Cairns Hospital: Suspected Acute Coronary Syndrome Pathways. DO NOT USE if a non cardiac cause for the chest pain can be diagnosed
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1 Cairns Hospital: Suspected Acute Coronary Syndrome Pathways DO NOT USE if a non cardiac cause for the chest pain can be diagnosed Clinical pathways never replace clinical judgement. Care outlined on this pathway must be altered if not clinically appropriate for the patient Presentation with clinical features consistent with Acute Coronary Syndrome? High Risk Criteria - ECG - ischaemic changes - Troponin I (TnI) >0.04mcg/l - Left Ventricular Ejection Fraction (LVEF) <40% - New Mitral Valve Regurgitation - Haemodynamic compromise - Syncope - Percutaneous Coronary Intervention within 6 months - Coronary Bypass Grafting (CABG) - Diabetes Mellitus (DM) with typical symptoms - Estimated Glomerular Filtration Rate (egfr) <60ml/min with typical symptoms and? 40 year-old Low Risk Criteria - < 40 year-old - < 18 year-old if Indigenous Australian - ECG no ischaemic changes - First TnI? 0.04mgm/l - egfr > 60ml/kg - No history of DM Intermediate Risk Criteria -? 40 year-old - ECG - no ischaemic changes - First TnI? 0.04mgm/l -? 18 year-old if Indigenous Australian - DM with atypical symptom at any age - egfr? 60ml/min and atypical symptoms Recurrent presenters Treat as per pathway unless: the patient has a specific personalised pathway; or after a documented ED or Cardiology consultant plan Recurrent symptoms during assessment period A recurrence of symptoms requires a ressessment of risk Risk assessment HIGH RISK? (one or more high risk criteria present) NO LOW RISK? (ALL low risk criteria present) NO INTERMEDIATE RISK (one or more intermediate risk criteria present) Action ADMIT CARDIOLOGY Retest TnI and ECG after 6 hours Cardiology registrar in hours (69907) OR Medical registrar out-of-hours (69999) Admit to ESSU Retest TnI and ECG after 2 hours If TnI > 0.04 mcg/l: Admit as high risk (see above) If TnI? 0.04 mcg/l: Discharge for GP follow up Discharge with patient information, preformatted letter for GP and ED discharge letter NO OUT PATIENT REFERRAL ADMIT CARDIOLOGY Retest TnI and ECG after 2 hours If TnI? 0.04 mcg/l: Assess if suitable for accelerted pathway (see management of intermediate risk patient) If TnI > 0.04 mcg/l: Admit as high risk Cardiology registrar in hours (69907) OR Medical registrar out-of-hours (69999) Monitoring On presentation for all possible cardiac chest pain All high risk patients Monitoring not required Low or Intermediate risk patients after first TnI? 0.04 mcg/l and pain free
2 Cairns Hospital: Accelerated Pathway for Intermediate Risk suspected ACS APIRA Intermediate Risk Criteria -? 40 year-old - ECG - no ischaemic changes - First TnI? 0.04mgm/l -? 18 year-old if Indigenous Australian - DM with atypical symptom at any age - egfr? 60ml/min and atypical symptoms NOT HIGH OR LOW RISK for suspected ACS INTERMEDIATE RISK (First TnI? 0.04 mcg/l) PRINT the intermediate risk ACS pack from sharepoint or desk top - EST FAX referral - Discharge letter to GP - Patient information Pre - second troponin - Flag admission with TL (APIRA noted on FirstNet in TL comments) - Chest pain registrar (in hours) or medical registrar (out of hours) notified that a patient is now on the intermediate chest pain pathway - Screen for EST contraindications and referral for EST (by MO) to CIU - form found in intermedicate risk ACS pack on share point - CIU phone or and CIU fax Expected rate of conversion to high risk only 2.5% Stay in ED Off monitoring Awaiting 2hr troponin Notify chest pain reg Able to physically do stress test? If yes: FAX EST request (24/7) Flagged for admission Second (2 hour) Troponin? 0.04 mcg/l and ECG unchanged? NO NO about 2.5% Exit accelerated pathway and refer to Cardiolgy or to Gen Med intermediate risk for ACS but NOT on accelerated p/w TL commnets Not for APIRA on FirstNet Second troponin negative - Patient admitted to Cardiac Investigation Unit (CIU in EST hrs*) or Ward (out of EST hrs) under cardiology - Consultant ED interim order completed and Medical admission on the ward (if not already done in ED) - Chest pain registrar and CIU notified that a patient is admitted or transfered to CIU with a second negative Troponin - CIU staff (in EST hrs*) will work based on a pull model of care. If no bed available on CCU or Cardiac ward - Bed management to find alternate non-monitored bed - Not to be admitted to ESSU (except as part of a code yellow response) Patient admitted to CIU (in EST hrs) or Ward (out of hrs) ED consultant interim plan (if patient not already seen by cardiology/medical reg) *Stess testing hours (or in EST hrs) - Monday to Friday 0800 to 1800hrs - Saturday and Sunday 0800 to 1200hrs Normal EST NOT NORMAL about 2-4% High Risk (referral to cardiology) iemr documentation: - Working diagnosis = Chest Pain RE-STRATIFIED TO LOW RISK Discharge patient from Cardiology with information letter and GP letter
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5 Cairns Hospital Cardiology Department Cardiology Department Cairns Hospital 165 The Esplanade, Cairns QLD 4870 Phone: Dear Dr, Regarding: Patient Name DOB URN This patient presented today to the Emergency Department at Cairns Hospital with possible cardiac chest pain. Risk stratification was undertaken and the patient was considered to be of Intermediate risk of experiencing acute coronary syndrome. The patient was placed on an accelerated chest pain pathway for assessment. The ECG and Troponin I level taken at arrival and at 2 hours after arrival was negative. The patient received an inpatient Exercise Stress Test (EST). The EST was normal. We have asked your patient to return to you for assessment of the need for risk factor modification for cardiovascular disease. Yours sincerely, Cairns ED Medical Officer Date:
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7 Cairns Hospital Cardiology Department Patient Information Sheet Cardiology Department Cairns Hospital 165 The Esplanade, Cairns QLD 4870 Phone: Accelerated Chest Pain Pathway: Exercise Stress Test As part of your health care today, you have been placed on an accelerated pathway to allow us to rapidly diagnose the cause of your chest pain. Our evidence-based management plan has been designed with your safety as its highest priority along with avoiding unnecessary time in hospital. You have received two blood tests and an ECG which check for any damage to the heart muscle. Both tests were negative. You have also undergone an exercise stress test, which was normal. Although a cardiac cause or heart problem can never be completely ruled out, the risks to you are very low and allow you to be safely discharged. We recommend that you follow up with your GP within one week to discuss modification to risk factors for heart disease. Should you have any concerns about your condition at any time, you should contact your local General Practitioner, taking the discharge letter you have been given, or return to your nearest Emergency Department.
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