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Minimum Standards for Chest Pain Evaluation
Implementation Support Guide
Consultation Edition (October 2011)
Contact details NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060
Tel. (02) 9391 9000 Fax. (02) 9391 9101 www.health.nsw.gov.au
Copyright information This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the NSW Department of Health.
© NSW Department of Health 2011
Further copies details
1. For further copies of this document please contact: Better Health Centre – Publications Warehouse Locked Mail Bag 5003 Gladesville 2111 Tel. (02) 9816 0452 Fax. (02) 9816 0492
2. For further copies of this document please contact:
Health Services Performance Improvement Branch Tel. (02) 9391 9823 Email. [email protected]
3. Further copies of this report can be downloaded from the NSW Health website:
www.health.nsw.gov.au
Disclaimer Content within this publication was accurate at the time of publication.
Current Publication Date October 2011
Foreword
The NSW Health system is highly complex, relying on the expertise of 100,000+ employees to provide quality health care services to the citizens of NSW.
A significant wealth of experience exists in specialised management for patients presenting with symptoms of chest pain. A number of chest pain pathways already exist to guide the safety and quality of care provided to patients. However, there is inconsistency in the content and use of these pathways within and between hospitals across NSW.
Root Cause Analysis and Coronial investigations demonstrate that significant adverse events continue to occur, due to inconsistencies in the practice of the minimum standards for chest pain evaluation.
Responding to this need, the State-wide Cardiology Project developed the Chest Pain Pathway working group to work with clinicians and health service teams to redesign better patient journeys for patients presenting to hospitals for chest pain evaluation. The work of this group links into broader improvement strategies for adult patients with Acute Coronary Syndrome.
It is critical to note that these minimum standards have been developed by the working party, comprising multi-disciplinary staff from across NSW health facilities.
The Chest Pain Pathway working group should be acknowledged for their focus on the importance of early and sustained key stakeholder engagement. The minimum standards for chest pain evaluation has included consultation with Local Health District representatives, including Cardiology, Emergency Department, frontline clinicians, Patient Flow Management Team, and Clinical Redesign Unit staff, as well as Ambulance NSW, the Clinical Excellence Commission, the Agency for Clinical Innovation Cardiac Network, the Critical Care Taskforce, Rural Critical Care and consumer representatives.
The minimum standards also align with the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the management of Acute Coronary Syndrome.
The recently issued Policy Directive (CPD2011_037) for the minimum standards for chest pain evaluation will assist clinicians to provide evidence based care to a high risk group of patients who frequently present to our Emergency Departments.
This implementation support guide complements the Policy Directive and aims to assist managers and clinicians to meet the minimum standards outlined in the policy. I commend this resource to you and hope that it assists you and your teams to improve the management of chest pain, every patient, every time.
Mr Mike Wallace A/Deputy Director-General, System Purchasing and Performance Division NSW Health
ContentsExecutive Summary .................................................................................................... 4
Objectives ............................................................................................................ 4
Background ..........................................................................................................4
Mandatory Requirements ..................................................................................... 4
Key questions to guide implementation ............................................................... 5
Key messages for clinicians and managers ......................................................... 5
Ordering the NSW Chest Pain Pathway ............................................................... 7
Case For Change .......................................................................................................... 8
Coroner’s recommendations ................................................................................ 8
Final RCA Report ................................................................................................. 9
Minimum Standards for Chest Pain Evaluation ....................................................... 13
Minimum Standards Explanation ......................................................................... 13
Generic NSW Chest Pain Pathway ...................................................................... 17
Implementation of minimum standards for chest pain evaluation – Making Change ............................................................................................................ 19
1. Getting started ................................................................................................ 20
2. Review before you rebuild ............................................................................. 21
3. Plan the way forward ..................................................................................... 22
4. Making Change .............................................................................................. 24
5. Monitor and evaluate .................................................................................... 24
APPENDIX A — Frequently Asked Questions .......................................................... 27
APPENDIX B — Minimum standards implementation — What’s my role?� ............. 29
APPENDIX C — Self audit of local pathways ............................................................ 31
APPENDIX D ................................................................................................................35
APPENDIX E ................................................................................................................39
APPENDIX F .................................................................................................................41
APPENDIX G — Chest Pain Patient Journey — Working Party ............................... 43
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Executive Summary
ObjectivesTo improve patient safety by implementing minimum standards for chest pain evaluation in NSW Public Hospitals, for every patient, every time.
BackgroundThere is a significant wealth of experience in care for patients presenting with chest pain to hospitals. A number of chest pain pathways already exist; however, there is inconsistency in the use of pathways within and between hospitals across NSW.
The minimum standards for chest pain evaluation and Chest Pain Pathway were developed in response to significant adverse events in NSW that required investigation and attention to preventative measures.
After a review of Incident Information Management System data, the Clinical Excellence Commission prepared two Clinical Focus reports on Acute Coronary Syndrome, delivered to the Clinical Risk Review Committee (CRRC). The CRRC then determined that the Health Services Performance Improvement Branch of the NSW Department of Health be charged with addressing issues identified in the reports.
The Chest Pain Patient Journey Steering Committee (see page 44) began this process and included Senior doctors and nurses representing Emergency and Cardiology Departments, Ambulance Service of NSW, the Australian Heart Foundation, the Agency for Clinical Innovation, Clinical Safety, Quality and Governance, rural and metropolitan stakeholders.
After significant consultation and discussion the steering committee endorsed a chest pain pathway that is applicable to both Primary Percutaneous Coronary Intervention (PCI) sites and non-Primary PCI sites.
Mandatory Requirements1. All facilities with Emergency Departments must have and use a
pathway that meets the following minimum standards for chest pain patients:
• Assigns triage category 2
• ECGs are taken and reviewed by someone competent in ECG interpretation
• Includes risk stratification
• Troponin levels are taken and reviewed
• Vital signs are taken and documented
• Critical times are documented (symptom onset, presentation)
• Aspirin is given, unless contraindicated
• A Senior Medical Officer is assigned to provide advice and support on chest pain assessment and initial management, 24/7
• A nominated Cardiologist is assigned to provide advice on further management 24/7
• The pathway gives instruction regarding atypical chest pain presentations
• High risk alternate diagnosis listed for consideration e.g. Aortic Dissection, Pulmonary Embolism & Pericarditis.
Incident Information Management System data
Clinical Excellence Commission
Clinical Focus Report
Clinical Focus Report
Clinical Risk Review Committee
NSW Dept of Health
Chest Pain Steering Committee
Minimum Standards
For further explanation of the minimum standards, see page 14 in this guide.
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• Sites that do not have 24/7 PCI capability must have Thrombolysis as the default STEMI management strategy unless there is an existing documented system for transfer.
2. All facilities that do not have, or do not use, an existing Chest Pain Pathway that meets the minimum standards must implement the standard NSW Chest Pain Pathway that matches their facility (i.e. only sites that can provide 24/7 Primary PCI are able to use the Primary PCI site Pathway) as the minimum standard.
Key questions to guide implementationMonitoring the minimum standards for chest pain evaluation should form an ongoing part of the local quality and safety program. There are three basic questions to answer to determine the current state of your hospital against the minimum standards and guide your implementation focus:
1. Does our hospital have a Chest Pain Pathway?�If no – implement the generic NSW Chest Pain Pathway appropriate to your hospital → Then – monitor the pathway to ensure that it is used (every patient, every time)
2. Does our existing pathway meet the minimum standards?�If no – either amend the existing pathway to meet the minimum standards or implement the appropriate generic pathway. → Then – monitor the pathway to ensure that it is used (every patient, every time)
3. Is our existing pathway used (every patient, every time)?�If no – understand why the existing pathway is not being used consistently and develop a plan to improve compliance → Then – monitor the pathway to ensure that it is used (every patient, every time)
Key messages for clinicians and managersPatients presenting with chest pain for evaluation in NSW EDs are suffering significant adverse events due to inconsistencies in the practice of minimum standards for chest pain evaluation.
The mandated minimum standards for chest pain evaluation must be implemented to ensure consistency of practice for every patient, every time.
The take-home message from this implementation support guide is slightly different depending on who you are. Consider the following questions:
Clinicians in Emergency Departments (doctors and nurses)
• Do we have a local chest pain pathway?
• Do I know what is on it and how to use it?
• Do I use this pathway for every patient every time?
For more information on the differences between Primary and non-Primary PCI sites, see: page 18
A template is available to evaluate your current position and guide implementation: page 32
For more information on roles, see: page 30
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Cardiology and Emergency Department Directors
• Do we have a local chest pain pathway that meets the minimum standards?
• Have we trained our clinicians in how to use the pathway?
• Do we monitor compliance with the local pathway and feed back to staff?
Hospital and Local Health District Executive (particularly Directors of Clinical Governance)
• Is there Hospital/District sponsorship for a chest pain pathway?
• Does our Hospital/District meet all requirements of the mandated minimum standards for chest pain evaluation (PD2011_037)?
• Do our clinicians have the training and resources required to use the chest pain pathway for every patient, every time?
Safety and Quality Departments
• Do we monitor patient safety against the performance of existing local chest pain pathways?
• How can we integrate monitoring of the minimum standards for chest pain evaluation into ongoing quality and safety improvement?
Common issues with Chest Pain Pathway compliance
In May 2006 the Chest Pain Evaluation Area Toolkit was released by the Health Services Performance Improvement Branch. Research relating to the use of existing pathways and in conjunction with the repeated findings of Root Cause Analyses and Coronial investigations, highlights some common issues to be:
Category IssuesGeneral Issues • Varying degree of use of chest pain pathways
leading to differences in clinician practices
• Cultural aversion to pathways, despite evidence-based good practice.
• Implementation of pathways have not always followed procedural ‘good practice’ – change management principles need to be followed (e.g. sponsorship, use of a “process owner” at each site, etc).
Process Issues • Delayed or lack of access to stress test inhibits the use of pathway.
• Inconsistencies with acquisition and accurate interpretation of ECGs
• Inconsistencies with acquisition and interpretation of Troponins
People Issues • Insufficient leadership and Executive agreement - Variations in ED and cardiology buy-in.
