The Key to Success in the Chest Pain Emergency Department: The Observational Role of the Nurse
Katherine A. Lyle, RNClinical Hospital Representative
Genentech, Inc.
Pasadena, MD
Quick Overview
Embracing the Concept of Early Heart Attack Care
Despite a decade of extraordinary advances in the treatment of ischemic heart disease (IHD), including acute myocardial infarction (AMI), IHD remains the leading cause of death in the United States. (2) Numerous clinical trials have established that timely intervention in AMI saves lives. (3) Because time is of the essence, early and prioritized care for patients with suspected IHD has become a national focus. (4) The Chest Pain Emergency Department (CPED) represents a relatively new system of patient care management, providing an efficient method for the timely evaluation of patients experiencing chest pain/discomfort in a user-friendly, outpatient setting. (5) For those patients without clear indications of AMI, the use of repeated patient assessments, serial electrocardiograms (ECGs), and serial biochemical markers are a part of routine evaluation.The name CPED implies a separation of chest pain patients from the general emergency department (ED) population. This separation of patients may be physical, for example, a separate treatment area with dedicated staff adjacent to the main ED, or a conceptual separation, that is, designating a certain number of beds within the ED exclusively for evaluating chest pain patients. Regardless of how the chest pain evaluation area is set up, what remains important is the ability of the system to rapidly evaluate those patients with possible AMI. (2) With the development of the first CPED in 1981, the role of the CPED nurse was not clearly established. However, as the concept of the CPED matured and flourished over the years, so did the role of the CPED nurse, who plays a critical role in facilitating rapid identification and treatment of patients with IHD. The success of the CPED is dependent on the nurse's ability to accurately assess the underlying etiology of the patient's chest pain and/or discomfort, elicit a personal and family history, identify risk factors for heart disease, and evaluate results of the physical examination. (6) The CPED nurse will then initiate a plan of action to secure appropriate care for the patient. Table 1 is a sample triage and assessment protocol, based on a similar model used in the CPED at St. Agnes HealthCare in Baltimore, Md.
Protocol-Driven Care
Protocol-driven care has precipitated the development of critical pathways in the ED and CPED. In the emergency setting, critical pathways provide caregivers with a framework for ensuring that all required therapies, treatments, and diagnostic tests are done in a timely, cost-effective manner. These paths build on the strengths native to the ED such as clinical expertise and physician-nurse collaboration. Critical pathways help to bridge the gap between the different departments that interface with the ED and CPED by opening lines of communication and fostering a focused team approach for managing patients with suspected IHD.Developing Critical Thinking Skills
Decision making is the basis for emergency nursing. Nurses caring for patients in the CPED must continually develop their critical thinking skills. Critical thinking is a process that allows nurses to make a decision in favor of or against a particular action. This process is based on clinical knowledge gained over time in the practice of nursing. (5) The CPED nurse uses a systematic approach to decision making accomplished through application of the nursing process. The plan of care implemented during initial patient triage and assessment can be adjusted to meet the needs of patients throughout their CPED visit. Through collaboration with the ED physician we continually negotiate patient care management issues in an effort to efficiently and effectively deliver total quality care for each patient.Over the past 2 to 3 years there has been a virtual explosion of data regarding the diagnosis and treatment of patients with IHD. This new information has altered patient care management. Because of rapidly changing technology and increasing ability to acquire scientific information, it is imperative for nurses to continue to update their knowledge base. Reading current journals, attending educational conferences, and participating in nursing research are just a few ways that nurses can keep current. Research is a method for validating existing knowledge and generating new knowledge. (6) By collecting and analyzing door-to-drug times for AMI patients, for example, CPED nurses can provide valuable information regarding their hospital's effort to reduce time to treatment and compare themselves with the National Heart Attack Alert Program's 30-minute recommendation. Nurses are utilizing research results to make informed decisions regarding patient care management issues rather than relying on the persistence of habitual behavior.
