC

/AH

A G

uide

lines

)2

Abs

olut

e- R

ecur

rent

che

st p

ain

- Acu

te m

yoca

rdia

l inf

arct

ion,

with

in 2

day

s

- Hig

h-ris

k un

stab

le a

ngin

a

- Unc

ontro

lled

card

iac

arrh

ythm

ias

caus

ing

sym

ptom

s or

hae

mod

ynam

ic c

ompr

omis

e

- Sym

ptom

atic

sev

ere

aorti

c st

enos

is

- Unc

ontro

lled

sym

ptom

atic

hea

rt fa

ilure

- Acu

te p

ulm

onar

y em

bolu

s or

pul

mon

ary

infa

rctio

n

- Acu

te m

yoca

rditi

s or

per

icar

ditis

- Acu

te a

ortic

dis

sect

ion

Rel

ativ

e- C

ritic

al le

ft m

ain

coro

nary

ste

nosi

s

- Mod

erat

e st

enot

ic v

alvu

lar h

eart

dise

ase

- Ele

ctro

lyte

abn

orm

aliti

es

- Sys

tolic

hyp

erte

nsio

n >

200

mm

Hg

- Dia

stol

ic h

yper

tens

ion

> 10

0 m

mH

g

- Tac

hyar

rhyt

hmia

s or

bra

dyar

rhyt

hmia

s

- New

ons

et a

trial

br

illat

ion

- Hyp

ertro

phic

car

diom

yopa

thy

and

othe

r for

ms

of o

ut o

w o

bstru

ctio

n

- Men

tal o

r phy

sica

l im

pairm

ent l

eadi

ng to

the

inab

ility

to e

xerc

ise

adeq

uate

ly- H

igh-

degr

ee a

triov

entri

cula

r blo

ck

- Res

ting

EC

G w

hich

will

mak

e E

ST

inte

rpre

tatio

n di

f cu

lt (e

g LB

BB

, LV

H w

ith s

train

, Ven

tricu

lar p

acin

g, V

entri

cula

r pre

exci

tatio

n.)

2 Gib

bons

eta

l, C

ircul

atio

n 10

6:18

83,2

002

Abb

revi

atio

ns:

AC

S –

Acu

te C

oron

ary

Syn

drom

e

CA

BG

– C

oron

ary

Arte

ry B

ypas

s G

raft

ECG

– E

lect

roca

rdio

gram

EST

– E

xerc

ise

Stre

ss T

est

FMC

– F

irst M

edic

al C

onta

ct

GTN

– G

lyce

ryl

trini

trate

LBB

B –

Lef

t Bun

dle

Bra

nch

Blo

ck

LVF

– L

eft V

entri

cula

r Fai

lure

LVH

– L

eft V

entri

cula

r Hyp

ertro

phy

PCI –

Per

cuta

neou

s C

oron

ary

Inte

rven

tion

SMO

– S

enio

r Med

ical

of

cer

STEM

I – S

T E

leva

tion

Myo

card

ial I

nfar

ctio

n

N

O W

RIT

ING

P

age

1 of

4

NO

WR

ITIN

G

Pag

e 4

of 4

¶SMRÊ(ÎfuÄSMR080070

Gen

eral

Man

agem

ent

O

xyge

n

Asp

irin

I

V A

cces

s

P

ain

Rel

ief

P

atho

logy

inc

l Tro

poni

n

Che

st X

-ray

NS

W H

EA

LTH

PR

IMA

RY

PC

I SIT

E C

P A

SS

ES

SM

EN

T.in

dd

120

/05/

2011

11

:48:

47 A

M

APPENDIX E

App

endi

ces

41

NH606600 - 120511


Faci

lity:

CH

EST

PAIN

PAT

HW

AY

PRIM

ARY

PC

I SIT

E C

OM

PLE

TE A

LL D

ETA

ILS

OR

AFF

IX P

ATIE

NT

LAB

EL

HE

RE

FAM

ILY

NAM

EM

RN

GIV

EN N

AME

MAL

E

FEM

ALE

D.O

.B.

____

___

/ ___

____

/ __

____

_M

.O.

