right is right - nacns...if definite stemi: 1. activate stemi alert 5-5523 2. send ecg to cardiac...
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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
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Case 1: ECG may be normal in any ACS…
Case 1: Troponin may also be normal on 1st measure…
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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
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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
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