• Insufficient training for ED clinicians in local pathways – rotation of staff accentuates this problem. A key cause of this problem is a lack of ownership of pathways at each location to help educate staff in its use.
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This confirms that the issue with existing Chest Pain Pathways in NSW is not the level of sophistication of the pathway, but the implementation of minimum standards of chest pain evaluation into core practice.
Ordering the NSW Chest Pain PathwayThere are 2 generic NSW Chest Pain Pathway forms to select from:
• PCI Hospital Pathway
• Non PCI Hospital Pathway
These forms are now available for order from Salmat:
Chest Pain Pathway PCI SiteStockcode NH606600
Chest Pain Pathway Non PCI Site Stockcode NH606601
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Case For ChangeSignificant adverse events continue to occur where patients presenting to NSW Emergency Departments experience inconsistencies in the minimum standards for chest pain evaluation.
The high rate of chest pain presentations, coupled with the potentially catastrophic outcomes when inconsistencies lead to suboptimal care, demands a strategic response.
The NSW State Coroner and Root Cause Analysis (RCA) Committees have called for the use of minimum standards of chest pain evaluation for every patient, every time.
Real life examples below highlight the need to ensure that the minimum standards are implemented and actively used consistently in all NSW Public Hospitals.
NOTE: the causes identified in Coronial and Root Cause Analysis investigations frequently relate to lapses in the basic fundamentals of care for chest pain patients, rather than the use of sophisticated treatment protocols.
Coroner’s recommendationsThe NSW State Coroner’s recommendations arising from investigation of recent deaths include the need to:
• Consider Chest Pain as the cause of other related symptoms presented
• Consider the different causes of Chest Pain
• Follow a Chest Pain pathway in its entirety
• Train all staff in any chest pain treatment protocol
• Stratify the risk of a patient’s condition deteriorating
Excerpts from the Coronial Inquest into the death of a 61 year-old man at a metropolitan hospital in 2006:
… Acute Chest Pain Protocol should be reviewed and amended as appropriate to emphasise the necessity to consider and exclude life-threatening conditions other than cardiac ischaemia, specifically aortic dissection, coronary artery occlusion and pulmonary embolism, in all presentations of acute chest pain.
The … Acute Chest Pain Protocol should be reviewed and amended as appropriate to emphasise that all sections of the Chest Pain Evaluation ED Management Form are to be completed …Specifically, the person filling in the form must note the likelihood of ischaemic heart disease, the risk stratification, the preliminary diagnosis and the action to be taken.
… an exercise stress test is not to be carried out in any case where the patient is experiencing any form of chest pain at the time of the proposed test. … an induction program presented by a senior cardiologist to ensure that all residents and interns caring for cardiac patients are familiar with relevant protocol …
“every patient, every time.”
Implementing standardised protocols of care has been shown to significantly improve patient outcomes.
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Death of a 51 y-o male (rural district hospital) Contributing factor:
The network specific- chest pain/ ACS pathway was not initiated for an atypical acute coronary syndrome presentation resulting in a missed opportunity for further assessment and acute coronary syndrome risk stratification and subsequent management which may have reduced the likelihood of cardiac arrest resulting in death.
Recommendation:
“…the RCA team recommend that all patients presenting to the emergency department with both typical and atypical chest discomfort/tightness or symptoms suggestive of ACS be triaged category 2 and have a chest pain /ACS pathway initiated and followed according to ACS stratification.”
Contributing Factor:
Lack of timely Troponin T analysis resulted in missed opportunity for early recognition and management of acute coronary syndrome which may have prevented cardiac arrest and death.
Recommendation:
“If Troponin T analysis is clinically indicated it should be processed immediately and results known before patients leave the department.”
Root Cause Analysis Report FindingsThe following factors have been consistently identified through the RCA process as contributing to Acute Coronary Syndrome incidents:
• Failure to undertake appropriate investigations, e.g. ECG, Troponin testing
• Failure to interpret ECGs correctly
• No formal system for obtaining senior clinician review of the ECG
• Delay or failure to notify the consultant on call / consultant responsible for the patient
• Failure to review results prior to patient transfer or discharge
• Failure to have a chest pain pathway in place for the management of patients with cardiac / possible cardiac pain
These are illustrated by factors and recommendations highlighted in the following real-life RCA investigations.
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Death of a 76 year old female, district hospital Contributing factor:
A delay in seeking specialist advice … may have contributed to further myocardial ischaemia and the patient’s deterioration which contributed to the patient’s death.
Recommendation:
“… ensure the emphasis on the use of the Chest Pain Pathway and ensure knowledge of the process for obtaining specialist medical advice and support 24 hours a day.”
Contributing Factor:
A chest pain pathway was not initiated and the recommended treatment was not followed.
Recommendation:
“ … a chest pain pathway is initiated at triage for patients with chest pain regardless of the cause of the pain.”
Death of 52 year old female, rural referral hospital and tertiary hospitalContributing Factor:
Failure to review the patient’s pathology results prior to discharge meant that a patient with a positive Troponin was discharged home with an incorrect diagnosis. As a consequence the patient experienced an acute cardiac event at home resulting in cardiac arrest from which they did not survive.
Recommendation:
“Patients who have test results pending, specifically Troponin results, are not to be discharged from hospital until the results have been reviewed, documented in the notes and appropriate actions have been undertaken to address the findings.”
Contributing Factor:
Chest Pain Pathway … was not used. These tools are designed to assist clinicians to recognise acute cardiac events and to reduce the possibility of a missed diagnosis.
Recommendation:
“Patients presenting to the Emergency Department with cardiac/possible cardiac pain are to be commenced in the NSW Health state-wide Chest Pain Pathway documentation…”
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Incident involving 70 year old female, metropolitan hospitalContributing Factor:
There are gaps in competence of ECG analysis and/or interpretation skills among medical and nursing staff in ED. This led to an inability to identify ST elevation on ECG and resulted in delay in diagnosing an acute STEMI that required an urgent coronary angioplasty.
Recommendation:
“Implementation of a formal education program on ECGs for both medical and nursing staff and a competency assessment according to the expected standard for each.”
Minimum Standards for Chest Pain Evaluation
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Minimum Standards for Chest Pain Evaluation
Minimum Standards ExplanationThe minimum standards for chest pain evaluation must be implemented in all NSW hospitals. They aim to ensure that the fundamentals of care are delivered, every patient, every time.
The following explains some basic detail for each of the minimum standards and the generic NSW Chest Pain Pathway.
1. Assigns triage category 2
All patients who present to an Emergency Department with chest pain or other symptoms of myocardial ischaemia, (eg. sweating, sudden orthopnea, dyspnea, syncope, epigastric discomfort, jaw pain or arm pain) within the last 48hrs MUST be assigned triage category 2.
Where the patient’s clinical situation demands it, these patients could also be assigned triage category 1.
2. ECGs are taken and reviewed
Within 10 minutes of starting on the Chest Pain Pathway, all patients are to have a 12 Lead ECG taken, reviewed and interpreted by a professional who is accredited to interpret the ECG.
A formal process to document that the review has occurred should be in place.
3. Includes risk stratification
All Chest Pain pathways must contain a process for risk stratification that assigns either:
• High Risk
• Intermediate Risk, or
• Low Risk
This risk stratification must be in line with the NHF/CSANZ guidelines for the management of Acute Coronary Syndromes.
4. Troponin levels are taken and reviewed
All patients MUST have a blood sample collected for testing that includes Troponin (or equivalent cardiac biomarker) level on arrival. Once the sample is collected, it must be labelled “urgent” and sent for processing immediately.
The staff member who ordered the Troponin (or equivalent cardiac biomarker) test must actively seek the results to ensure that they are reviewed in a timely fashion.
National Heart Foundation of Australia Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006, MJA, 184:8
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NO patient is to be discharged prior to the review of a Troponin (or equivalent cardiac biomarker) test that has been ordered.
Sites that are able to conduct high sensitivity Troponin assay are encouraged to do so providing that the timeframes meet the recommendations in the 2011 addendum to the NHF/CSANZ guidelines for the management of Acute Coronary Syndromes.
It is recommended that the laboratory reports elevated Troponin levels to the ordering physician as soon as possible.
5. Vital signs are taken and documented
Vital signs (Blood Pressure, Temperature, Pulse, Respiratory Rate and Pain) must be taken and documented in the patient notes at the time that they are taken. If any of the results are outside the acceptable parameters then they must be acted upon, in line with the recognition and management of a deteriorating patient.
If it is not possible to obtain a pain score, a description of the pain is also very useful. A report of ongoing, unresolved pain requires a repeat ECG to be taken and reviewed.
6. Critical times are documented (symptom onset, presentation)
All patients must have critical times documented. These include, but are not limited to, symptom onset and time of presentation.
Other important times to document are:
• Diagnostic (or “trigger”) ECG
• Thrombolytic administration
• Cath Lab arrival
• On table time
• First device use
• TIMI 3 flow
• Discussion with Cardiologist.
7. Aspirin is given, unless contraindicated
Aspirin use is recommended as per the NHF/CSANZ guidelines
If patients present via Ambulance, ensure that Aspirin administered by Paramedics is recorded in the patient record.
This should already be documented in the paramedics' notes. A reference to the advice provided by the paramedics should subsequently be sufficient.
8. A Senior Medical Officer is assigned to provide advice and support on chest pain assessment and initial management, 24/7
Identifying Senior Medical Officers should be considered based on the local staff base and could be defined as:
• Consultants
• Visiting Medical Officers
• Staff Specialists
National Heart Foundation of Australia Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006, MJA, 184:8
Recognition and management of a patient who is clinically deteriorating: PD2010_026
National Heart Foundation of Australia Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006, MJA, 184:8
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• Career Medical Officers
• Registrars
• Senior Nurses (as a first line of assistance where a senior doctor is not immediately available)
Consideration should be given to strengthening networking linkages through local referral networks and centralised ECG reading services.