ADD

RES

S

LOC

ATIO

N /

WAR

D

Faci

lity: C

HES

T PA

IN P

ATH

WAY

PR

IMA

RY P

CI S

ITE

STEM

I MA

NA

GEM

ENT

CO

MP

LETE

ALL

DE

TAIL

S O

R A

FFIX

PAT

IEN

T LA

BE

L H

ER

E

FAM

ILY

NAM

EM

RN

GIV

EN N

AME

MAL

E

FEM

ALE

D.O

.B.

____

___

/ ___

____

/ __

____

_M

.O.

ADD

RES

S

LOC

ATIO

N /

WAR

D

Rec

omm

ende

d Fu

rthe

r Man

agem

ent

Ref

er to

dru

g pr

otoc

ols

&/o

r The

rape

utic

Gui

delin

es

HIG

H R

ISK

A

DM

IT o

r TR

AN

SFER

INTE

RM

EDIA

TE R

ISK

RES

TRAT

IFY

LOW

RIS

K

DIS

CH

AR

GE

Con

tinuo

us c

ardi

ac m

onito

ring

&

frequ

ent v

ital s

igns

R

epea

t EC

G im

med

iate

ly if

sym

ptom

s

re

curs

R

epea

t EC

G 8

hrs

pos

t ons

et o

f

sy

mpt

oms

R

epea

t Tro

poni

n at

8 h

rs if

1st

sam

ple

nega

tive

*

EC

G/T

ropo

nin

revi

ew b

y m

edic

al

o

f ce

r

Ant

ipla

tele

t the

rapy

Yes

No

If no

reas

on__

____

____

____

____

____

____

____

____

____

____

____

____

___

Bet

ablo

cker

Y

es

N

oIf

no re

ason

____

____

____

____

____

____

____

____

____

____

____

____

____

_

Ant

icoa

gula

nt

Yes

N

o

If

no re

ason

____

____

____

____

____

____

____

____

____

____

____

____

____

__

Sym

ptom

atic

trea

tmen

t of o

ngoi

ng

pain

/hyp

erte

nsio

n

IV

GTN

(titr

ate

agai

nst p

ain

& B

P)

I

V M

orph

ine

Ref

er to

nom

inat

ed c

ardi

olog

ist

fo

r fur

ther

man

agem

ent

C

ontin

uous

car

diac

mon

itorin

g &

freq

uent

vita

l sig

ns

Rep

eat E

CG

imm

edia

tely

if s

ympt

oms

rec

ur

R

epea

t EC

G 8

hrs

pos

t ons

et o

f

sym

ptom

s

Rep

eat T

ropo

nin

at 8

hrs

if 1

st s

ampl

e

n

egat

ive

*

EC

G/T

ropo

nin

revi

ew b

y m

edic

al o

f ce

r

R

efer

for E

xerc

ise

Stre

ss T

est *

* if :

N

o fu

rther

che

st p

ain/

sym

ptom

s an

d

2

neg

ativ

e Tr

opon

in te

sts

and

N

o ne

w E

CG

cha

nges

and

N

o co

ntra

indi

catio

ns to

stre

ss te

st

(pa

ge 4

)

Res

trat

ify to

Hig

h R

isk

if:

Rec

urre

nt is

chae

mic

che

st p

ain

or

Pos

itive

Tro

poni

n or

N

ew E

CG

cha

nges

or

P

ositi

ve s

tress

test

Res

trat

ify to

Low

Ris

k &

Dis

char

ge if

:

Neg

ativ

e st

ress

test

or

S

tress

test

ava

ilabl

e w

ithin

72

hrs*

*

and

N

o fu

rther

che

st p

ain/

sym

ptom

s

Rep

eat E

CG

& v

ital s

igns

, if s

tabl

e

dis

char

ge

R

egul

ar v

ital s

igns

Rep

eat E

CG

imm

edia

tely

if

s

ympt

oms

recu

r

Rep

eat E

CG

8 h

rs p

ost o

nset

of s

ympt

oms

R

epea

t Tro

poni

n at

8 h

rs if

1st

sam

ple

nega

tive

*

EC

G/T

ropo

nin

revi

ew b

y

m

edic

al o

f ce

r__

____

____

____

____

____

_R

estr

atify

Ris

k if:

