2/7/17  

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RIGHT IS RIGHT CHEST PAIN:

Changing Outcomes one call at a TIME! The RN CHEST pain team:

Barbara  McLean,  MN,  RN,  CCNS-­‐BC,  NP-­‐BC,  CCRN,  FCCM  Cri8cal  Care  Clinical  Specialist,  Cri8cal  Care  Division,  Grady  Health  

Systems  404-­‐626-­‐2843  

bamclean@mindspring.com  

RIGHT IS RIGHT Objectives

1.  Identify the barriers to early in patient STEMI identification 2.  Define the components of chest pain assessment 3.  Discuss the methods of creating a nurse driven team 4.  Discuss the methods of evaluation in a case study

framework

Grady  Hospital,  Atlanta  GA  

2/7/17  

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Objec8ves  

BeQer  to  have  a  STEMI    and  come  to  ER  than  to  have  STEMI  in-­‐pa8ent  

Mortality  is  higher  for  In  Pa8ent  STEMi  

Why:    failure  to  recognize    Failure  to  create  a  bundle  of  symptoms    Busy  staff    AdmiQed  for  unrelated  reasons      tunnel  vision  

 Not  on  Cardiac  Service  

2/7/17  

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Case  1:  ECG  may  be  normal  in  any  ACS…  

Case  1:  Troponin  may  also  be  normal  on  1st  measure…  

2/7/17  

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My  goal  supported  by  my  system  was  to  make  a  simple  method  for  any  nurse,  family  or  housekeeper  to  call  in  chest  pain  (NOT  MET  or  RRT)  1  Proposed  an  5  week  intensive  8  hour  course  for  nurses  from  Medical  ICU  and  Cardiac  Step  down  floor.  Trained  to  perform  ECG  and  must  interprete  200  in    order  to  graduate  from  course    2.  Develop  a  simple  strategy  for  bedside  nurses  anywhere  in  the  hospital  to  make  as      a  strong  evlalua8on  of  chest  pain,  vital  signs  and  simple  therapy    3.  No8fy  the  operator  “CODE  chest  pain”    4.  No8fy  ECG  STAT  STEMI  screen  ECG    5.  Within  5  minutes  approved  cardiac  nurses  arrive  at  bedside  perform  (if  necessary)  and  evaluate  ECG    6.  ECG  loaded  into  “tracemaster”  a  remote  viewing  system    7.  If  nurse  feels  diagnosis  defin8ve,  checks  quickly  with  caardiology  OR  ac8vates  the  CCL    8.  Diagnos8c  uncertainty,  uploads  ECG  and  communicates  with  cardiology.    24/7  

Barriers  abound  Chief  of  cardiology  strongly  against  it…nurses  cannot  evaluate!  We  are  a  teaching  hospital  and  our  interns  and  residents  can  do  it    Interven8onal  cardiologist  completely  uncertain,  but  our  8mes  and  sta8s8cs  were  appalling.    Nurses  had  been  trained  to  accept  whatever    whomever  said…even  thought  they  may  not  have  ECG/  Cardiology  trained    BUT    they  were  willing  to  give  it  a  try  

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Making  the  program  1.  Training  ICU  and  Cardiac  ward  nurses  2.  Training  all  nurses    how  to  objec8vely  evaluate  

chest  pain  3.  Sehng  up  a  system  alert  4.  Achieving  all  equipment  (portable  ECG,  cell  phone  

with  alert)  5.  Sehng  up  6  day  intensive  courses,  ECG  

performance  training  6.  Sehng  up  monthly  review  classes  7.  Sehng  up  QI  follow  up  

So  lets  look  at  a  case:  A  54  year  old  man  call  you  to  his  room,  clenching  his  fist  to  his  chest  

Subjec've:  "My  chest  feels  8ght  and  I  feel  really  weak."    Step  1:    Ini'al  Assessment  Level  of  consciousness:  Conscious  and  alert  to  person,  place  and  8me;  restless  and  anxious.  Airway  and  breathing:  Airway  is  patent;  respira8ons  are  slightly  increased  and  unlabored.  Oxygen  satura'on:  97%  (on  room  air).  Circula'on:  Radial  pulse  is  rapid,  strong  and  regular;  skin  is  cool,  clammy  and  pale.    