9. A nominated Cardiologist is assigned to provide advice on further management 24/7
All Emergency Departments MUST have a defined and documented process that ensures that a nominated Cardiologist is contacted to provide further management advice for the following patient groups:
• STEMI
• High Risk ACS
• Intermediate Risk ACS who are being discharged without access to stress testing within 72hrs
Consideration should be given to strengthening networking linkages through local referral networks and centralised ECG reading services.
10. The pathway gives instruction regarding atypical chest pain presentations
Most chest pain presentations are 'typical' with symptoms, such as: sweating, orthopnea, syncope, dyspnoea, epigastric discomfort, jaw pain and arm pain. There are, however, occasions when chest pain presentations are 'atypical'.
Pathways must contain a listing of common high risk atypical presentations eg. diabetes, renal failure, female, elderly or aboriginal.
Some populations require additional considerations/awareness of the presence of Acute Coronary Syndrome due to the nature of atypical presentations for chest pain and other symptoms of myocardial ischaemia or for the increased prevalence of cardiovascular disease.
These populations are patients with diabetes or renal failure, age>65yrs, chronic renal failure or aboriginal.
11. High risk alternative diagnosis listed for consideration e.g. Aortic Dissection, Pulmonary Embolism & Pericarditis.
Following advice from the Coroner the alternate High Risk diagnoses MUST be included on the pathway to ensure consideration during the initial diagnostic process.
Chest discomfort is a common challenge for clinicians in the emergency department. The differential diagnosis includes conditions affecting organs throughout the thorax and abdomen, with prognostic implications that vary from benign to life-threatening. Failure to recognize potentially serious conditions such as acute ischaemic heart disease, aortic dissection, tension pneumothorax, or pulmonary embolism can lead to serious complications, including death. Conversely, overly conservative management of low-risk patients leads to unnecessary hospital admissions, tests, procedures, and anxiety.
Review the Generic NSW Chest Pain Pathway for an example of atypical chest pain: APPENDIX E
Source: Expert opinion of Chest Pain Patient Journey Working Group
Review the Generic NSW Chest Pain Pathway for an example of high risk alternative diagnoses being integrated into the pathway: APPENDIX E
Reference :Harrison’s Principles of Internal Medicine, Seventeenth Edition (2008) Chapter 12:1
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Aortic dissection, pulmonary embolus, expanding pneumothorax, pericarditis with impending tamponade or serious gastrointestinal pathology are all potentially life threatening and may closely mimic presentations of an acute coronary syndrome. Further, the presence or absence of reproducible chest wall pain does not preclude the possibility of a more serious underlying cause.
12. Sites that do not have 24/7 PCI capability must have Thrombolysis as the default STEMI management strategy unless there is an existing documented system for transfer.
Sites that do not have 24/7 PCI capability (referred to in the Chest Pain Pathway as Non Primary PCI Sites) must have Thrombolysis as the default STEMI management strategy. The only exceptions to this directive are sites that have a predetermined and documented process for the emergency transfer of patients to a defined Primary PCI site that is able to deliver this service 24/7. The documented system for transfer MUST ensure that the maximum acceptable delay from First Medical Contact (FMC) to percutaneous intervention is not exceeded.
Maximum Acceptable Delay from First Medical Contact (FMC)Time since symptom onset Acceptable delay from FMC to
percutaneous intervention< 1hours 60 minutes1-3 hours 90 minutes3-12 hours 120 minutes>12hours Not routinely recommendedfrom NHF/CSANZ Guidelines for the management of acute coronary syndromes 2006
Reference: Institute for Clinical Systems Improvement, Diagnosis and Treatment of Chest Pain and ACS, 2010 pp.26
National Heart Foundation of Australia Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006, MJA, 184:8
NB: It is accepted that some non Primary PCI sites have the capability to perform primary PCI during limited hours. However, outside these hours, thrombolysis must be the default strategy unless a documented system for transfer exists.
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THROMBOLYSIS UNLESS
Transfer to PRIMARY PCI SITE if appropriate
5. THROMBOLYSE
PCI HospitalA PCI Hospital is one that does Percutaneous Coronary Intervention, i.e. Coronary Angioplasty.
The PCI site pathway provides users with opportunity to perform primary angioplasty or thrombolysis depending on the clinical situation of the patient.
Non-PCI HospitalA non-PCI Hospital is one that does not have access to a Cardiac Catheter Laboratory to perform Percutaneous Coronary Interventions, i.e. Coronary Angioplasty.
The non-PCI site pathway directs users to perform thrombolysis on patients unless contraindicated.
Non-PCI sites may also choose to transfer the patient directly to a PCI site for Coronary Angioplasty, as long as the referral network is established and can meet the timeframes identified on the pathway.
A copy of the generic PCI Hospital pathway can be found at APPENDIX E
A copy of the non-PCI Hospital pathway can be found at APPENDIX F
Generic NSW Chest Pain PathwayIf your hospital does not have an existing chest pain pathway, you must implement the generic NSW Chest Pain Pathway to ensure compliance against the minimum standards.
There are two versions of the generic NSW Chest Pain Pathway that are applicable to two different hospital types:
PRIMARY PCI UNLESS
5. TRANSFER TO CATH LABTHROMBOLYSE if appropriate
Implementation of minimum standards for chest pain evaluation – Making Change
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Implementation of minimum standards for chest pain evaluation – Making Change The policy mandates the implementation of the minimum standards for chest pain evaluation, as described in the previous chapter.
The good news is that if your hospital already has a functioning chest pain pathway, you can continue to use it, as long as:
1. It meets all of the minimum standards
2. Your hospital can demonstrate that it is used completely and consistently.
Even if your hospital cannot answer ‘yes’ to the two points above, it does not mean that you have to implement an entirely new pathway. You may choose to review an existing pathway and see where it meets the minimum standards and where it does not. You must also check if the pathway is used or not.
Implementing any change requires a planned approach. Resistance to change is perfectly normal and expected. Managing this resistance well will aid the sustainability of the change.
The following section is a helpful guide to identify and make the necessary changes to implement the minimum standards for chest pain evaluation.
A resource aimed at facilitating effective local change projects has been developed and is available for review (http://www.archi.net.au/resources/moc/making-change).
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1. Getting started1.1 Minimum standards for chest pain evaluation
Review the minimum standards and the two default pathways.
1.2 Case for Change
Read the compelling case for change and consider what it means for your facility. Being able to relate this rationale to the clinicians and managers at your facility is crucial in generating momentum.
The underlying message is simple: people presenting to hospitals with chest pain are experiencing unexpected significant adverse incidents and the root cause is often due to inconsistency in the minimum standards.
1.3 Sponsorship
Who has the authority to make change count? There may be a need to identify a sponsor for Cardiology, a sponsor for Emergency and an overarching sponsor to link the two together. At the facility level, this may be the General Manager or the Director of Medical Services. Implementation at the LHD level should sit under the Director of Clinical Governance.
Minimum Standards: page 14
Primary PCI Site Pathway: APPENDIX E
Non-Primary PCI Site Pathway: APPENDIX F
Case for Change: page 9
LHD Director of Corporate Governance
General Manager
ED DirectorHead
Cardiology
Chest Pain Pathway Consistency:“every patient, every time”
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1.4 Engagement, and involving the right people
Think carefully about who needs to be involved and when, so that any changes to the local Chest Pain Pathway include collaboration from all who are impacted, e.g. (but not limited to):
• Senior doctors
• Junior doctors
• Nursing (particularly Triage)
• Cardiology and Emergency Departments
• Pathology
• Cardiac Catheter Laboratories
• Hospital executive
• Patient Flow Managers
2. Review before you rebuild Understand your local starting point. At the highest level there are 3 questions that every facility must ask itself when considering implementation of the minimum standards for chest pain evaluation:
1. Do we have an existing Chest Pain Pathway?
2. Does our pathway meet the minimum standards in the new policy directive?
3. Do clinicians in our facility consistently use the pathway from start to finish?
There are a number of ways to source information that will help you to get a full understanding of the starting position of your facility against the minimum standards.
2.1 The facts:
• Paper audit of the minimum standards – use the Self Audit of Existing Local Pathways Template to review the elements of any existing local pathway against the mandated minimum standards.
• File audit of local pathway use – undertake a sample file audit of patients presenting with chest pain. Using the Self Audit of Existing Local Pathways Template review the files to record which elements of the minimum standards were completed for each patient.
Tabulate the compliance rate for each of the minimum standards and look for trends.
• Observation / tagalong – observe the journey of patients presenting in the Emergency Department with chest pain. Look for successes, barriers and opportunities to successful implementation of the mandated minimum standards.
• Incident review of patients presenting with chest pain – review a series of local incidents that relate to patients presenting with chest pain. What are the patterns? Where are the barriers, risks and opportunities?
Self Audit of Existing Local Pathways Template: APPENDIX C
An example data analysis spreadsheet is available to download on the ARCHI Cardiology Model of Care web page: www.archi.net.au/resources/moc/cardio
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2.2 The experience and perceptions of clinicians:
Talk to frontline clinicians to give context to the factual information. Some options to consider are:
• One on one interviews – booking time for conversations with a number of different types of clinicians can help to generate a deeper understanding of why the existing pathway works as it does and the potential impact of any change.
• Focus groups – Focus groups are great for bouncing ideas off one another and to generate some respectful, but challenging discussion. Make sure that all those participating in a focus group have a clear understanding of what is in and out of scope.
• Surveys – Surveys are another option for gathering information, as not everyone feels comfortable speaking out in a group scenario.
Questions that are rated on numerical scales are easier to compare and generally have higher completion rates. However, open ended questions can deliver some valuable detail.
Consider the question types carefully in any survey.
2.3 The facts and the experience – prioritise the issues
The risk of any investigation is that you get lost in the detail.
Compare the facts of your local Chest Pain Pathway structure and compliance with completion with the experience of what clinicians are telling you.
To create some sense of the list of issues, barriers and opportunities keep bringing your thinking back to the key message: Minimum standards for chest pain evaluation: every patient, every time.