R

ecur

rent

isch

aem

ic c

hest

p

ain

or

Pos

itive

Tro

poni

n or

N

ew E

CG

cha

nges

If lo

w R

isk

AC

S

Dis

char

ge

Fol

low

up

GP

/LM

O w

ithin

3-5

day

s of

D/C

Con

side

r Spe

cial

ist f

ollo

w u

p

Con

side

r dis

char

ge o

n

Asp

irin

(dis

cuss

with

SM

O)

V

ital s

igns

prio

r to

disc

harg

e

If un

likel

y ca

rdia

c ca

use

C

onsi

der a

ltern

ativ

e di

agno

sis

Exit

Path

way

*If a

hig

h se

nsiti

vity

trop

onin

ass

ay is

use

d, th

e te

stin

g in

terv

al m

ay b

e re

duce

d to

3 h

ours

, pro

vide

d th

e se

cond

sa

mpl

e is

take

n at

leas

t 6 h

ours

afte

r sym

ptom

ons

et.

Med

ical

Of

cer:

Prin

t nam

e &

sig

n___

____

____

____

____

____

____

____

____

____

____

__ D

ate_

____

____

____

Med

ical

Of

cer D

esig

natio

n___

____

____

____

____

____

____

____

____

____

____

____

____

___

This

tool

is in

tend

ed a

s a

guid

elin

e fo

r clin

ician

s to

pro

vide

qual

ity p

atie

nt c

are.

It is

not

inte

nded

, nor

sho

uld

it re

plac

e, in

divid

ual c

linica

l ju

dgem

ent.

Som

e pa

tient

s w

ith c

o-m

orbi

ditie

s or

pat

ient

s no

t sui

tabl

e fo

r inv

asive

inve

stig

atio

ns m

ay b

e ap

prop

riate

ly m

anag

ed m

edica

lly.

N

O W

RIT

ING

P

age

2 of

4

NO

WR

ITIN

G

Pag

e 3

of 4

NB

: ** I

f str

ess

test

is n

ot

avai

labl

e w

ithin

72

hrs

of

disc

harg

e, tr

eatm

ent p

lan

shou

ld b

e gu

ided

by

nom

inat

ed

SMO

/Car

diol

ogis

t

Pha

rmac

olog

ical

stre

ss te

st o

r C

T co

rona

ry a

ngio

grap

hy m

ay b

e in

dica

ted

R

efer

to lo

cal

p

roto

cols

&/o

r

The

rape

utic

Gui

delin

es

plea

se u

se

24 h

r Clo

ck

C

ardi

ac m

onito

ring

E

CG

IV

Can

nula

X 2

Rou

tine

bloo

ds

Oxy

gen

Ana

lges

ia –

Mor

phin

e

Nitr

ates

-Sub

lingu

al o

r IV

CX

R

B

eta

Blo

cker

s

Con

rm

adm

inis

trat

ion

or g

ive:

A

spiri

n

300

mg

(sol

uble

)

C

lopi

dogr

el

300

- 60

0 m

g

(o

r pra

sugr

el &

/or t

iro b

an)

E

noxa

parin

3

0 m

g IV

then

bd

(or I

V h

epar

in o

r biv

aliru

din)

1 m

g/kg

sub

cut

(Max

100

mg)

PR

IMA

RY P

CI U

NLE

SS

Sig

ni c

ant d

elay

to a

vaila

bilit

y of

Cat

h La

b or

inte

rven

tiona

l tea

m o

r

Pat

ient

doe

s no

t con

sent

to p

rimar

y P

CI

H

isto

ry, c

ontra

st a

llerg

y

Vas

cula

r acc

ess

prob

lem

s

D

iscu

ss w

ith In

terv

entio

nal c

ardi

olog

ist:

Ti

me

:

D

ecis

ion

rega

rdin

g re

perfu

sion

met

hod:

T

ime

:

5.

