nurs-ed-53 - strac

Acute Coronary Syndrome (ACS) and Heart Alert in the Emergency Department of 14

NURS-ED-53 Approval Date: 08/14

Title: Acute Coronary Syndrome (ACS) and Heart Alert

in the Emergency Department

Document Number: NURS-ED-53

Document Type: Policy, Procedure

Affected Departments: Emergency Department (ED), Catheterization Lab

(Cath Lab)

Review Bodies:

Position or Committee Date Review

Completed

BHS Regional Chest Pain Steering

Committee

(Owning body)

08/14

BHS Cardiovascular Service Line 09/14

BHS ED Service Line 08/14

Revision/(Review) Dates: (Dates that included only a review, but no content

revision, are in parentheses)

07/14

Effective Date: 08/14

SUMMARY OF ATTACHMENTS:

Associated Policies/Procedures: Nursing Care Protocols Guidelines for the Emergency

Department, NURS-ED-23

Patient Transfer, RM-EMTALA-01

Other Associated Document(s): Heart Alert Audit Tool, Attachment A

IMPACT Protocol, Attachment B

STEMI Walk-In/EMS Pathway, Attachment C

Transfer Process for MTB, Attachment D

Risk Stratification, Attachment E

ACS Clinical Pathways, Attachment F

Associated Form(s): EMS Prehospital ECG/Rhythm Strip, BHS-MR 90508802

Thrombolytic Orders for STEMI, BHS Orders Set #CA-CL08

CDU: Chest Pain Possible ACS, BHS-CD-CA03

AMI Admission Orders, CM-BH01

APPROVED BY:

Approval Body

(Position or Committee) Name Authentication Date

Quality & Patient Safety Steering

Committee

Meeting Minutes &

Digital Signatures

08/14

Medical Executive Board

Meeting Minutes 09/14



I. PURPOSE

To define and outline the process of an Emergency Department (ED) ACS and Heart Alert

patient from first medical contact to percutaneous coronary intervention (PCI).

II. DEFINITION(S)

A. Heart Alert

Heart Alert is the notification process that triggers a rapid chain of events leading to the

activation of the Cardiac Catheterization Lab (Cath Lab) team and the interventional

cardiologist on-call to the Cath Lab for acute treatment of a patient with symptoms of an

ST-segment elevation myocardial infarction (STEMI) or new left bundle branch block

(LBBB). The treating Cardiologist will determine the appropriate treatment of patients

with new or presumed new LBBB and possible Acute Coronary Syndrome. Heart Alert

is designed to shorten the door to PCI times (D2B) and heighten awareness using a

single paging system and calling Interventional Cardiology.

B. ST-segment Elevation Myocardial Infarction (STEMI)

STEMI is a clinical syndrome defined by characteristic symptoms of myocardial

ischemia in association with persistent electrocardiographic (ECG) diagnostic ST

elevation (at the J point in at least 2 contiguous leads of _2 mm (0.2 mV) in men or _1.5

mm (0.15 mV) in women in leads V2–V3 and/or of _1 mm (0.1 mV) in other contiguous

chest leads or the limb leads) and subsequent release of biomarkers of myocardial

necrosis. New or presumably new Left Bundle Branch Block (LBBB) has been

considered a STEMI equivalent (ACCF/AHA, 2013).

C. Percutaneous Coronary Intervention (PCI)

Percutaneous Coronary Intervention (PCI) is a non-surgical, minimally invasive

procedure that uses a catheter (a thin flexible tube) inserted into a blood vessel either in

the leg or arm to place a small structure called a stent to open up blood vessels in the

heart that have been narrowed by plaque buildup, a condition known as atherosclerosis.

D. Early Risk Assessment

For admitted patients, risk stratification is done after exclusion of STEMI/New LBBB

and other non-cardiac diagnoses.

Stratification is based on history, physical exam, ECG, lab and x-ray as determined by

the treating physician. A variety of tools such as TIMI, Braunwald, and Grace criteria

have been used to measure risk of mortality and recurrent cardiac events. However, in

the Emergency Department the decision to admit or discharge a patient should be based

on clinical judgment since these criteria have not been shown to be superior to physician

judgment. Risk stratification of admitted patients may guide additional therapies as an

inpatient.