So  lets  look  at  a  case:  A  54  year  old  man  call  you  to  his  room,  clenching  his  fist  to  his  chest  

Now,  Assess  

Step  2:  Focused  Ques'ons  regarding  Chest  Pain  (use  the  tool)  Onset:  "This  began  suddenly.  It  woke  me  from  my  sleep.”  Provoca'on/Pallia'on:  "This  pressure  in  my  chest  is  constant.  Nothing  that  I  do  makes  it  beQer  or  worse.”  Quality:  "My  chest  feels  very  8ght.”  Radia'on/Referred:  "The  pressure  stays  in  my  chest.  I  don't  hurt  anywhere  else.”  Severity:  Seven  on  a  0-­‐-­‐10  scale.  Time  of  onset:  "This  began  about  an  hour  ago.”    

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T: TemporalHow long have they had the pain? Does it come and go? Has the pain lasted longer than 5 mins

RN Chest Pain Assessment Evaluation GuideSubjective: I have chest pain / pressure / discomfort

Assessment:Chest Pain:Chest pain is a feeling of pain or discomfort in the chest

SqueezingBurning of the chestTightness around the chest

Symptoms : AnxietyNauseaVomiting

DiaphoresisDizzinessSyncope

Dyspnea,Extreme fatiguePalpitations

P: Palliative or Provocative?What makes the pain better? Activity, Position, Eating, Antacids, Other

What makes the pain worse?

Activity, Breathing, Palpation, Position, Other

Q: Quality of the Discomfort?Describe the quality of the pain?

Indigestion, Sharp, Dull, Crushing, Sensation of burning, Tightness, Pressure or heaviness in the chest

R: Radiation?Does the pain go to other areas?Epigastrium Neck /Jaw Shoulder Arms Back Other

S: SeveritySeverity of the pain / Rate on a scale of 0 -100 = no pain and 10 = the worst pain

Background : History/ Admit Diagnosis

When reporting include:History of smoking / how long / how much

All cardiac, blood pressure, erectile dysfunction medica-tions

Recommendation:IP RN chest pain order set

Notify RN chest pain team

Notify primary team

Stay with and treat the patient as ordered

5-03-15

Now    Evaluate  and  Further  Inves8gate    

Step  4:  Back  to  pa8ent:  Apply  2  L  n/c  oxygen  Sit  up  at  35  to  40  degrees  and  evaluate  vitals    

TIME  for  the  Chest  Pain  TEAM!!  

Blood  pressure:  160/92  mmHg.  Pulse:  112  beats/min,  strong  and  regular.  Respira'ons:  22  breaths/min  and  unlabored.  Oxygen  satura'on:  99%  (on  100%  oxygen).  Signs  and  symptoms:  Chest  pressure,  restlessness,  diaphoresis,  tachycardia,  hypertension.  

Allergies:  None.  He  is  not  allergic  to  aspirin.  Medica'ons:  Nitroglycerin  (as  needed)  and  Vasotec.  He  has  not  taken  any  Viagra.  Per'nent  past  history:  "I  have  high  blood  pressure  and  the  doctor  told  me  I  may  have  a  heart  aQack  if  I  don't  start  exercising.  “  Last  oral  intake:  "I  ate  supper  last  night,  but  can't  remember  the  exact  8me."  Events  leading  to  the  present  illness:  "I  was  asleep  when  the  pressure  in  my  chest  woke  me  up."  

Patient c/o chest pain ANYWHERE In Patient, In Hospital other than

ECC�The Bedside Nurse�

1�Immediately �

Assess P,Q, R, S, T�Evaluate history�

use pocket card for guidance�

4 Call Cardiac Fellow�1. PHONE the emory operator: at 404-686-1000 �2. Ask operator to text 50912, Cardiac Fellow with “URGENT CP, Nurse name and callback number “

Diagnosis Non-STEMI�Order ED/IP Non-STEMI

order set

2�Immediately �

perform�Vital Signs

4�NURSE: Enter IP RN chest pain

order set �Enter: Protocol all others �

Order ECG: STEMI SCREEN�Nurse/ Ward Clerk: CALL ECG:

404-207-0255

3�Call 911 to in house

operator �REQUEST:�

RN CHEST PAIN Team �

5�Apply 02 via N/C at 2 L�Sit patient at 35 to 40 0�

VS q 5 mins x 3, Q15 until diagnosis /disposition

1�Review ECG or

Perform ECG if not done�

**If inferior with posterior reciprocals, perform/request right sided ECG, send to

fellow

2� If DEFINITE STEMI: �

1. Activate STEMI alert �5-5523�2. Send ECG to Cardiac Fellow via Tracemaster �3. PHONE the emory operator at 404-686-1000 � Ask operator to text 50912, Cardiac Fellow message: “URGENT CP, Nurse name and callback number “�4.Notify the primary team