TR

AN

SFER

TO

CAT

H L

AB

Dis

cuss

adj

unct

ive

treat

men

t w

ith C

ardi

olog

ist

OR

TH

RO

MB

OLY

SE if

app

ropr

iate

N

o co

ntra

indi

catio

ns (s

ee p

age

4)

Tene

ctep

lase

/ R

etep

lase

Bod

y W

eigh

t __

____

__kg

D

ose

____

____

Tim

e ad

min

iste

red

:

R

epea

t EC

G a

t 60

min

s po

st th

rom

boly

tic

Dis

cuss

furth

er m

x w

ith c

ardi

olog

ist

F

ailu

re to

repe

rfuse

(les

s th

an 5

0%

r

educ

tion

in S

T el

evat

ion)

Con

side

r Res

cue

Ang

iopl

asty

Cat

h La

b ar

rival

tim

e

:

On

tabl

e tim

e

:

Firs

t dev

ice

use

time

:

Tim

e of

dia

gnos

tic E

CG

:

C

hest

pai

n >

30 m

in a

nd <

12

hrs

P

ersi

sten

t ST

segm

ent e

leva

tion

of ≥

1 m

m in

two

or m

ore

c

ontig

uous

lim

b le

ads

or S

T se

gmen

t ele

vatio

n of

≥ 2

mm

in

two

cont

iguo

us c

hest

lead

s or

pre

sum

ed n

ew L

BB

B p

atte

rn

Myo

card

ial i

nfar

ct li

kely

from

his

tory

Tim

e to

Rev

ascu

laris

atio

n (T

IMI 3

ow

)

Ye

s / N

o T

ime

:

0-3

0 m

ins

31-

45 m

ins

46-

60 m

ins

61-

75 m

ins

76-

90 m

ins

>90

min

s

R

easo

n fo

r del

ay

Med

ical

Of

cer:

Prin

t nam

e &

sig

n___

____

____

____

____

____

____

____

____

____

____

__ D

ate_

____

____

____

Med

ical

Of

cer D

esig

natio

n___

____

____

____

____

____

____

____

____

____

____

____

____

___

This

tool

is in

tend

ed a

s a

guid

elin

e fo

r clin

icia

ns to

pro

vide

qua

lity p

atie

nt c

are.

It is

not

inte

nded

, nor

sho

uld

it re

plac

e, in

divi

dual

clin

ical

ju

dgem

ent.

Som

e pa

tient

s w

ith c

o-m

orbi

ditie

s or

pat

ient

s no

t sui

tabl

e fo

r inv

asiv

e in

vest

igat

ions

may

be

appr

opria

tely

man

aged

med

ical

ly.

¶SMRÊ(ÎfuÄ SMR080070

Dis

cuss

with

card

iolo

gist

/S

MO

}

1.

CO

NFI

RM

IN

DIC

ATIO

NS

for

REP

ERFU

SIO

N

2.

GEN

ERA

L M

AN

AG

EMEN

T

3.

AD

MIN

ISTE

R

AN

TITH

RO

MB

OTI

CTH

ERA

PY

4.C

HO

OSE

R

EPER

FUSI

ON

MET

HO

D

NS

W H

EA

LTH

PR

IMA

RY

PC

I SIT

E C

P A

SS

ES

SM

EN

T.in

dd

220

/05/

2011

11

:48:

54 A

M

App

endi

ces

42

APPENDIX F◆

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◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

◆◆

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◆◆

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◆◆

Faci

lity:

CH

EST

PAIN

PAT

HW

AYN

ON

PR

IMA

RY P

CI S

ITE

CO

MP

LETE

ALL

DE

TAIL

S O

R A

FFIX

PAT

IEN

T LA

BE

L H

ER

E

FAM

ILY

NAM

EM

RN

GIV

EN N

AME

MAL

E

FEM

ALE

D.O

.B.

____

___

/ ___

____

/ __

____

_M

.O.

ADD

RES

S

LOC

ATIO

N /

WAR

D

CHEST PAIN PATHWAYNON PRIMARY PCI SITE SMR080.071


Faci

lity:

CH

EST

PAIN

PAT

HW

AYN

ON

PR

IMA

RY P

CI S

ITE

CO

MP

LETE

ALL

DE

TAIL

S O

R A

FFIX

PAT

IEN

T LA

BE

L H

ER

E

FAM

ILY

NAM

EM

RN

GIV

EN N

AME

MAL

E

FEM

ALE

D.O

.B.

____

___

/ ___

____

/ __

____

_M

.O.