E. First Medical Contact

The point at which the patient is either initially assessed by EMS or other medical

personnel in the pre-hospital setting or the patient arrives at the hospital’s emergency

department.



III. POLICY

The American College of Cardiology Foundation (ACCF) and the American Heart

Association (AHA) Task Force on Practice Guidelines recommend a Regional Systems of

STEMI Care, Reperfusion Therapy, and Time-to-Treatment Goals to enable rapid

recognition and timely reperfusion of patients with STEMI. System delays to reperfusion are

correlated with higher rates of mortality and morbidity.

The Southwest Regional Advisory Council (STRAC) formed a Regional Cardiac Systems

Committee in January 2008 to develop a cooperative and regional approach to STEMI care.

The Baptist Health System worked with other members of the healthcare community to

develop the HEART ALERT activation system to enable rapid recognition and timely

reperfusion of patients with STEMI.

IV. PROCEDURE

A. EMS Pre-hospital to Cath Lab

Patients arriving to the ED via EMS.

1. Pre-hospital Work Up

a. EMS completes a 12-lead ECG in the field to identify a STEMI or new LBBB.

2. ED Notification

a. After a STEMI or new LBBB is identified, the 12-lead ECG is transmitted to the

ED’s ECG receiving station where it is reviewed by the ED physician and/or ED

nurse.

b. If EMS is unable to transmit the ECG or the ECG receiving station is inoperable,

EMS will relay his/her findings to ED staff via the EMS phone or radio.

Additionally EMS will provide a detailed assessment of the 12-lead ECG to

include the computer derived interpretation and a description of the leads with

ST segment elevation.

3. Activation of Heart Alert

a. Based on the pre-hospital 12-Lead ECG and the EMS report of Heart Alert, the

ED Physician and/or ED nurse will activate a Heart Alert prior to the patient’s

arrival using a single paging system and calling Interventional Cardiology (see

below and STEMI Walk-In/EMS Pathway Flowchart (Attachment C)).

b. Initiating a BHS Heart Alert includes calling the on-call Interventionalist and

activating the Cath Lab team using a single page system. Nursing directors,

house officer, and administration will also be notified with paging system.

c. The pre-hospital ECG’s are mounted on BHS Pre-Hospital ECG/Rhythm Strip

mounting sheet. The pre-hospital ECG is given to the ED physician (goal less

than 10 minutes) who will generate a written record of their interpretation and

place in patient’s permanent medical record.

d. Reference to STEMI Walk-In/EMS Pathway Flowchart (Attachment C).

4. Patient Preparation

a. The ED staff will initiate the IMPACT protocol (Attachment B).



5. Transport to the Cath Lab

a. Once the Cath Lab team arrives the patient is transported to the Cath Lab by ED

personnel and/or Cath Lab team.

b. Verbal report providing pertinent information and the ED chart; medication

reconciliation, heart alert audit tool, original ECG, ED nursing documentation,

ED physician documentation is given to the Cath Lab team.

B. ED Walk-in to Cath Lab

Patients presenting to the ED with signs or symptoms of acute coronary syndrome, not

arriving by EMS.

1. Triage

a. The patient is initially greeted by a Registered Nurse or an employee who has

had annual formal training in ACS signs and symptoms.

2. ED Work-up

a. The triage nurse will ensure a 12-lead ECG is completed as soon as possible

upon identifying the chief complaint of Chest Pain or ACS symptoms. (Goal: less

than five minutes from time of arrival).

b. The ED Physician will review the ECG for evidence of STEMI and sign the

ECG. The triage nurse triages the patient based on standard Emergency Severity

Index (ESI) guidelines. (Goal: less than 10 minutes)

c. After the ECG is performed, patient will be transferred from triage to an

Emergency Department room if bed available. If no bed available chest pain

protocols will be initiated per BHS Nursing Care Protocols Guidelines for the

Emergency Department, NURS-ED-23.