Create the priority list that will help your facility to first meet the mandated minimum standards for every patient, every time, before becoming more sophisticated.
3. Plan the way forwardThere are most likely a number of different ways that you can successfully move from your current state to your desired state – having a fully-compliant pathway.
Your job now is to plan the most effective way to shift your current practice to a compliant pathway while maintaining focus and motivation.
START
Current State Compliant Pathway
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Try and learn from the successes and challenges of others. There is a high probability that another hospital has faced, or is facing the same issue that you are now and has implemented a useful solution.
• Brainstorm and develop solutions to the issues you have identified. It is very important to maintain good engagement with the different clinical and non-clinical groups that will be affected.
These stakeholders understand the existing local practices, so it is important to make use of their knowledge to help design the relevant solutions.
Consider mechanisms that will ensure the local Chest Pain Pathway both meets the minimum standards and is consistently used, e.g.:
o Senior leadership involvement
o Governance, policy, evaluation and monitoring
o Pathway awareness and communications
o Education and training
• Prioritise the solutions to meet all of the minimum standards, before going beyond specific minimum standards. Further prioritise against the Pathway to see if implementing one solution is dependent on another already being in place. For example, ensure Troponin testing is in place before implementing a solution that expands to high sensitivity assays.
• Plan the sequence of work, including a description of the work to be undertaken at each stage, timeframes and who is responsible for each section of work.
• Communicate throughout change. Plan the important key messages that may include: what will change? when? and, what is everybody’s role?
START
Current State Compliant Pathway
First — Minimum Standards
Later — Go beyond the Minimum Standards
START
Current State Compliant Pathway
Which changes can be done together, and which must follow on from each other?
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4. Making ChangeNewton’s third law says that for every action there is an equal and opposite reaction. Therefore you should expect some resistance if you make any change to the existing local Chest Pain Pathway.
If you’ve planned well to this point it is not hard, just hard work. You need to stick to your communication plan and actively manage timeframes, risks and issues.
Pay now or pay later
The faster you expect a change in process to include the minimum standards for chest pain evaluation the greater the effort will be to monitor and evaluate compliance with the change.
The concept is that you can either pay now by building early commitment and engagement to design a change, or pay later, by having to enforce compliance with the pre-determined changes. Neither of these options is incorrect, you just need to decide on the approach that is appropriate for the local context for change:
1. There is a serious deficiency against the minimum standards that is a risk to patient care = Enforce the change and “pay later”
2. There is some minor tweaking to be done that will set up the local Chest Pain Pathway to go beyond the minimum standards = Design and build the change with clinicians, “pay now”
5. Monitor and evaluate Evaluating change is essential. Without a regular monitoring and evaluation strategy your change is likely to slip back down the hill to where it began.
The work that you and your facility undertook in section 2 (Review before you rebuild) will give you an excellent baseline to continue monitoring and evaluation.
Monitoring compliance against consistent completion of the minimum standards on every chest pain pathway should start with:
• high frequency (monthly audit of X% of chest pain files), and;
• high profile (direct feedback to key stakeholder groups).
Feeding back to stakeholder groups means both up and down the chain. When providing the feedback, consider the type of feedback that resonates best with the group it is being provided to (e.g. formal report, newsletter, one on one briefing, staff meeting, focus groups etc).
Wherever possible, try to include opportunities for a feedback loop in the opposite direction so that there is a continual dialogue about the process, results and the context of potential barriers and opportunities.
As the implementation of the minimum standards for chest pain evaluation settle towards core business then the monitoring plan can reduce in frequency to quarterly, half-yearly and then annually.
It is important that if you detect deterioration in performance the high profile and frequency of monitoring is returned immediately.
Increasing monitoring is not just to check up on people, but to understand why there has been a change in performance. By understanding the facts and the clinician context for change, there is a greater chance of taking corrective and sustainable action.
A resource aimed at facilitating effective local change projects has been developed and is available for review: http://www.archi.net.au/resources/moc/making-change
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Appendices
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1. What is a pathway?�
A pathway provides the standard map of care for all patients presenting to hospital with a particular clinical condition or set of symptoms.
The generic NSW Chest Pain Pathway is targeted at all patients presenting with symptoms of chest pain or symptoms suggestive of myocardial ischaemia and directs their care to achieve definitive diagnosis of Acute Coronary Syndrome or not and their subsequent management.
2. Why have a Chest Pain Pathway?�
Acute Coronary Syndrome is a time-critical and potentially life-threatening condition. Using an evidence-based, standardised protocol of care for every patient, every time, will help to quickly identify the patients with the greatest clinical need.
3. We have a pathway already. Why change?�
If you have an existing pathway, it meets the minimum standards and you can demonstrate that the pathway is actively and consistently used in your facility, then you do not need to change a thing.
However, if your facility does not have a pathway, or has one that does not meet the minimum standards or your facility has a low compliance rate with an existing pathway, then you need to make change. The Implementation Support Guide is designed to help.
4. How do I utilise the Chest Pain Pathway in a facility using an electronic Medical Record for patients?�
The Chest Pain Pathway is flagged as a high priority to be integrated into the State Based Build for EMR. However (as at June 2011), it does not currently exist in the integrated electronic form.
Unless facilities have existing Chest Pain Pathways (meeting the minimum standards) integrated into their local EMR, paper based forms must continue to be used.
5. How do the minimum standards apply to rural and regional NSW?�
The policy (PD2011_037) mandates that the minimum standards are implemented and that all hospitals have a Chest Pain Pathway for patients presenting to Emergency Departments.
Frequently Asked Questions
APPENDIX A
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Rural and regional hospitals are advised to implement the minimum standards in a locally appropriate way, by exploring linkages with rural referral networks and centralised ECG reading services.
6. What are ‘the basics’?�
The minimum standards are defined in this toolkit, however, there is also a list of considered ‘basics’ with respect to care for patients presenting with symptoms of chest pain. It is these ‘basics’ that are often found to have been suboptimal in the root cause analyses of critical adverse events. ‘The basics’ include:
• Triage category 2 being assigned
• ECG being taken
• ECG being reviewed (accurately)
• Troponins being taken
• Troponins being reviewed (accurately)
• Lack of senior leadership being available or sought
7. Do the minimum standards apply to children?�
The minimum standards for chest pain evaluation have been developed in response to critical adverse events occurring in the adult population presenting with symptoms of chest pain.
It is very rare that children with presenting with symptoms of chest pain or associated symptoms are in fact experiencing Acute Coronary Syndrome (ACS). It is therefore considered that the minimum standards for chest pain evaluation do not apply as a value-add to the existing specialised care of paediatric patients.
8. Do the minimum standards for chest pain evaluation apply to inpatients on wards?�
The minimum standards and associated generic NSW Chest Pain Pathway have been designed for patients presenting to Emergency Departments (e.g. Assigns triage category 2).
Hospitals are recommended to focus their implementation on the Emergency Department initially. However, the minimum standards should be considered transferable to tailored implementation for patients who experience chest pain or associated symptoms on inpatient wards. The Emergency Department pathway would need to be altered, but the bulk of the minimum standards remain highly relevant to safe clinical care.
9. If a patient is part of a clinical trial, do they still use the pathway?�
Clinical trials are highly important for researching treatment regimes that lead to improvement of the way we deliver healthcare. This however must not stop a patient presenting with chest pain commencing on a chest pain pathway that meets the minimum standards when they present to hospitals.
There is no reason why patients on a Chest Pain Pathway cannot be enrolled in a clinical trial, as the pathway mandates the minimum standards only.
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Implementation of the minimum standards is of critical importance and requires that all of the necessary clinicians and managers understand and perform their necessary roles.
LHD Chief Executives • Direct a LHD gap analysis against the chest pain evaluation minimum
standards
• Assign LHD sponsorship to the appropriate Executive figure to implement the minimum standards for chest pain evaluation (likely Director of Clinical Governance)
• Report minimum standards for chest pain evaluation implementation to the LHD Governing Board
• Report Chest Pain Pathway implementation and performance against the minimum standards to NSW Department of Health as requested
LHD Directors of Clinical Governance • Provide Hospitals direction and lead the LHD initial gap analysis of compliance
against the minimum standards for chest pain evaluation
• Ensure data from current information systems is accessible
• Develop and sponsor the implementation strategy to ensure LHD compliance with the minimum standards
• Coordinate appropriate educational resources for clinicians
• Evaluate LHD momentum and performance against the local implementation strategy to meet the minimum standards
• Investigate RCA incidents relating to the minimum standards for chest pain evaluation
Facility General Managers and Heads of Cardiology and Emergency Departments• Undertake the local gap analysis against the minimum standards for chest
pain evaluation – 1) Do we have a pathway; 2) Does it meet the minimum standards, and; 3) Do we actively and consistently use our local pathway?
• Involve clerical and medical records staff as appropriate to access date from existing information systems
• Communicate a united message that patients presenting with symptoms of chest pain must commence and complete a chest pain pathway that meets the minimum standards – every patient, every time.
• Lead local implementation of the chest pain evaluation minimum standards
• Engage junior and senior clinicians to get feedback on current barriers, risks and opportunities relating to any existing chest pain pathway and the implementation of the minimum standards.
• Engage junior and senior clinicians in implementation.
Minimum standards implementation — What’s my role?�
APPENDIX B
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• Engage Imaging, Pathology and Cardiac Catheter Laboratory teams to ensure that each understand the needs of the minimum standards as they relate to them and can be involved in implementation.
• Evaluate and monitor local implementation momentum and performance
• Determine requirements and provide local education for clinicians
• Coordinate local rostering to ensure that a senior clinician is available to assist 24/7 as per the chest pain evaluation minimum standards or utilise documented referral networks
Clinicians• Triage nurses will be the first point to initiate the use of a local chest pain
pathway that meets the minimum standards and hand over to subsequent clinicians that the patient is on the chest pain pathway.
• Junior doctors should provide feedback to senior clinicians regarding the challenges and opportunities relating to the use of any current chest pain pathway.