ADD

RES

S

LOC

ATIO

N /

WAR

D

Dat

e of

Pre

sent

atio

n

/

/

Tim

e

:

T

ime

of S

ympt

om O

nset

:

:

CH

ES

T P

AIN

or

O

TH

ER

SY

MP

TOM

S o

f

MY

OC

AR

DIA

L IS

CH

AE

MIA

(eg

sw

eatin

g, s

udde

n or

thop

nea,

s

ynco

pe, d

yspn

oea,

epi

gast

ric

dis

com

fort,

jaw

pai

n, a

rm p

ain)

Be

awar

e:

HIG

H R

ISK

ATY

PIC

AL

PR

ESEN

TATI

ON

S (

eg d

iabe

tes,

rena

l fai

lure

, fem

ale,

el

derly

or A

borig

inal

)

T

RIA

GE

C

AT

EG

OR

Y

2

ECG

& V

ital S

igns

, exp

ert

inte

rpre

tatio

n w

ithin

10

min

utes

ST E

LEVA

TIO

Nor

(pre

sum

ed n

ew) L

BB

B

Con

side

r Aor

tic D

isse

ctio

n (

back

pai

n, h

yper

tens

ion,

abs

ent

p

ulse

, BP

diffe

renc

e) C

onsi

der P

ulm

onar

y

Em

bolis

m

(se

vere

dys

pnoe

a, re

spira

tory

dist

ress

, low

sub

scrip

t O2 s

atur

atio

n)

Dia

gnos

eN

ON

ST

ELE

VA

TIO

N A

CU

TE

C

OR

ON

AR

Y S

YN

DR

OM

E (

AC

S)

ST

RA

TIF

Y A

CS

RIS

K

Gen

eral

Man

agem

ent

O

xyge

n

Asp

irin

I

V A

cces

s

P

ain

Rel

ief

P

atho

logy

inc

l Tro

poni

n

Che

st X

-ray

Con

side

r Per

icar

ditis

(sha

rp c

hest

pai

n, re

spira

tory

or

pos

ition

al c

ompo

nent

)

Go

imm

edia

tely

to

STEM

I M

AN

AG

EMEN

T (p

age

3)

N N

N

Y

HIG

H R

ISK

Any

of t

he fo

llow

ing

INTE

RM

EDIA

TE R

ISK

Any

of t

he fo

llow

ing

and

no h

igh

risk

feat

ures

LOW

RIS

K

Any

of t

he fo

llow

ing

and

no h

igh

or

inte

rmed

iate

risk

feat

ures

£ A

CS

sym

ptom

s ar

e re

petit

ive

or

pro

long

ed (>

10

min

) & s

till p

rese

nt.

£ S

ynco

pe£

His

tory

of c

hron

ic le

ft ve

ntric

ular

s

ysto

lic d

ysfu

nctio

n (e

spec

ially

if

kno

wn

LVE

F <

40%

) OR

cur

rent

clin

ical

evi

denc

e of

LV

F.£

Pre

viou

s P

CI/C

AB

G <

6 m

onth

s £

Dia

bete

s +

typi

cal A

CS

sym

ptom

s£

Chr

onic

rena

l fai

lure

+ ty

pica

l AC

S

sym

ptom

s£

Hae

mod

ynam

ic c

ompr

omis

e

(sus

tain

ed S

BP

< 90

mm

Hg

and

/ or

n

ew o

nset

mitr

al re

gurg

itatio

n)

£ E

leva

ted

Trop

onin

(co

nsid

er h

aem

olys

is, r

enal

failu

re)

£ A

CS

sym

ptom

s w

ithin

48

hrs

that

occ

urre

d at

rest

, or w

ere

repe

titiv

e or

pro

long

ed (b

ut c

urre

ntly

reso

lved

)£

Pre

viou

s P

CI/C

AB

G >

6 m

onth

s £

Kno

wn

coro

nary

hea

rt di

seas

e-

E

sp if

prio

r AM

I or k

now

n co

rona

ry

l

esio

n >

50%

ste

nosi

s£

Tw

o or

mor

e ris

k fa

ctor

s of

:

H

yper

tens

ion,

fam

ily h

isto

ry,

activ

e sm

okin

g or

hyp

erlip

idae

mia

£

Chr

onic

rena

l fai

lure

(esp

ecia

lly if

kn

own

GFR

< 6

0 m

L/m

in) +

at

ypic

al A

CS

sym

ptom

s£

D

iabe

tes

+ at

ypic

al A

CS

sym

ptom

s£

A

ge >

65

year

s

£ P

rese

ntat

ion

with

clin

ical

feat

ures

con

sist

ent w

ith A

CS

with

out

in

term

edia

te- r

isk

or h

igh-

risk

feat

ures

.