Diagnosis STEMI�ED/IP STEMI Timed

order set�

No cardiac involvement�Refer Back to Primary

TEAM

In Patient (IP) RN Chest Pain Flow Sheet

RN Chest Pain TEAM: RRT, MICU and 5A�CP Beeper carried by Boot TRAINED RN ONLY�

3�If NOT DEFINITE STEMI�

1. Send ECG to Cardiac Fellow via Tracemaster �2. PHONE the emory operator at 404-686-1000: Ask operator to text 50912, Cardiac Fellow with message: “URGENT CP, Nurse name and callback number “�3.Notify the primary team

1.Initiate Order Set with primary nurse/team�

2. Prepare for transport to CCL��

10/8/2014 BaM

Notify Primary TeamGather patient historyApply 02 via N/C at 2LSit patient up to 35-40°

VS Q 5 mins x 3, Q 15 unitl diagnosis/disposition

5

Patient c/o chest pain ANYWHERE In Patient, In Hospital other than

ECC�The Bedside Nurse�

1�Immediately �

Assess P,Q, R, S, T�Evaluate history�

use pocket card for guidance�

4 Call Cardiac Fellow�1. PHONE the emory operator: at 404-686-1000 �2. Ask operator to text 50912, Cardiac Fellow with “URGENT CP, Nurse name and callback number “

Diagnosis Non-STEMI�Order ED/IP Non-STEMI

order set

2�Immediately �

perform�Vital Signs

4�NURSE: Enter IP RN chest pain

order set �Enter: Protocol all others �

Order ECG: STEMI SCREEN�Nurse/ Ward Clerk: CALL ECG:

404-207-0255

3�Call 911 to in house

operator �REQUEST:�

RN CHEST PAIN Team �

5�Apply 02 via N/C at 2 L�Sit patient at 35 to 40 0�

VS q 5 mins x 3, Q15 until diagnosis /disposition

1�Review ECG or

Perform ECG if not done�

**If inferior with posterior reciprocals, perform/request right sided ECG, send to

fellow

2� If DEFINITE STEMI: �

1. Activate STEMI alert �5-5523�2. Send ECG to Cardiac Fellow via Tracemaster �3. PHONE the emory operator at 404-686-1000 � Ask operator to text 50912, Cardiac Fellow message: “URGENT CP, Nurse name and callback number “�4.Notify the primary team

Diagnosis STEMI�ED/IP STEMI Timed

order set�

No cardiac involvement�Refer Back to Primary

TEAM

In Patient (IP) RN Chest Pain Flow Sheet

RN Chest Pain TEAM: RRT, MICU and 5A�CP Beeper carried by Boot TRAINED RN ONLY�

3�If NOT DEFINITE STEMI�

1. Send ECG to Cardiac Fellow via Tracemaster �2. PHONE the emory operator at 404-686-1000: Ask operator to text 50912, Cardiac Fellow with message: “URGENT CP, Nurse name and callback number “�3.Notify the primary team

1.Initiate Order Set with primary nurse/team�

2. Prepare for transport to CCL��

10/8/2014 BaM

Bedside Nurse1. Patient c/o chest pain and meets criteria for ACS2. All patients EVERYWHERE in the hospital except ECC

On EPIC, Go to all orders: Choose IP RN Chest Pain

Ask for STEMI screen: 404-207-0255

5-03-15

2/7/17  

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12 lead ECG interpretation Boot Camp Basic A and P review ACS: the spectrum STEMI and NON STEMI PCI: interventions Hemostasis Pharmacologic Management CHF and Pulmonary Edema Pacemakers and AICD patients

MICU and SICU attendees will be required to complete the course with two days of shock, impella and IABP in April

There will be homework and quizzes and on-line education requirements. Be ready, it is intense!

Monday 2/20/2017 8: 8:30-4:30 Day 1 ECG

Tuesday2/21/2017 8:30-4:30 Day 2 ECG

Monday2/272017 8:30-4:30 Day 3 A and P

Monday3/06/2017 8:30-4:30 Day 4 ACS and

PCI , CHFTuesday

3/14/2017 8:30-4:30 Day 5 Pharmacology and Pacemakers

1. All classes will be held in 6E Critical Care ClassroomGrady Memorial Hospital

2. Attending the 2 day 12 Lead ECG is MANDATORY for those who wish to enroll in boot camp: Both days are essential!

3. No class can be missed and late arrival is discouraged

4. All attendees must complete readings and homework

5. All work must be complete by last day of class

register with: bamclean@mindspring.complease document your directors agreement to support the time all conflicts resolved before registeringplease send preferred email and cell phone in

registration email

8 hour days for 5 days!

8:30 AM to 4:30 PM All 5 days required for nurses attending Boot Camp (BC)

12 lead ECG is mandatory for BOOT CAMP.

