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For cardiac care nurses in ICU or emergency units, the faster-paced decision process provides them several advantages, according to a clinical decision unit supervisor at Medical City Dallas.

Patients from age 21 to 94 occupy all 10 beds in the cardiac-intensive clinical decision unit (CDU) in Medical City Dallas at noon on a recent Friday.

Downstairs in the ED, a 77-year-old man has arrived in the triage unit complaining of overall fatigue and weakness. But since the day is young, nurses know the pace is just warming up for the weekend rush that will get rolling over the next few hours.

These patients represent a small number of the hospitalized who might be suffering a heart attack. Dozens more could already have been admitted to the surgical, telemetry/progressive care, and hemodialysis units, having been “ruled in” for possible or obvious warning signs of myocardial infarction or other cardiac-related dangers.

One person you won’t see worried by the traffic build-up is Tony Baxter, RN, BA, CEN, the ED nurse manager at Medical City. He knows most of these patients will be home by the end of the day.

“We’re able to get [the ED] emptied out by the middle of the day most times,” says Baxter. “[Then] we check in the majority of our patients, as much as 50% of our volume, from 3 PM to 11PM.”

This level of efficiency would not be possible without the capabilities of Medical City’s accredited chest pain center, a unit that operates within the confines of the ED. The chest pain center is a collective of emergency, laboratory, and surgical services that speeds the diagnosis and treatment process of patients with cardiac symptoms, giving victims immediate life-saving care. It also provides the “false-alarm” patients with a faster path to
discharge by cutting back on costly, lengthy, and ultimately unnecessary hospital stays.

According to the Society for Chest Pain Centers (SCPC), more than five million Americans enter the hospital every year with chest pain. About 1.25 million of them will have true cardiac distress symptoms, and 600,000 will die of heart disease.

Chest pain centers have been around for nearly 25 years at numerous hospitals, but it’s been only in the past 18 months that certain facilities across the country, like Medical City, have earned accredited status, in recognition of some of the advanced procedures that these centers have brought to EDs.

The accreditation is offered by the SCPC, a Columbus, Ohio–
based association formed in 1998 to promote changes in hospital procedures for diagnosing and treating patients with ischemic heart disease. The society’s accreditation process encourages hospitals to adopt specific triage-evaluation procedures for patients with chest pain.

“We have seen incredible improvements in the outcomes of our multidisciplinary team,” says Jack Kauffman, director of cardiac services at Riverside (Calif.) Community Hospital. “Our door-to-EKG time improved 56%, and our door-to-balloon time was reduced. We’ve improved in a lot of areas, including the education to our ER 85 and nursing staff.”

“This will help us monitor ourselves and continue to work on those processes,” says Famy Bialon, RN, BSN, MPA, vice president of patient care services at Riverside.

Medical City has reduced its total average length of stay for patients with chest pain who undergo secondary testing to 14.82 hours — accounting for the 1,200 patients a year who are discharged early after finding out their pain didn’t signal “the big one.” Formerly, this patient may have been hospitalized at Medical City for two to three days.

The major difference for hospitals running chest pain centers is the inclusion of an integrated cardiac cath lab that allows for near-bedside testing of enzymes, ECGs, and ultrasounds. This produces faster results than the traditional observational method through a hospital admission.

For example, the enzymes tests, which can detect likely myocardial damage through the elevation of troponin I, CKMB, and myoglobin levels, are usually back from the lab within 15 minutes of admission triage, instead of more than an hour, says Baxter. A patient with a possible MI sent to the CDU will undergo further serial enzyme testing to examine the levels at different time intervals and have a cardiology consultation that will eventually clear the patient for either discharge, hospitalization, or a corrective procedure.