£ P

ersi

sten

t or d

ynam

ic E

CG

cha

nges

of

l

ST

depr

essi

on ≥

0.5

mm

or

l

new

T w

ave

inve

rsio

n ≥

2 m

m

£ T

rans

ient

ST

elev

atio

n (≥

0.5

mm

) in

m

ore

than

two

cont

iguo

us le

ads

£ S

usta

ined

VT

£ E

CG

is n

ot n

orm

al a

nd h

as c

hang

ed

f

rom

pre

viou

s pa

in fr

ee E

CG

but

doe

s

not

con

tain

hig

h ris

k ch

ange

s.

£ E

CG

Nor

mal

or u

ncha

nged

from

pre

viou

s pa

in fr

ee E

CG

All

case

s to

be

disc

usse

d w

ith S

enio

r Med

ical

Offi

cer

Rec

omm

ende

d M

anag

emen

t on

page

2

This

tool

is in

tend

ed a

s a

guid

elin

e fo

r clin

icia

ns to

pro

vide

qua

lity

patie

nt c

are.

It is

not

inte

nded

, nor

sho

uld

it re

plac

e, in

divi

dual

c

linic

al ju

dgem

ent.

Som

e pa

tient

s w

ith c

o-m

orbi

ditie

s or

pat

ient

s no

t sui

tabl

e fo

r inv

asiv

e in

vest

igat

ions

may

be

appr

opria

tely

man

aged

med

ical

ly.

Con

trai

ndic

atio

ns a

nd c

autio

ns fo

r thr

ombo

lysi

s us

e in

STE

MI1

Abs

olut

e co

ntra

indi

catio

ns:

Ris

k of

ble

edin

g- A

ctiv

e bl

eedi

ng o

r ble

edin

g di

athe

sis

(exc

ludi

ng m

ense

s)- S

igni

fican

t clo

sed

head

or f

acia

l tra

uma

with

in 3

mon

ths

- Sus

pect

ed a

ortic

dis

sect

ion

(incl

udin

g ne

w n

euro

logi

cal s

ympt

oms)

Ris

k of

intr

acra

nial

hae

mor

rhag

e- A

ny p

rior i

ntra

cran

ial h

aem

orrh

age

- Isc

haem

ic s

troke

with

in 3

mon

ths

- Kno

wn

stru

ctur

al c

ereb

ral v

ascu

lar l

esio

n (e

g, a

rterio

veno

us m

alfo

rmat

ion)

- Kno

wn

mal

igna

nt in

tracr

ania

l neo

plas

m (p

rimar

y or

met

asta

tic)

Rel

ativ

e co

ntra

indi

catio

ns:

Ris

k of

ble

edin

g- C

urre

nt u

se o

f ant

icoa

gula

nts:

the

high

er th

e in

tern

atio

nal n

orm

alis

ed ra

tio (I

NR

), th

e hi

gher

the

risk

of b

leed

ing

- Non

-com

pres

sibl

e va

scul

ar p

unct

ures

- Rec

ent m

ajor

sur

gery

(< 3

wee

ks)