Anyone interested in 12 lead may come to day one and two.

ECG  and  A  Chest  Pain  Nurse  will  arrive  shortly!  

Do  not  give  nitroglycerin  ini8ally  Call  the  primary  team  and  let  them  know  the  chest  pain  team  is  on  the  way  Stay  with  the  pa8ent,  con8nue  to  assess  and  comfort  If  the  team  is  not  there  within  5  minutes,  call  the  opreator  again!  

Site Facing Reciprocal Septal V1, V2 None

Anterior V3, V4 None Lateral I, aVL, V5, V6 II, III, aVF

Inferior II, III, aVF I, aVL Posterior Special ECG V1, V2, V3, V4

Chest  Pain  SBAR  

Hello,  I  am from  the  RN  Chest  Pain  Team.    I  am  calling  about    pa8ent with  MRN  # .    This  pa8ent  is  on  the     (primary  service).          I  am  calling  because  the  pa8ent  has  chest  discomfort  and  the  ECG  shows  (ST    eleva8on/depression)  of  mms  in   (lead  groups)                and  reciprocals  in  (lead  groups)

.    There  is  /is  not  any  evidence    of  LVH  or  LBB.        Heart  Rate: ,  Respiratory  rate: BP:                                                            Pain  level: .  Admihng  diagnosis  is:        I  have/have  not  ini8ated  a  STEMI  ac8va8on  based  on  my  evalua8on.        Any  other  informa8on  you  might  require  regarding  the  pa8ent  or  orders  that  you    might  give  (STEMI  protocol,  NSTEMI  protocol  or  others)  will  go  through  the  primary    nurse  (name) .  Let  me  give  the  phone  to  them.            

5-03-15

2/7/17  

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Hard  to  miss  

2/7/17  

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Less  Common    Evalua8ons  

1.  LVH  with  chest  pain  ,  ST  segment    changes  for  LVH  only  

2.  Subtle  changes  3.  Inferior  changes  4.  Posterior  changes  

53  year  old  female  medical  floor,  stated  feeling  poorly,    physician  said  not  to  call  chest  pain  team,  gave  NTG  

20  minutes  later  chest  pain  worse,  hypotension  ensued  NOW  chest  pain  team  no8fed  

Most  defini8ve  

2/7/17  

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Most  defini8ve  

264  chest  pain  ac8va8ons    4  STEMI      2  LVH  masking  STEMI    6  NSTEMI    60  LVH  without  STEMI      

Compara8ve  retrospec8ve  data    average  8me  to  open  artery  pre  chest  pain  team    400  min  (+/-­‐  180)  

Aser  chest  pain  team    average  8me  to  open  artery  130  min  (+/-­‐  40  )  

More  rapid  evalua8on  Direct  communica8on  to  cardiology  Includes  the  primary  team,  does  not  require  their  

 agreement  

What  has  happened  

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Compara8ve  retrospec8ve  data    average  8me  to  open  artery  pre  chest  pain  team    400  min  (+/-­‐  180)  

Aser  chest  pain  team    average  8me  to  open  artery  130  min  (+/-­‐  40  )  

More  rapid  evalua8on  Direct  communica8on  to  cardiology  Includes  the  primary  team,  does  not  require  their  

 agreement  

What  has  happened  

Fast  response  Fast  diagnosis  Confirmed  directly  with  cardiology  Three  groups  can  ac8vate  STEMI  (alert)  

 cardiologist    the  Central  opera8ng  desk  in  ER    the  chest  pain  team  

Has  it  changed  pa8ent  care?  Has  it  iproved  outcomes?  Is  it  8me  consuming  and  nurse  intense?    

Why  Develop  an  Expert  RN  Chest  Pain  team?  

Fri.,  Nov.  25,  2016   Chest  Pain  Nurse   Cath  Team  

61  y.o.m.  w/chest  pain   Myrta  Ortenaga   Rajesh  Sachdeva  MD  

16:52   Chest  pain  ac8va8on   Samantha  Hester   Daniel  Buchmueller  RTR  

17:02   EKG   Floor  Team   Brenda  Sturdivant  RN  

17:13   STEMI  alert   Edward  SteQner  MD   Eric  Nejedly  RN  

17:54   Cath  case  start   Kahra  Nix  MD   Lansana  Musa  CVT  

18:04   1st  interven8on   Olga  Karaniska  RN   ICU  Team  

Kendra  Coxall  RN   Marilyn  Foreman  MD  

Aaron  Cooper  MD  

Florence  Tembo  RN  

Thanks  to  all!    Recogni8on  to  interven8on:  74  minutes