• Senior clinicians need to be available and place a high value on providing clinical advice to more junior colleagues with regards to questions relating to chest pain evaluation.
• Junior clinicians need to proactively seek out the advice of more senior colleagues when they are concerned about any aspect of management for patients presenting with symptoms of chest pain.
• All clinicians should seek opportunities to engage in implementation of the minimum standards for chest pain evaluation.
• All clinicians must comply with the minimum standards of chest pain evaluation.
• All clinicians need to provide Safe Clinical Handover when there is a transfer of accountability and responsibility for patient care (e.g. shift change, when seeking advice from senior colleagues or when a patient transfers for a test).
• Escalate management of deteriorating patients as per Between the Flags (PD2010_026).
• In Emergency Departments that do not have a medical officer accessible 24/7, it will be necessary to implement processes where the nurse in charge of the ED signs the Chest Pain Pathway form in place of the medical officer. Where the nurse in charge of the ED is not accredited or competent and active in interpreting ECGs, a process must also be implemented to engage suitably accredited practitioners through ECG reading networks with coronary care or other facilities.
• Clerical data and medical records staff have a role in accessing data during implementation and ongoing monitoring.
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Self audit of local pathways
APPENDIX C
PD2011_037 mandates the implementation of a set of minimum standards for chest pain evaluation for patients presenting to Emergency Departments in all NSW public hospitals.
Hospitals are advised that they may continue to use any existing pathway, as long as it complies with the minimum standards and they can demonstrate that it is actively used.
The following tool is designed to facilitate hospitals to review any existing local pathways with the mandated minimum standards.
Evaluating a local pathway has 3 steps:Step 1: Does your hospital have an existing local pathway?
Step 2: Does the existing local pathway meet the mandated minimum standards for chest pain evaluation?
Step 3: Is the existing pathway actively used – every patient, every time?
Hospital: _______________________________________
Date local pathway reviewed: _____________________________________
Name of person reviewing local Chest Pain Pathway: ______________________________
Position of person reviewing local Chest Pain Pathway: ____________________________
Step 1Does your hospital have an existing local pathway?�Answer Secondary question/instruction Secondary answer(s)Yes What is the name of the local
pathway?Is the pathway formal, or informal (i.e. backed by a local policy or guideline?, if so, what is the Policy reference)Who owns the pathway? (e.g. content, usage, education, monitoring and evaluation)Who knows about the local pathway?Who is expected to fill out the local pathway?Please progress to Step 2 of the self audit
No If no existing local pathway, you do not need to complete the rest of this self audit, and must implement the generic NSW Chest Pain Pathway to meet the minimum standards for chest pain evaluation
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Step 2
Does the existing local pathway meet the mandated minimum standards for chest pain evaluation?�
Further explanation on the minimum standards for chest pain evaluation will assist with completion of the audit tool. This information is available from the Minimum Standards for Chest Pain Evaluation Implementation Support Guide (www.archi.net.au/resources/moc/cardio)
Minimum standard Local compliance (Y/N)If no, add item to the mal-compliance list at the end of the audit
Exceeds minimum standard(detail if appropriate)
Assigns triage category 2
Document when ECGs have been taken
Document when ECGs have been reviewed
Stratify risk into high, intermediate or low risk patient groups (in alignment with the NHF/CSANZ guidelines)
Document when Troponin levels have been taken
Document with Troponin levels have been reviewed
Document when vital signs are taken
Direct action to be taken if vital signs move outside of acceptable ranges (as per Between the Flags PD2010_026)
Document critical times within the patient journey, specifically:
Symptom onset
Presentation
Time of diagnostic ECG
Time of Thrombolytic administration, if given
Catheter Laboratory arrival time (if applicable)
□ On table time
□ First device used
□ TIMI 3 flow time
Discussion with cardiologist
Direct that Aspirin is given, unless contraindicated
Direct that a Senior Medical Officer is assigned to provide advice and support on chest pain evaluation and initial management, 24/7 (an SMO could include consultant or VMO ED Physician, Cardiologist, General Physician, Career Medical Officer, Cardiac or Emergency Registrars)
Direct that a nominated cardiologist is assigned to provide advice on further management, 24/7
Give instruction regarding atypical chest pain presentations
List high risk alternate diagnoses for consideration
Indicate the process to initiate either Thrombolysis or PCI as the default management strategy for STEMI
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Local pathway mal-compliance list – list each of the minimum standards that are not met by the local pathway.
If choosing to amend an existing pathway, instead of implementing the generic NSW Chest Pain Pathway, these are the items that must be addressed prior to plans to exceed the minimum standards in any other item.
#1
#2
#3
#4
#5
Please progress to Step 3 of the self audit
Step 3
Is the existing pathway actively used – every patient, every time?�
Perform a sample file audit of patients presenting to your hospital with Chest Pain over the past 3 months. A helpful automated data analysis tool is available for download (www… ARCHI Cardiology page)
Transcribe results below.
Date range of files audited
Number of files audited
Number of Chest Pain presentations during the audit date range (best approximate from HIE – variability due to coding and potential multiple co-morbidities of patient cohort)
% of chest pain presentation files audited (#files audited / # of Chest Pain presentations)
Overall compliance (% compliance of total positive responses across all files audited) Xx%
Minimum standard evaluated (in the file there is documented evidence of…)
Activity compliance (% compliance of total positive responses across all files audited)
Triage category 2 assigned
ECG taken
ECG reviewed
risk stratified
Troponin level taken
Troponin level reviewed
Vital signs taken at regular intervals as appropriate
Vital signs documented at same time as being taken
Escalation of care when vital signs move outside acceptable parameters (BTF indicators)
Time symptom onset documented
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Time of presentation documented
Time of ECG documented
Time of thrombolytic administered documented (if applicable)
Cath Lab arrival time documented (if applicable)
On table time documented (if applicable)
First device used documented (if applicable)
TIMI 3 flow time documented (if applicable)
Discussion with Senior Medical Officer documented (if required)
Discussion with Cardiologist documented (if required)
Aspirin given unless contraindication recorded
High risk alternate diagnoses are considered and clinical reasoning documented
Where suboptimal compliance is found through this activity audit, the answers obtained in Step 1 should be reviewed and considered to give insight into the potential causes/solutions, specifically:
• Is the pathway formal, or informal?
• Who owns the pathway? (e.g. content, usage, education, monitoring and evaluation)
• Who knows about the local pathway?
• Who is expected to fill out the local pathway?
What do we do now?�1. If necessary, undertake further diagnostic review to understand why an existing pathway does not
already meet the minimum standards, or why it is not actively used (further advice on understanding the ‘as is’ state can be found in the Minimum Standards for chest Pain Evaluation Implementation Support Guide)
2. Create a plan that is designed to:
a. Ensure the local pathway meets the minimum standards
b. Ensure the local pathway is actively used – every patient, every time
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APPENDIX D
Policy Directive
Department of Health, NSW73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101
http://www.health.nsw.gov.au/policies/
spacespace
Chest Pain Evaluation (NSW Chest Pain Pathway)space
Document Number PD2011_037
Publication date 09-Jun-2011
Functional Sub group Clinical/ Patient Services - Governance and Service DeliveryClinical/ Patient Services - Medical Treatment
Summary The Policy outlines the minimum standards for the management ofpatients presenting with Chest Pain or other symptoms of myocardialischaemia.
NOTE: This Policy also applies to Local Health Networks until LocalHealth Districts commence on 1 July 2011.
Author Branch Health Services Performance Improvement Branch
Branch contact James Dunne 9391 9555
Applies to Local Health Networks, Board Governed Statutory Health Corporations,Network Governed Statutory Health Corporations, NSW AmbulanceService, Public Hospitals
Audience All staff involved in the management and risk stratification of patients whopresent with chest pain
Distributed to Public Health System, Divisions of General Practice, GovernmentMedical Officers, Health Associations Unions, NSW Ambulance Service,NSW Department of Health, Tertiary Education Institutes
Review date 09-Jun-2016
Policy Manual Patient Matters
File No.
Status Active
Director-GeneralspaceThis Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatoryfor NSW Health and is a condition of subsidy for public health organisations.
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POLICY STATEMENT
PD2010_037 Issue date: June 2011 Page 1 of 3
IMPLEMENTATION OF MINIMUM STANDARDS FOR CHEST PAIN EVALUATION (NSW CHEST PAIN PATHWAY)
PURPOSEThe policy mandates the implementation of minimum standards for chest pain evaluation, by all hospitals in the NSW Health system for patients presenting to Emergency Departments with chest pain. Compliance with these minimum standards for chest pain evaluation will improve the management of patients by guiding clinicians through risk stratification and outlining the best practice management. Facilities may continue to use existing local Pathways provided that they meet all of the minimum standards and are in active use in emergency departments.Facilities who do not use an existing Chest Pain Pathway that meets the minimum standards must implement the standard NSW Chest Pain Pathway. The NSW Chest Pain Pathway aligns with the National Heart Foundation/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes.
MANDATORY REQUIREMENTS
1. All facilities with Emergency Departments must have and use a pathway that meets the following minimum standards for chest pain patients:
• Assigns triage category 2• Includes risk stratification• ECGs are taken and reviewed• Troponin levels are taken and reviewed • Vital signs are taken and documented• Critical times are documented (symptom onset, presentation)• Aspirin is given, unless contraindicated• A Senior Medical Officer is assigned to provide advice and support on
chest pain assessment and initial management, 24/7• A nominated Cardiologist is assigned to provide advice on further
management 24/7• The pathway gives instruction regarding atypical chest pain presentations• High risk alternate diagnosis listed for consideration e.g. Aortic Dissection,
Pulmonary Embolism & Pericarditis.• Sites that do not have 24/7 PCI capability must have Thrombolysis as the
default STEMI management strategy unless there is an existingdocumented system for transfer.
2. All facilities who do not use an existing Chest Pain Pathway that meets the minimum standards must implement the standard NSW Chest Pain Pathway that matches their facility (i.e. only sites that can provide 24/7 Primary PCI are able to use the Primary PCI site Pathway) as the minimum standard.
