The Heart Beat
Chest pain centers are on the frontlines of ED cardiac care.

By Glen Fest
February 14, 2005

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.

For cardiac care nurses in ICUs or EDs, the faster-paced decision process provides several advantages, according to a CDU supervisor at Medical City.

“It makes us feel like we’re getting things done,” says Gail Allen, RN, CCRN. “Doctors pay more attention to us here in the ER area, and we do things much faster and more efficiently, I think.”

By delineating the patient load among heart attack victims, likely candidates, and those fully cleared, Allen says she’s able to devote more time to her patients. “We can actually give them the attention they need vs. on the floor with 60 beds,” she says. “With my 10 beds, even though there’s only two of us here, if they need to have a heparin drip or something going, I can usually get to it right away.”

When Medical City and sister HCA Dallas/Fort Worth–area hospitals Medical Center of Plano and North Hills Hospital of North Richland Hills were granted accreditation last October, all three were the first in North Texas to be designated. Only 92 hospital chest pain centers nationwide have been designated, including 11 in Texas.

SCPC accreditation is a comprehensive process that measures eight elements required of a hospital’s operations:

• ED integration with EMS systems
• Emergency assessment, diagnosis, and treatment of acute coronary syndrome (ACS) patients
• Assessment of patients found with low to moderate risk for ACS
• Functional facility design
• Personnel, competencies, and training
• Organizational structure
• Process improvement orientation
• Community outreach program

Baxter says the chest pain center accreditation process can be arduous. He points to a phone-book-size binder in his office, containing Medical City’s documentation of its protocols meeting SCPC standards.

“If someplace doesn’t have bedside testing, doesn’t have clinical pathways that are set up for treatment recommendations 85 if they’re not looking at ways to improve their door-to-inflation time, if they’re not looking at a door-to-EKG time of less than 10 minutes 85 they have a lot of work to do,” says Baxter. “A lot of those things were already in place 85 here at Medical City Dallas. Some of those weren’t as big of a hurdle for us.”

Gaining the accreditation does not stop the quest for improved care. Kadlec Medical Center of Richland, Wash., is among several accredited hospitals looking to streamline the process of wirelessly transmitting paramedics’ 12-lead ECG field tests into the hospital before a patient’s arrival.

“We had a case in August or September where a guy at a hotel 85 woke up at 2 AM with a heart attack,” says Kadlec’s Roger Casey, RN, BSN, CEM. “The paramedics responded, ran [and transmitted] the 12-lead EKG in the field, and we had the cath team here by the time he got to the door.”

Only a small percentage of patients have actual cardiac episodes when admitted to the ED — as little as 10% to 15%, according to the SCPC. From 4% to 13% are mistakenly discharged, with 11% to 25% of those dying from heart attack.

Cardiac diagnoses have a major impact on the bottom line. Mistaken diagnoses are the most costly subject of malpractice litigation against emergency physicians. On the other hand, patients admitted for false symptoms cost both the patient and the hospital in excessive medical fees.

Generally, though, according to the SCPC and advocates for chest pain centers, the losses they most want to prevent are the lives of patients themselves.

Links:

• Society of Chest Pain Centers
  http://www.scpcp.org/
• Clinical Information and Concepts in Chest Pain Centers
  http://jumpstart.chestpaincenters.org/chestpaincenters/default.cfm

Glen Fest is a managing editor for NurseWeek.