Diagnostic Reasoning
The spectrum of clinical presentations for AMI, including both typical and atypical signs and symptoms, can present a challenge for the most astute clinician. The nurse evaluating CPED patients must be aware that often elderly patients may not experience any chest discomfort and often present with shortness of breath or a neurologic sequela. The same is true for diabetics. They may describe vague symptoms or complain of generalized weakness or nausea. Female patients also often present atypically and often report epigastric pain or discomfort.Another challenge facing emergency caregivers is the fact that up to 50% of patients experiencing an AMI may present to the ED or CPED with a normal or nondiagnostic ECG. Therefore, it seems reasonable for the nurse to address stabilization and triage of all CPED patients as if they are at high risk for IHD. The nurse must maintain a high index of suspicion while aggressively searching for signs and symptoms of ischemia. It is important to have a mechanism in place that will aid in the evaluation and identification of these high-risk patients. This can be accomplished through the use of updated protocols or critical pathways that require frequent, serial diagnostic evaluations.
We have come a long way in the care of patients with IHD, but there is still much to accomplish. Embracing the concept of early heart attack care will at least point us in the right direction.
References
1. Donahue PM. Nursing, The Finest Art: An Illustrated History. St. Louis, Mo: The CV Mosby Co.; 1985:508.
2. Bahr RD. The changing paradigm of acute heart attack prevention in the emergency department: a futuristic viewpoint? Ann Emerg Med. 1995;25:95-96.
3. Cannon CP, Antman EM, Walls R, Braunwald E. Time as an adjunctive agent to thrombolytic therapy. J Thromb Thrombolysis 1994;1:27-34.
4. National Heart Attack Alert Program Coordinating Committee 60 Minutes to Treatment Working Group. Emergency department: rapid identification and treatment of patients with acute myocardial infarction. Ann Emerg Med. 1994;24:311-329.
5. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, Calif: Addison-Wesley Publishing Co., Nursing Division; 1984:307.
6. Thelan LA, Davie JK, Urden LD, et al. Textbook of Critical Care Nursing: Critical Care Nursing: Diagnosis and Management. St. Louis, Mo: Mosby; 1990:993.
7. Lee TH, Rouan GW, Weisberg MC, et al. Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Cardiol. 1987;60:219-224.
Return to Index of Articles for Clinician;
Volume 14.4
- Faculty Listing 3
- Introduction: Community Message in Acute Myocardial Ischemia 4
- Concept of Community Chest Pain Centers in Emergency Departments 5
- Reawakening Awareness of the Importance of Prodromal Symptoms in the Shifting Paradigm to Early Heart Attack Care (EHAC) 7
- The Role of Emergency Medicine in the Future of American Medical Care: A Summary of the Josiah Macy, Jr, Foundation Conference 12
- From ACC/AHA Guidelines to Best Practice: Can "Acute MI Report Cards" Save Lives?Measuring Quality of Care for Patients With Cardiovascular Disease 16
- Improving Lay Responses to Cardiovascular Emergencies and the Potential of Shifting the Paradigm to Early Heart Attack Care 18
- National Survey of Chest Pain Centers Rationale and Potential Results 21
- Outpatient Rule-Out Myocardial Infarction in Observation Units 22
- Reducing Time to Thrombolytic Treatment 24
- Intervention Programs to Reduce Patient Delays in Acute Myocardial Infarction 29
- Public Education Using the Early Heart Attack Care Program Shawnee Mission Medical Center 31
- School Component: Early Heart Attack Care Program Development and Evaluation 33
- Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction 36
- Precipitating Factors in Acute Cardiovascular Disease 41
- Use of Myocardial Perfusion Imaging in the Emergency Department for Risk Stratification 44
- The Evolution of Chest Pain Centers: The Impact of Technological Advances on the Evaluation of Patients With Possible Acute Ischemic Coronary Syndrome 47
- Critical Pathways for Triage and Treatment of Chest Pain Patients in the Emergency Department 53
- Chest Pain Centers: An Emerging Model for the Emergency Evaluation of Chest Pain and Treatment of Acute Myocardial Infarction 56
- The Key to Success in the Chest Pain Emergency Department: The Observational Role of theNurse 59
- Triage in Moderate Risk Patients With Chest Pain: The Emerging Role of Real-Time Continuous ECG Monitoring 61
- Diffusion of Innovations: The Introduction and Impact of the Chest Pain Emergency
- Department and its Comparison to the Coronary Care Unit Development 64
- Economics of Chest Pain Centers: What Really Matters? 68
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