Evidence Based PracticeTreatment of Chest Pain in the

Emergency Department

John Cates, RNNortheastern State University

EBP Symposium April 23, 2010

jcatesrn@suddenlink.net

WHAT IS EVIDENCE BASE PRACTICE (EBP)?

DEFINITION:The process involving the examination and

application of research findings or other reliable evidence that has been integrated

with scientific theories

EVIDENCE BASED PRACTICE

• Researched based information• Clinical Expertise• Patient Preferences

WHAT IS THE NURSES ROLE IN EBP?

• Identify clinical problems• Participate in EBP changes• Serve as change agents or opinion leaders• Establish a vision for the organization

WHAT IS THE EBP PROJECT?

• A clinical problem or area of concern that requires a solution that can be described, explained or predicted to improve nursing practice.

CHEST PAIN

CHEST PAIN

Chest pain is one of the most common problems in the emergency room

CHEST PAIN PRESENTATION

Pain (Heaviness) in chest which may radiate to neck, jaw, shoulder, upper back, abdomen

Shortness of breath Nausea and/or vomiting Diaphoresis

OTHER SIGNS AND SYMPTOMS

Abdominal painHeartburnLightheadednessDizzinessFatigue

CHEST PAIN IN WOMEN

Signs and symptoms are similar to men but may be atypical

Prevalence is usually lower until the age of 70 Consequences are often more severe

CHEST PAIN IN CHILDREN

Usually there is an underlying cause such as: Musculoskeletal Pulmonary Gastrointestinal Cardiac Psychogenic

IT IS IMPORTANT TO GATHER A THOROUGH FAMILY HISTORY AND ASK THE RIGHT QUESTIONS!!!

RISK FACTORS

Smoking Obesity Hypertension Diabetes Prior Cardiac History Family History

RESEARCH

A study by Wright et al. (2006) showed that triage nurses can identify pleuritic chest pain and start relevant evaluation and treatment. 175 participants were chosen after meeting certain criteria. The study concluded that triage nurses identified pleuritic chest pain 92.7 percent of the time. This suggests that triage nurses are more sensitive in recognizing cardiac chest pain as opposed to pleuritic chest pain.

RESEARCH

Another study by White et al. (2008) suggests using a CTA or CT angiography to diagnose cardiac chest pain in the emergency department. The CTA gives the physician a better picture of the heart and is of valuable clinical significance in diagnosing a cardiac problem in 95 percent of the study cases.

RESEARCH

A study by Steele et al. (2006) was to determine if relief of chest pain with nitroglycerin (NTG) can be used as a diagnostic test to help differentiate cardiac chest pain and non-cardiac chest pain. Of those patients who experienced relief with NTG, 34 percent had defined cardiac chest pain and 66 percent had non-cardiac chest pain.

RESEARCH (CONT)

For those who had no relief with NTG, 25 percent were found to have cardiac chest pain and 75 percent were found to have non-cardiac chest pain. There were 35 AMIs, based on troponin levels in the study population. Of those diagnosed with AMI, 20 experienced relief with NTG and 15 did not obtain relief. There were 9 deaths, and 3 in the group that did respond to NTG and 6 in the group that did not. A telephone follow-up at 4 weeks was conducted with a 95 percent contact rate.

EMERGENCY DEPARMENT PROTOCOL

A simple and thorough assessment and use of a written protocol can have a drastic and

desired effect for patient’s outcomes.

PROTOCOL

Obtain an EKG within 10 minutes upon arrival Initiate assessment for fibrinolytic therapy Administer oxygen Obtain IV access and draw blood for lab Administer pain medication per protocol

PROTOCOL (CONT)

• Aspirin on arrival– Aspirin allergy– Coumadin prescribed as pre-arrival medication

• Beta blocker within the first 24 hour– Beta blocker allergy– Bradycardia, CHF, 2nd or 3rd degree AV block, shock

• Door to Drug and Door to Needle times– Clinical reasons are acceptable

• i.e. CT to R/O ICH, BP control, family consultation re: risks, benefits– System reasons are NOT acceptable

• i.e. equipment related, staff related, awaiting consult

PROTOCOL

Everyone remember the gold standard?

MONA

NOT THESE MONA’S

MONA

MorphineOxygenNitroglycerinAspirin

DEVELOP A PLAN

• Talk to administration• Form a policy and procedure– Possibly develop clinical guidelines

• Educate and encourage the staff• Provide In-Services• Encourage feedback

INTERVENTIONS

• ASSESS!– Ask about history of chest pain– Identify risk factors– Document– Identify allergies– Notify physician– Administer appropriate medications as ordered– Continue to monitor the patient

EVALUATION

• Measured by monitoring the incidence of chest pain.– Inpatient Assessment prior to discharge– Continued Assessment after discharge• Follow-up phone call• Patient Satisfaction Survey

POSTIVE ASPECTS

• Decreased length of stay• Decreased costs for the facility• Increased patient satisfaction• Increased family satisfaction• Increased patient outcome• Quality Care

Conclusion

• The overall aim is to provide quality care by accurately assessing and treating chest pain and providing quality care. In addition, the patient would have increased satisfaction and overall positive outcome.

• The role of the nurse in the emergency department is crucial.

• By providing evidence based research, nurses can improve the care that patients receive.

QUESTIONS?

THANK YOU FOR YOUR TIME