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POLICY STATEMENT
PD2010_037 Issue date: June 2011 Page 2 of 3
IMPLEMENTATIONROLES AND RESPONSIBILITIES
• Review the minimum standards of a Chest Pain Pathway in line with relevant national guidelines and best practice evidence.
NSW Department of Health:
• Develop and make accessible implementation support tools.• Evaluate Chest Pain Pathway implementation and performance against the
minimum standards across the NSW Health system.
• Ensure effective implementation of the minimum standards for chest pain evaluation in all LHN Emergency Departments
LHN Chief Executives:
• Report minimum standards for chest pain evaluation implementation to the LHN Governing Council
• Report Chest Pain Pathway implementation and performance against the minimum standards to NSW Department of Health as requested
• Direct a LHN gap analysis against the chest pain evaluation minimum standardsLHN Directors of Clinical Governance:
• Develop and lead implementation strategy• Coordinate appropriate educational resources for clinicians• Evaluate LHN Chest Pain Pathway implementation and performance against the
minimum standards• Investigate RCA incidents relating to the minimum standards for chest pain
evaluation
• Direct a local gap analysis against the chest pain evaluation minimum standardsFacility General Managers and Heads of Cardiology and Emergency Departments:
• Implement the chest pain evaluation minimum standards locally• Evaluate and monitor local implementation and performance against the chest
pain evaluation minimum standards• Coordinate local education requirements for clinicians• Coordinate local rostering to ensure that a senior clinician is available to assist
24/7 as per the chest pain evaluation minimum standards or utilise documented referral network
• Comply with the minimum standards of chest pain evaluationClinicians:
• Escalate management of deteriorating patients as per Between the Flags (PD2010_026)
• In Emergency Departments that do not have a medical officer accessible 24/7, it will be necessary to implement processes where the nurse in charge of the ED signs the Chest Pain Pathway form in place of the medical officer.
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POLICY STATEMENT
PD2010_037 Issue date: June 2011 Page 3 of 3
REVISION HISTORYVersion Approved by Amendment notesJune 2011(PD2011_037)
Dr Tim Smyth, Deputy Director-General, HSQPID
New Policy
ATTACHMENTS1. NSW Chest Pain Pathway: Primary PCI Site2. NSW Chest Pain Pathway: Non Primary PCI Site
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ON
S (
eg d
iabe
tes,
rena
l fai
lure
, fem
ale,
el
derly
or A
borig
inal
)
TR
IAG
E
CA
TE
GO
RY
2
ECG
& V
ital S
igns
, exp
ert
inte
rpre
tatio
n w
ithin
10
min
utes
ST E
LEVA
TIO
Nor
(pre
sum
ed n
ew) L
BB
B
Con
side
r Aor
tic D
isse
ctio
n (
back
pai
n, h
yper
tens
ion,
abs
ent
p
ulse
, BP
diffe
renc
e) C
onsi
der P
ulm
onar
y
Em
bolis
m
(se
vere
dys
pnoe
a, re
spira
tory
dist
ress
, low
sub
scrip
t O2 s
atur
atio
n)
Dia
gnos
eN
ON
ST
ELE
VA
TIO
N A
CU
TE
C
OR
ON
AR
Y S
YN
DR
OM
E (
AC
S)
ST
RA
TIF
Y A
CS
RIS
K
Con
side
r Per
icar
ditis
(sha
rp c
hest
pai
n, re
spira
tory
or
pos
ition
al c
ompo
nent
)
Go
imm
edia
tely
to
STEM
I M
AN
AG
EMEN
T (p
age
3)
N N
N
Y
HIG
H R
ISK
Any
of t
he fo
llow
ing
INTE
RM
EDIA
TE R
ISK
Any
of t
he fo
llow
ing
and
no h
igh
risk
feat
ures
LOW
RIS
K
Any
of t
he fo
llow
ing
and
no h
igh
or
inte
rmed
iate
risk
feat
ures
A
CS
sym
ptom
s ar
e re
petit
ive
or
pro
long
ed (>
10
min
) & s
till p
rese
nt.
S
ynco
pe
His
tory
of c
hron
ic le
ft ve
ntric
ular
s
ysto
lic d
ysfu
nctio
n (e
spec
ially
if
kno
wn
LVE
F <
40%
) OR
cur
rent
clin
ical
evi
denc
e of
LV
F.
Pre
viou
s P
CI/C
AB
G <
6 m
onth
s
Dia
bete
s +
typi
cal A
CS
sym
ptom
s
Chr
onic
rena
l fai
lure
+ ty
pica
l AC
S
sym
ptom
s
Hae
mod
ynam
ic c
ompr
omis
e
(sus
tain
ed S
BP
< 90
mm
Hg
and
/ or
n
ew o
nset
mitr
al re
gurg
itatio
n)
E
leva
ted
Trop
onin
(co
nsid
er h
aem
olys
is, r
enal
failu
re)
A
CS
sym
ptom
s w
ithin
48
hrs
that
occ
urre
d at
rest
, or w
ere
repe
titiv
e or
pro
long
ed (b
ut c
urre
ntly
reso
lved
)
Pre
viou
s P
CI/C
AB
G >
6 m
onth
s
Kno
wn
coro
nary
hea
rt di
seas
e-
E
sp if
prio
r AM
I or k
now
n co
rona
ry
l
esio
n >
50%
ste
nosi
s
Tw
o or
mor
e ris
k fa
ctor
s of
:
H
yper
tens
ion,
fam
ily h
isto
ry,
activ
e sm
okin
g or
hyp
erlip
idae
mia
Chr
onic
rena
l fai
lure
(esp
ecia
lly if
kn
own
GFR
< 6
0 m
L/m
in) +
at
ypic
al A
CS
sym
ptom
s
D
iabe
tes
+ at
ypic
al A
CS
sym
ptom
s
A
ge >
65
year
s
P
rese
ntat
ion
with
clin
ical
feat
ures
con
sist
ent w
ith A
CS
with
out
in
term
edia
te- r
isk
or h
igh-
risk
feat
ures
.
P
ersi
sten
t or d
ynam
ic E
CG
cha
nges
of
ST
depr
essi
on ≥
0.5
mm
or
new
T w
ave
inve
rsio
n ≥
2 m
m
T
rans
ient
ST
elev
atio
n (≥
0.5
mm
) in
m
ore
than
two
cont
iguo
us le
ads
S
usta
ined
VT
E
CG
is n
ot n
orm
al a
nd h
as c
hang
ed
f
rom
pre
viou
s pa
in fr
ee E
CG
but
doe
s
not
con
tain
hig
h ris
k ch
ange
s.
E
CG
Nor
mal
or u
ncha
nged
from
pre
viou
s pa
in fr
ee E
CG
All
case
s to
be
disc
usse
d w
ith S
enio
r Med
ical
Of
cer
Rec
omm
ende
d M
anag
emen
t on
page
2
This
tool
is in
tend
ed a
s a
guid
elin
e fo
r clin
icia
ns to
pro
vide
qua
lity
patie
nt c
are.
It is
not
inte
nded
, nor
sho
uld
it re
plac
e, in
divi
dual
clin
ical
judg
emen
t. So
me
patie
nts
with
co-
mor
bidi
ties
or p
atie
nts
not s
uita
ble
for i
nvas
ive
inve
stig
atio
ns m
ay b
e ap
prop
riate
ly m
anag
ed m
edic
ally.
Con
trai
ndic
atio
ns a
nd c
autio
ns fo
r thr
ombo
lysi
s us
e in
STE
MI1
Abs
olut
e co
ntra
indi
catio
ns:
Ris
k of
ble
edin
g- A
ctiv
e bl
eedi
ng o
r ble
edin
g di
athe
sis
(exc
ludi
ng m
ense
s)- S
igni c
ant c
lose
d he
ad o
r fac
ial t
raum
a w
ithin
3 m
onth
s- S
uspe
cted
aor
tic d
isse
ctio
n (in
clud
ing
new
neu
rolo
gica
l sym
ptom
s)R
isk
of in
trac
rani
al h
aem
orrh
age
- Any
prio
r int
racr
ania
l hae
mor
rhag
e- I
scha
emic
stro
ke w
ithin
3 m
onth
s- K
now
n st
ruct
ural
cer
ebra
l vas
cula
r les
ion
(eg,
arte
riove
nous
mal
form
atio
n)- K
now
n m
alig
nant
intra
cran
ial n
eopl
asm
(prim
ary
or m
etas
tatic
)R
elat
ive
cont
rain
dica
tions
:R
isk
of b
leed
ing
- Cur
rent
use
of a
ntic
oagu
lant
s: th
e hi
gher
the
inte
rnat
iona
l nor
mal
ised
ratio
(IN
R),
the
high
er th
e ris
k of
ble
edin
g- N
on-c
ompr
essi
ble
vasc
ular
pun
ctur
es- R
ecen
t maj
or s
urge
ry (<
3 w
eeks
)- T
raum
atic
or p
rolo
nged
(> 1
0 m
inut
es) c
ardi
opul
mon
ary
resu
scita
tion
- Rec
ent (
with
in 4
wee
ks) i
nter
nal b
leed
ing
(eg,
gas
troin
test
inal
or u
rinar
y tra
ct h
aem
orrh
age)
- Act
ive
pept
ic u
lcer
Ris
k of
intr
acra
nial
hae
mor
rhag
e- H
isto
ry o
f chr
onic
, sev
ere,
poo
rly c
ontro
lled
hype
rtens
ion
- Sev
ere
unco
ntro
lled
hype
rtens
ion
on p
rese
ntat
ion
(> 1
80 m
mH
g sy
stol
ic o
r > 1
10 m
mH
g di
asto
lic)
- Isc
haem
ic s
troke
mor
e th
an 3
mon
ths
ago,
dem
entia
, or k
now
n in
tracr
ania
l abn
orm
ality
not
cov
ered
in c
ontra
indi
catio
nsO
ther
- Pre
gnan
cy1 A
dapt
ed fr
om N
HF/
CS
AN
Z G
uide
lines
for t
he m
anag
emen
t of a
cute
cor
onar
y sy
ndro
mes
200
6
Con
trai
ndic
atio
ns to
Exe
rcis
e Te
stin
g (A
CC
/AH
A G
uide
lines
)2
Abs
olut
e- R
ecur
rent
che
st p
ain
- Acu
te m
yoca
rdia
l inf
arct
ion,
with
in 2
day
s
- Hig
h-ris
k un
stab
le a
ngin
a
- Unc
ontro
lled
card
iac
arrh
ythm
ias
caus
ing
sym
ptom
s or
hae
mod
ynam
ic c
ompr
omis
e
- Sym
ptom
atic
sev
ere
aorti
c st
enos
is
- Unc
ontro
lled
sym
ptom
atic
hea
rt fa
ilure
- Acu
te p
ulm
onar
y em
bolu
s or
pul
mon
ary
infa
rctio
n
- Acu
te m
yoca
rditi
s or
per
icar
ditis
- Acu
te a
ortic
dis
sect
ion
Rel
ativ
e- C
ritic
al le
ft m
ain
coro
nary
ste
nosi
s
- Mod
erat
e st
enot
ic v
alvu
lar h
eart
dise
ase
- Ele
ctro
lyte
abn
orm
aliti
es
- Sys
tolic
hyp
erte
nsio
n >
200
mm
Hg
- Dia
stol
ic h
yper
tens
ion
> 10
0 m
mH
g
- Tac
hyar
rhyt
hmia
s or
bra
dyar
rhyt
hmia
s
- New
ons
et a
trial
br
illat
ion
- Hyp
ertro
phic
car
diom
yopa
thy
and
othe
r for
ms
of o
ut o
w o
bstru
ctio
n
- Men
tal o
r phy
sica
l im
pairm
ent l
eadi
ng to
the
inab
ility
to e
xerc
ise
adeq
uate
ly- H
igh-
degr
ee a
triov
entri
cula
r blo
ck
- Res
ting
EC
G w
hich
will
mak
e E
ST
inte
rpre
tatio
n di
f cu
lt (e
g LB
BB
, LV
H w
ith s
train
, Ven
tricu
lar p
acin
g, V
entri
cula
r pre
exci
tatio
n.)