3. Activation of Heart Alert

a. Based on the 12-lead ECG, the ED physician will activate a Heart Alert using a

single paging system and calling Interventional Cardiology for a STEMI or

presumed new LBBB.

b. Initiating a BHS Heart Alert includes calling the on-call Interventionalist and

activating the Cath Lab team using a single page system. Nursing directors,

house officer, and administration will also be notified with paging system.

4. Patient Preparation

a. The ED staff will initiate the IMPACT protocol (Attachment B).

5. Transport to the Cath Lab

a. Once the Cath Lab team arrives the patient is transported to the Cath Lab by ED

personnel and/or Cath Lab team.

b. Verbal report providing pertinent information and the ED chart; medication

reconciliation, heart alert audit tool, original ECG, ED nursing documentation,

ED physician documentation is given to the Cath Lab team.

6. Reference STEMI Walk-In/EMS Pathway Flowchart (Attachment C).



C. Thrombolytic Therapy

1. In some patients with identified STEMI the ED physician may decide the patient

would benefit from Thrombolytic therapy if PCI will be delayed. For example, a

patient in the first 120 minutes of symptoms where there will be greater than a 90

minute delay in PCI may do better if given thrombolytic. Refer to BHS

Thrombolytic Orders for STEMI.

D. Mission Trail Baptist Hospital Transfer Process

1. Mission Trails Baptist hospital does not perform heart catheterizations for acute

treatment. If the patient presents with STEMI or presumed new LBBB, a heart alert

is paged alerting Baptist Medical Center Cath Lab and the interventional cardiologist

is notified.

2. Following the BHS Patient Transfer Policy, RM-EMTALA-01, the patient is

transferred to Baptist Medical Center Cath Lab by EMS (Attachment D).

3. See Attachment D for transfer process flowchart.

E. Risk Stratification Guide

1. Risk stratification is done for admitted patients using the guide after exclusion of

STEMI/New LBBB and other non-cardiac diagnoses (Attachment E). Consider

utilization of the BHS Low Risk Chest Pain Orders (order number) for low risk

patients or BHS Admission Orders Acute MI (order number) for non-low risk

patients.

2. Patient’s being admitted will be admitted to a cardiac monitoring unit.

3. Nursing handoff per BHS Hand-Off Communication, RM-PS-04, with original ECG

accompanying the patient and an additional copy scanned into the medical record.

4. Reference BHS ACS Clinical Pathways flowchart (Attachment F).

V. REFERENCES

American Heart Association. (2013). ACCF/AHA practice guideline. Circulation, 127,

e663-e828. doi: 10.1161/CIR.0b013e31828478ac. Retrieved from:

http://circ.ahajournals.org/content/127/23/e663.full

Hess, E. (2012). Diagnostic accuracy of the TIMI risk score in patients with chest pain in the

emergency department: A meta-analysis. Canadian Medical Association Journal,

182(10), 1039-1044. doi: 10.1503/cmaj.092119

Manini, A., Dannemann, N., Brown D., Butler, J., Nagurney, J., et al. (2009). Limitations of

risk score models in patients with acute chest pain. American Journal of Emergency

Medicine, 27(1), 42-48. doi: 10.1016/j.ajem/2008.01.022

Meyer, M., Mooney, R., & Sekera, A. (2006). A critical pathway for patients with acute

chest pain and low risk for short-term adverse cardiac events: Role of outpatient

stress testing. Annals of Emergency Medicine, 47(5). doi:

10.1016/j.annemergmed.2005.10.010

Norekyl, T., Lindahl, B., Hasin, Y., McLean, S., Tubaro, M., & et al. (2012). Pre-hospital

treatment of STEMI patients: A scientific statement of the working group acute care

of the European society of cardiology. Acute Cardiology Care, 13, 56-67.

http://circ.ahajournals.org/content/127/23/e663.full



O’Gara, P., Kushner, F., Ascheim, D., Casey, D., Chung, M., & et al. (2013). 2013

ACCF/AHA Guideline for the management of ST-evelation myocardial infarction:

Executive summary. Journal of the American College of Cardiology, 61(4), 485-510.

doi: 10.1016/j.jacc.2012.11.018



Heart Alert Audit Tool

Attachment A



IMPACT Protocol

Attachment B

The IMPACT protocol was designed to expedite STEMI care in the ED while the Heart Alert team

is in route to the facility. IMPACT is an acronym for the following:

1. Identify and consent the patient (if applicable)

2. Medicate the patient. Communicate with the physician(s) regarding the patient’s

medication needs (example: ASA, pain medication, heparin, beta blockers, etc.). Remember,

the key is good communication

3. Pads. Use radiolucent defibrillator pads (white leads). Place one pad on the right back and

the other on the left side.

4. Access X 2. Please provide two (2) IV access points. Draw labs/cardiac biomarkers.

5. Clip (both sides of groin). Trim from the groin to just above the knee. Electric clipper only.

6. Transport on monitor with defibrillator/external pacing capability. Assist Cath Lab staff

with transporting the patient to the Cath lab and transferring the patient to the procedure

table. Assist with lead, BP monitor, O2, and SPO2 placement. When applicable, assist

family members to the waiting area.



YES

NO

Clinical pathways never replace judgment. Care outlines in the pathway must be altered if it is not clinically appropriate for the individual

patient. Timing of referral to cardiology/medical may vary for local circumstances.

RN Triage

Signs & Symptoms

of Acute Coronary

Syndrome

Perform ECG

Interpret for STEMI, signed &

placed on chart with Goal within

10 minutes.

STEMI

Initiate BHS Nursing Care Protocols

Guidelines for the Emergency

Department, NURS-ED-23.

Initiate HEART ALERT

utilizing one-call system

ED physician calls report to

Interventional Cardiologist

IMPACT

PROTOCOL

To Cath Lab for

Invasive Intervention

ED Physician Evaluation

RISK STRATIFICATION

(ACS Clinical Pathways, Attachment F)

EMS- transmits ECG via LifeNet - call

ED to activate Heart Alert.

If unable to transmit ECG- call ED &

activate Heart Alert identified by EMS

provider.

Walk-in

Baptist Health System

STEMI WALK-IN/EMS PATHWAY

Attachment C



Transfer Process for Mission Trails Baptist

Attachment D

ED Physician decides Thrombolysis may be

preferable to transport in select patients

Thrombolysis Order Set



Risk Stratification

Attachment E

Risk Stratification for Likelihood of Acute Coronary Syndrome and

Short Term morbidity/mortality

For Admitted patients after exclusion of STEMI/New LBBB and other non-cardiac diagnoses.

Stratification based on history, physical exam, ECG, lab and x-ray as determined by the treating

physician. This is a guide, but not a substitute for clinical judgment, which in multiple studies has

been found to be equivalent or better than scoring tools.

High Risk any of the following (suggest use of appropriate ACS physician order set)

☐Known Medical history of Coronary Artery Disease, MI, or Revascularization.

☐Chest or Left arm pain similar to prior symptom of angina or MI

☐Elevated cardiac troponin

☐Hypotension OR pulmonary edema on presentation

☐New (or presumed new) ST deviation (≥0.5 mm)

☐New (or presumed new) T-wave inversion (>1mm or in multiple precordial leads)

☐New RBBB

☐Ventricular tachycardia

Moderate Risk (suggest use of appropriate ACS physician order set)

☐Chest or Left arm pain or discomfort as chief symptom (do not mark if clearly chest wall pain,

GERD or pleuritic in nature)

☐Diabetes

☐Extracardiac vascular disease (CVA, PVD, AAA)

☐Pathologic Q waves

☐Age >70

☐2-3 risk factors for CAD

Low Risk (suggest use of appropriate ACS physician order set)

☐Absence of STEMI/New LBBB, High Risk Criteria or Moderate risk



Baptist Health System ACS Clinical Pathways

Attachment F

Diagnosis STEMI Angioplasty STEMI Thrombolysis

Probable NSTEMI Possible ACS Non-ACS

Clinical Evaluation/Symptoms

Based on ED Physician evaluation

Consistent with ACS Consistent with ACS Consistent with ACS Consistent with ACS or atypical Not consistent with ACS

ECG (as indicated)

Completed in <5 MINUTES

ECG given to physician for interpretation. Goal within 10 minutes.

