Demonstration

Demonstration: Focusing in on chest pain



The delivery of care to those who present with chest pain in the ED varies widely throughout different institutions and different patient populations An electronic web-based approach to the effective triaging of patients in the ED not only standardizes care but also presents an opportunity to provide increased efficiency, quality, and cost containment to our health care system

The user
 

The patient...or a health care provider Any qualified ER staff, including nurses and PA's after undergoing a simple basic training program Program is designed to be user friendly enough for certain portions to be completed by the patient, and the rest by any trained personnel regardless of degree

The first screen of ETRIAGE welcomes the patient and allows the user to specify the chief complaint that the patient is presenting with. In addition, the user can specify which language the patient uses as a primary language.

In this next screen, the user is prompted to supply basic and demographic patient data including sex and medical record number.

After submitting basic patient data, the user is prompted to obtain and input vital signs. This step is a valuable tool in collecting vital information that will help effectively triage the patient with minimal user input. After submitting vital signs, the program will identify critical vital signs and patients that need immediate attention. For instance, a patient with tachycardia and hypotension or low saturations will require immediate assessment by a physician and may need immediate securement of airway, breathing, and circulation.

Next, the user is prompted to obtain a 12 lead EKG and to have the EKG evaluated by a physician (fig. 4). This represents an important step as the results of the EKG will play a large role in the algorithmic determination of how to best manage, treat, and triage the patient.

The user is next prompted to obtain a history of present illness from the patient revolving around the chief complaint of chest pain. Important questions include history of prior heart attacks, previous work-up of chest pain in the Emergency Room and in the hospital, history of revascularization procedures. In addition, questions such as is this chest pain or discomfort similar to the pain you experienced during your previous myocardial infarction or heart attack? and Do you feel that your chest pain or discomfort represents a worsening of a previously stable angina? have been validated extensively in the literature to be good predictors of ACS related chest pain (8). This step represents a critical step in the patient history and information gathering. Utilization of such tools will allow the physicians to spend more time assessing critical information and less time gathering information. Information gathering of key patient data has been shown to be more accurately and effectively collected by trained personnel or via computers than physicians in numerous studies (9).

The user is then prompted to obtain a general medical history such as past medical history, past surgical history, medications, allergies, and social history (fig. 7). History of diabetes, hypertension, coronary artery disease, meth and tobacco use are all important and critical pieces of data that will help guide decision making.

The next step requires the user to obtain lab work and imaging from the patient. This is an important step in determining the treatment and triaging best suited for this patient. For instance, an elevated troponin will necessitate admission to the ICU with a diagnosis of either NSTEMI or STEMI depending on EKG findings. In addition, alternate diagnoses may be established.

Understanding lab values

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Lab values can be processed in a similar way to our own EMR MediTech. Abnormal values will be highlighted in colors for visual emphasis, yellow for abnormal and red for critical. Elevated troponins will instantly bump risk into the highest category and into active ACS. Abnormal potassium values will need to be evaluated and tied into the EKG findings. Elevated glucose levels themselves are not particularly concerning, but highly elevated levels (Glu > 200) should trigger a recommendation for Diabetic screening (HbA1c at a later time) and the patient will be automatically considered a +1 CAD risk equivalent.

This represents the extent of information gathering necessary to perform the appropriate algorithms to determine how to best treat and triage the patient. The algorithm will follow guidelines that have been presented and rigorously validated in the literature for the management of chest pain

A sample report is included here. The report can be printed out and included in the paper records, or can automatically become a part of the patients electronic records. This electronic record or paper print out can be immediately accessible to everyone else, including physicians on the admitting team, nurses directly taking care of the patient, the ICU team, and any cardiologists consulted for this patient.

References
1. Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, National Health Care Expenditures Data, January 2010. 2. Olson EJ. No room at the inn: a snapshot of an American emergency room. Stanford Law Rev. 1994 Jan;46(2):449-501. 3. Roberge D, Pineault R, Larouche D, Poirier LR. The continuing saga of emergency room

Questions???