2 Gib
bons
eta
l, C
ircul
atio
n 10
6:18
83,2
002
Abb
revi
atio
ns:
AC
S –
Acu
te C
oron
ary
Syn
drom
e
CA
BG
– C
oron
ary
Arte
ry B
ypas
s G
raft
ECG
– E
lect
roca
rdio
gram
EST
– E
xerc
ise
Stre
ss T
est
FMC
– F
irst M
edic
al C
onta
ct
GTN
– G
lyce
ryl
trini
trate
LBB
B –
Lef
t Bun
dle
Bra
nch
Blo
ck
LVF
– L
eft V
entri
cula
r Fai
lure
LVH
– L
eft V
entri
cula
r Hyp
ertro
phy
PCI –
Per
cuta
neou
s C
oron
ary
Inte
rven
tion
SMO
– S
enio
r Med
ical
of
cer
STEM
I – S
T E
leva
tion
Myo
card
ial I
nfar
ctio
n
N
O W
RIT
ING
P
age
1 of
4
NO
WR
ITIN
G
Pag
e 4
of 4
¶SMRÊ(ÎfuÄSMR080070
Gen
eral
Man
agem
ent
O
xyge
n
Asp
irin
I
V A
cces
s
P
ain
Rel
ief
P
atho
logy
inc
l Tro
poni
n
Che
st X
-ray
NS
W H
EA
LTH
PR
IMA
RY
PC
I SIT
E C
P A
SS
ES
SM
EN
T.in
dd
120
/05/
2011
11
:48:
47 A
M
APPENDIX E
App
endi
ces
41
NH606600 - 120511
BINDING MARGIN - NO WRITING
Faci
lity:
CH
EST
PAIN
PAT
HW
AY
PRIM
ARY
PC
I SIT
E C
OM
PLE
TE A
LL D
ETA
ILS
OR
AFF
IX P
ATIE
NT
LAB
EL
HE
RE
FAM
ILY
NAM
EM
RN
GIV
EN N
AME
MAL
E
FEM
ALE
D.O
.B.
____
___
/ ___
____
/ __
____
_M
.O.
ADD
RES
S
LOC
ATIO
N /
WAR
D
Faci
lity: C
HES
T PA
IN P
ATH
WAY
PR
IMA
RY P
CI S
ITE
STEM
I MA
NA
GEM
ENT
CO
MP
LETE
ALL
DE
TAIL
S O
R A
FFIX
PAT
IEN
T LA
BE
L H
ER
E
FAM
ILY
NAM
EM
RN
GIV
EN N
AME
MAL
E
FEM
ALE
D.O
.B.
____
___
/ ___
____
/ __
____
_M
.O.
ADD
RES
S
LOC
ATIO
N /
WAR
D
Rec
omm
ende
d Fu
rthe
r Man
agem
ent
Ref
er to
dru
g pr
otoc
ols
&/o
r The
rape
utic
Gui
delin
es
HIG
H R
ISK
A
DM
IT o
r TR
AN
SFER
INTE
RM
EDIA
TE R
ISK
RES
TRAT
IFY
LOW
RIS
K
DIS
CH
AR
GE
Con
tinuo
us c
ardi
ac m
onito
ring
&
frequ
ent v
ital s
igns
R
epea
t EC
G im
med
iate
ly if
sym
ptom
s
re
curs
R
epea
t EC
G 8
hrs
pos
t ons
et o
f
sy
mpt
oms
R
epea
t Tro
poni
n at
8 h
rs if
1st
sam
ple
nega
tive
*
EC
G/T
ropo
nin
revi
ew b
y m
edic
al
o
f ce
r
Ant
ipla
tele
t the
rapy
Yes
No
If no
reas
on__
____
____
____
____
____
____
____
____
____
____
____
____
___
Bet
ablo
cker
Y
es
N
oIf
no re
ason
____
____
____
____
____
____
____
____
____
____
____
____
____
_
Ant
icoa
gula
nt
Yes
N
o
If
no re
ason
____
____
____
____
____
____
____
____
____
____
____
____
____
__
Sym
ptom
atic
trea
tmen
t of o
ngoi
ng
pain
/hyp
erte
nsio
n
IV
GTN
(titr
ate
agai
nst p
ain
& B
P)
I
V M
orph
ine
Ref
er to
nom
inat
ed c
ardi
olog
ist
fo
r fur
ther
man
agem
ent
C
ontin
uous
car
diac
mon
itorin
g &
freq
uent
vita
l sig
ns
Rep
eat E
CG
imm
edia
tely
if s
ympt
oms
rec
ur
R
epea
t EC
G 8
hrs
pos
t ons
et o
f
sym
ptom
s
Rep
eat T
ropo
nin
at 8
hrs
if 1
st s
ampl
e
n
egat
ive
*
EC
G/T
ropo
nin
revi
ew b
y m
edic
al o
f ce
r
R
efer
for E
xerc
ise
Stre
ss T
est *
* if :
N
o fu
rther
che
st p
ain/
sym
ptom
s an
d
2
neg
ativ
e Tr
opon
in te
sts
and
N
o ne
w E
CG
cha
nges
and
N
o co
ntra
indi
catio
ns to
stre
ss te
st
(pa
ge 4
)
Res
trat
ify to
Hig
h R
isk
if:
Rec
urre
nt is
chae
mic
che
st p
ain
or
Pos
itive
Tro
poni
n or
N
ew E
CG
cha
nges
or
P
ositi
ve s
tress
test
Res
trat
ify to
Low
Ris
k &
Dis
char
ge if
:
Neg
ativ
e st
ress
test
or
S
tress
test
ava
ilabl
e w
ithin
72
hrs*
*
and
N
o fu
rther
che
st p
ain/
sym
ptom
s
Rep
eat E
CG
& v
ital s
igns
, if s
tabl
e
dis
char
ge
R
egul
ar v
ital s
igns
Rep
eat E
CG
imm
edia
tely
if
s
ympt
oms
recu
r
Rep
eat E
CG
8 h
rs p
ost o
nset
of s
ympt
oms
R
epea
t Tro
poni
n at
8 h
rs if
1st
sam
ple
nega
tive
*
EC
G/T
ropo
nin
revi
ew b
y
m
edic
al o
f ce
r__
____
____
____
____
____
_R
estr
atify
Ris
k if:
R
ecur
rent
isch
aem
ic c
hest
p
ain
or
Pos
itive
Tro
poni
n or
N
ew E
CG
cha
nges
If lo
w R
isk
AC
S
Dis
char
ge
Fol
low
up
GP
/LM
O w
ithin
3-5
day
s of
D/C
Con
side
r Spe
cial
ist f
ollo
w u
p
Con
side
r dis
char
ge o
n
Asp
irin
(dis
cuss
with
SM
O)
V
ital s
igns
prio
r to
disc
harg
e
If un
likel
y ca
rdia
c ca
use
C
onsi
der a
ltern
ativ
e di
agno
sis
Exit
Path
way
*If a
hig
h se
nsiti
vity
trop
onin
ass
ay is
use
d, th
e te
stin
g in
terv
al m
ay b
e re
duce
d to
3 h
ours
, pro
vide
d th
e se
cond
sa
mpl
e is
take
n at
leas
t 6 h
ours
afte
r sym
ptom
ons
et.
Med
ical
Of
cer:
Prin
t nam
e &
sig
n___
____
____
____
____
____
____
____
____
____
____
__ D
ate_
____
____
____
Med
ical
Of
cer D
esig
natio
n___
____
____
____
____
____
____
____
____
____
____
____
____
___
This
tool
is in
tend
ed a
s a
guid
elin
e fo
r clin
ician
s to
pro
vide
qual
ity p
atie
nt c
are.
It is
not
inte
nded
, nor
sho
uld
it re
plac
e, in
divid
ual c
linica
l ju
dgem
ent.