Physician records time and interpretation.

Findings:

ST Elevation/New LBBB



Findings:

ST Elevation/New LBBB

ECG given to physician for interpretation. Goal within 10 minutes. Physician records time and interpretation. Findings: Absence of ST Elevation/New LBBB


Physician records time and interpretation. Findings:

Absence of ST Elevation/New LBBB



Findings:

Not consistent with ACS

TESTS Labs/ Cardiac Biomarkers, CXR

Findings: Initial labs not a determinant of diagnosis or disposition

Labs/ Cardiac Biomarkers, CXR

Findings: Initial labs not a determinant of diagnosis or disposition

Labs/ Cardiac Biomarkers, CXR

Findings:

(+) Cardiac Troponin

Labs/Cardiac Biomarkers, CXR

Screening for non-ACS etiology as indicated.

Stress Test as indicated

Findings: (-) Cardiac Troponin

Diagnostic tests determined by ED Physician Evaluation. Screening for non-ACS etiology as indicated.

Findings: (-) Cardiac Troponin if ordered



Diagnosis STEMI Angioplasty STEMI Thrombolysis

Probable NSTEMI Possible ACS Non-ACS

MEDICATIONS ASA chewed (unless contraindicated)

*See IMPACT Protocol #2

ASA chewed (unless contraindicated)

*See IMPACT Protocol #2



Medications determined by ED Physician Evaluation, as appropriate for determined etiology

DISPOSITION Activate HEART ALERT- CONTACT INTERVENTIONAL CARDIOLOGIST

Initiate IMPACT Protocol.

TRANSFER TO CATHERIZATION LAB

(MTB Only)- Follow MTB to BMC STEMI Transfer Process

Activate HEART ALERT- CONTACT INTERVENTIONAL CARDIOLOGIST

Initiate IMPACT Protocol.

TRANSFER TO CATHERIZATION LAB

(MTB Only)- Follow MTB to BMC STEMI Transfer Process

In the event of a significant delay in the availability of the Cath lab or interventional cardiologist, consider Thrombolysis. Follow Thrombolytic Policy.

Admit to Cardiac Monitoring Unit. Implement AMI Physician Order Set

Secondary Risk Stratification

Further risk stratification using Risk Stratification tool (Attachment E)

Discharged Instructions based on determined etiology including specific information that includes risk and lifestyle modifications as indicated. Follow-up instructions provided.

Moderate or High Risk

Place patient in Observation Status to Cardiac Monitored Unit, use appropriate ACS physician order set.

Low Risk

Place in Observation Status to Cardiac Monitored Unit, use appropriate ACS Physician order set. May consider discharge from Emergency Department with follow up plan. Discharge patients receive information that includes risk and lifestyle modifications and outpatient follow-up. If Stress Test not done during initial visit, discharge instructions should include a follow up plan with physician.



1. (-) ECG means normal or unchanged from previous ECG

2. Non-STEMI Definition: Either one of the following criteria satisfies the diagnosis of an acute, evolving or recent MI:

a.) Rise and fall of biochemical markers for myocardial necrosis with at least one of the following: ischemic symptoms, development of pathologic Q waves on ECG, and ECG changes indicative of

ischemia (ST elevation or depression).

b.) Pathologic findings of AMI

3. Risk stratification tool for admitted patients only (Observation/Admit).

If the patient's condition changes, patient will be reassigned to the appropriate clinical pathway.

CLINICAL PATHWAYS NEVER REPLACE CLINICAL JUDGMENT. CARE OUTLINED IN THE PATHWAY MUST BE ALTERED IF IT IS NOT CLINICALLY APPROPRIATE FOR THE INDIVIDUAL PATIENT. TIMING OF THE

REFRERRAL TOO CARDIOLOGY/MEDICAL MAY VARY FOR LOCAL CIRCUMSTANCES.

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