- Tra

umat

ic o

r pro

long

ed (>

10

min

utes

) car

diop

ulm

onar

y re

susc

itatio

n- R

ecen

t (w

ithin

4 w

eeks

) int

erna

l ble

edin

g (e

g, g

astro

inte

stin

al o

r urin

ary

tract

hae

mor

rhag

e)- A

ctiv

e pe

ptic

ulc

erR

isk

of in

trac

rani

al h

aem

orrh

age

- His

tory

of c

hron

ic, s

ever

e, p

oorly

con

trolle

d hy

perte

nsio

n- S

ever

e un

cont

rolle

d hy

perte

nsio

n on

pre

sent

atio

n (>

180

mm

Hg

syst

olic

or >

110

mm

Hg

dias

tolic

)- I

scha

emic

stro

ke m

ore

than

3 m

onth

s ag

o, d

emen

tia, o

r kno

wn

intra

cran

ial a

bnor

mal

ity n

ot c

over

ed in

con

train

dica

tions

Oth

er- P

regn

ancy

1 Ada

pted

from

NH

F/C

SA

NZ

Gui

delin

es fo

r the

man

agem

ent o

f acu

te c

oron

ary

synd

rom

es 2

006

Con

trai

ndic

atio

ns to

Exe

rcis

e Te

stin

g (A

CC

/AH

A G

uide

lines

)2

Abs

olut

e- R

ecur

rent

che

st p

ain

- Acu

te m

yoca

rdia

l inf

arct

ion,

with

in 2

day

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____

____

____

____

____

____

____

____

____

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____

____

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____

____

____

____

____

____

____

____

____

____

____

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tool

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guid

elin

e fo

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nt c

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linica

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ent.

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gen

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ates

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a B

lock

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then

bd

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LESS

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or

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ocum

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AN

AG

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AD

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Med

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cer:

Prin

t nam

e &

sig

n___

____

____

____

____

____

____

____

____

____

____

__ D

ate_

____

____

____

Med

ical

Offi

cer D

esig

natio

n___

____

____

____

____

____

____

____

____

____

____

____

____

___

This

tool

is in

tend

ed a

s a

guid

elin

e fo

r clin

icia

ns to

pro

vide

qua

lity p

atie

nt c

are.

It is

not

inte

nded

, nor

sho

uld

it re

plac

e, in

divi

dual

clin

ical

ju

dgem

ent.

Som

e pa

tient

s w

ith c

o-m

orbi

ditie

s or

pat

ient

s no

t sui

tabl

e fo

r inv

asiv

e in

vest

igat

ions

may

be

appr

opria

tely

man

aged

med

ical

ly.

N

O W

RIT

ING

P

age

2 of

4

NO

WR

ITIN

G

Pag

e 3

of 4

Dis

cuss

with

card

iolo

gist

/S

MO

}

NB

: ** I

f str

ess

test

is n

ot

avai

labl

e w

ithin

72

hrs

of

disc

harg

e, tr

eatm

ent p

lan

shou

ld b

e gu

ided

by

nom

inat

ed

SMO

/Car

diol

ogis

t

Pha

rmac

olog

ical

stre

ss te

st o

r C

T co

rona

ry a

ngio

grap

hy m

ay b

e in

dica

ted

Tim

e of

dia

gnos

tic E

CG

:

¶SMRÊ(Îg|Ä SMR080071

NS

W H

EA

LTH

NO

N P

RIM

AR

Y P

CI S

ITE

CP

AS

SE

SS

ME

NT

.indd

2

12/0

5/20

11

10:3

2:22

AM

App

endi

ces

44

Membership GMCT Cardiac Network

• Prof Peter Fletcher

• Ms Karen Lintern

• Ms Bride Carr

Emergency Care Taskforce

• Dr Rod Bishop

• Dr Adam Chan

Critical Care Network

• Dr Garry Tall

Rural Critical Care Network

• Dr. Patricia Saccasan Whelan

• Ms Megan Tuipulotu

NSW Ambulance

• Mr Paul Stewart

Quality & Safety Branch

• Ms Christine Hapustein

Nursing & Midwifery Office

• Mr James Wedeswieler

Health System Performance Improvement Branch

• Mr Daniel Comerford

• Mr Neil Rickwood

Additional members

• Mr Lindsay Savage

• Dr Carolyn Hullick

• Dr Matthew Bragg

Project contact: James Dunne [email protected]

Chest Pain Patient Journey — Working Party

APPENDIX G

NSW Health

73 Miller St

North Sydney 2060

Minimum Standards for Chest Pain Evaluation · management 24/7 • The pathway gives instruction...

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Transcript of Minimum Standards for Chest Pain Evaluation · management 24/7 • The pathway gives instruction...