Som
e pa
tient
s w
ith c
o-m
orbi
ditie
s or
pat
ient
s no
t sui
tabl
e fo
r inv
asive
inve
stig
atio
ns m
ay b
e ap
prop
riate
ly m
anag
ed m
edica
lly.
N
O W
RIT
ING
P
age
2 of
4
NO
WR
ITIN
G
Pag
e 3
of 4
NB
: ** I
f str
ess
test
is n
ot
avai
labl
e w
ithin
72
hrs
of
disc
harg
e, tr
eatm
ent p
lan
shou
ld b
e gu
ided
by
nom
inat
ed
SMO
/Car
diol
ogis
t
Pha
rmac
olog
ical
stre
ss te
st o
r C
T co
rona
ry a
ngio
grap
hy m
ay b
e in
dica
ted
R
efer
to lo
cal
p
roto
cols
&/o
r
The
rape
utic
Gui
delin
es
plea
se u
se
24 h
r Clo
ck
C
ardi
ac m
onito
ring
E
CG
IV
Can
nula
X 2
Rou
tine
bloo
ds
Oxy
gen
Ana
lges
ia –
Mor
phin
e
Nitr
ates
-Sub
lingu
al o
r IV
CX
R
B
eta
Blo
cker
s
Con
rm
adm
inis
trat
ion
or g
ive:
A
spiri
n
300
mg
(sol
uble
)
C
lopi
dogr
el
300
- 60
0 m
g
(o
r pra
sugr
el &
/or t
iro b
an)
E
noxa
parin
3
0 m
g IV
then
bd
(or I
V h
epar
in o
r biv
aliru
din)
1 m
g/kg
sub
cut
(Max
100
mg)
PR
IMA
RY P
CI U
NLE
SS
Sig
ni c
ant d
elay
to a
vaila
bilit
y of
Cat
h La
b or
inte
rven
tiona
l tea
m o
r
Pat
ient
doe
s no
t con
sent
to p
rimar
y P
CI
H
isto
ry, c
ontra
st a
llerg
y
Vas
cula
r acc
ess
prob
lem
s
D
iscu
ss w
ith In
terv
entio
nal c
ardi
olog
ist:
Ti
me
:
D
ecis
ion
rega
rdin
g re
perfu
sion
met
hod:
T
ime
:
5.
TR
AN
SFER
TO
CAT
H L
AB
Dis
cuss
adj
unct
ive
treat
men
t w
ith C
ardi
olog
ist
OR
TH
RO
MB
OLY
SE if
app
ropr
iate
N
o co
ntra
indi
catio
ns (s
ee p
age
4)
Tene
ctep
lase
/ R
etep
lase
Bod
y W
eigh
t __
____
__kg
D
ose
____
____
Tim
e ad
min
iste
red
:
R
epea
t EC
G a
t 60
min
s po
st th
rom
boly
tic
Dis
cuss
furth
er m
x w
ith c
ardi
olog
ist
F
ailu
re to
repe
rfuse
(les
s th
an 5
0%
r
educ
tion
in S
T el
evat
ion)
Con
side
r Res
cue
Ang
iopl
asty
Cat
h La
b ar
rival
tim
e
:
On
tabl
e tim
e
:
Firs
t dev
ice
use
time
:
Tim
e of
dia
gnos
tic E
CG
:
C
hest
pai
n >
30 m
in a
nd <
12
hrs
P
ersi
sten
t ST
segm
ent e
leva
tion
of ≥
1 m
m in
two
or m
ore
c
ontig
uous
lim
b le
ads
or S
T se
gmen
t ele
vatio
n of
≥ 2
mm
in
two
cont
iguo
us c
hest
lead
s or
pre
sum
ed n
ew L
BB
B p
atte
rn
Myo
card
ial i
nfar
ct li
kely
from
his
tory
Tim
e to
Rev
ascu
laris
atio
n (T
IMI 3
ow
)
Ye
s / N
o T
ime
:
0-3
0 m
ins
31-
45 m
ins
46-
60 m
ins
61-
75 m
ins
76-
90 m
ins
>90
min
s
R
easo
n fo
r del
ay
Med
ical
Of
cer:
Prin
t nam
e &
sig
n___
____
____
____
____
____
____
____
____
____
____
__ D
ate_
____
____
____
Med
ical
Of
cer D
esig
natio
n___
____
____
____
____
____
____
____
____
____
____
____
____
___
This
tool
is in
tend
ed a
s a
guid
elin
e fo
r clin
icia
ns to
pro
vide
qua
lity p
atie
nt c
are.
It is
not
inte
nded
, nor
sho
uld
it re
plac
e, in
divi
dual
clin
ical
ju
dgem
ent.
Som
e pa
tient
s w
ith c
o-m
orbi
ditie
s or
pat
ient
s no
t sui
tabl
e fo
r inv
asiv
e in
vest
igat
ions
may
be
appr
opria
tely
man
aged
med
ical
ly.
¶SMRÊ(ÎfuÄ SMR080070
Dis
cuss
with
card
iolo
gist
/S
MO
}
1.
CO
NFI
RM
IN
DIC
ATIO
NS
for
REP
ERFU
SIO
N
2.
GEN
ERA
L M
AN
AG
EMEN
T
3.
AD
MIN
ISTE
R
AN
TITH
RO
MB
OTI
CTH
ERA
PY
4.C
HO
OSE
R
EPER
FUSI
ON
MET
HO
D
NS
W H
EA
LTH
PR
IMA
RY
PC
I SIT
E C
P A
SS
ES
SM
EN
T.in
dd
220
/05/
2011
11
:48:
54 A
M
App
endi
ces
42
APPENDIX F◆
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Faci
lity:
CH
EST
PAIN
PAT
HW
AYN
ON
PR
IMA
RY P
CI S
ITE
CO
MP
LETE
ALL
DE
TAIL
S O
R A
FFIX
PAT
IEN
T LA
BE
L H
ER
E
FAM
ILY
NAM
EM
RN
GIV
EN N
AME
MAL
E
FEM
ALE
D.O
.B.
____
___
/ ___
____
/ __
____
_M
.O.
ADD
RES
S
LOC
ATIO
N /
WAR
D
CHEST PAIN PATHWAYNON PRIMARY PCI SITE SMR080.071
BINDING MARGIN - NO WRITING
Faci
lity:
CH
EST
PAIN
PAT
HW
AYN
ON
PR
IMA
RY P
CI S
ITE
CO
MP
LETE
ALL
DE
TAIL
S O
R A
FFIX
PAT
IEN
T LA
BE
L H
ER
E
FAM
ILY
NAM
EM
RN
GIV
EN N
AME
MAL
E
FEM
ALE
D.O
.B.
____
___
/ ___
____
/ __
____
_M
.O.
ADD
RES
S
LOC
ATIO
N /
WAR
D
Dat
e of
Pre
sent
atio
n
/
/
Tim
e
:
T
ime
of S
ympt
om O
nset
:
:
CH
ES
T P
AIN
or
O
TH
ER
SY
MP
TOM
S o
f
MY
OC
AR
DIA
L IS
CH
AE
MIA
(eg
sw
eatin
g, s
udde
n or
thop
nea,
s
ynco
pe, d
yspn
oea,
epi
gast
ric
dis
com
fort,
jaw
pai
n, a
rm p
ain)
Be
awar
e:
HIG
H R
ISK
ATY
PIC
AL
PR
ESEN
TATI
ON
S (
eg d
iabe
tes,
rena
l fai
lure
, fem
ale,
el
derly
or A
borig
inal
)
T
RIA
GE
C
AT
EG
OR
Y
2
ECG
& V
ital S
igns
, exp
ert
inte
rpre
tatio
n w
ithin
10
min
utes
ST E
LEVA
TIO
Nor
(pre
sum
ed n
ew) L
BB
B
Con
side
r Aor
tic D
isse
ctio
n (
back
pai
n, h
yper
tens
ion,
abs
ent
p
ulse
, BP
diffe
renc
e) C
onsi
der P
ulm
onar
y
Em
bolis
m
(se
vere
dys
pnoe
a, re
spira
tory
dist
ress
, low
sub
scrip
t O2 s
atur
atio
n)
Dia
gnos
eN
ON
ST
ELE
VA
TIO
N A
CU
TE
C
OR
ON
AR
Y S
YN
DR
OM
E (
AC
S)
ST
RA
TIF
Y A
CS
RIS
K
Gen
eral
Man
agem
ent
O
xyge
n
Asp
irin
I
V A
cces
s
P
ain
Rel
ief
P
atho
logy
inc
l Tro
poni
n
Che
st X
-ray
Con
side
r Per
icar
ditis
(sha
rp c
hest
pai
n, re
spira
tory
or
pos
ition
al c
ompo
nent
)
Go
imm
edia
tely
to
STEM
I M
AN
AG
EMEN
T (p
age
3)
N N
N
Y
HIG
H R
ISK
Any
of t
he fo
llow
ing
INTE
RM
EDIA
TE R
ISK
Any
of t
he fo
llow
ing
and
no h
igh
risk
feat
ures
LOW
RIS
K
Any
of t
he fo
llow
ing
and
no h
igh
or
inte
rmed
iate
risk
feat
ures
£ A
CS
sym
ptom
s ar
e re
petit
ive
or
pro
long
ed (>
10
min
) & s
till p
rese
nt.
£ S
ynco
pe£
His
tory
of c
hron
ic le
ft ve
ntric
ular
s
ysto
lic d
ysfu
nctio
n (e
spec
ially
if
kno
wn
LVE
F <
40%
) OR
cur
rent
clin
ical
evi
denc
e of
LV
F.£
Pre
viou
s P
CI/C
AB
G <
6 m
onth
s £
Dia
bete
s +
typi
cal A
CS
sym
ptom
s£
Chr
onic
rena
l fai
lure
+ ty
pica
l AC
S
sym
ptom
s£
Hae
mod
ynam
ic c
ompr
omis
e
(sus
tain
ed S
BP
< 90
mm
Hg
and
/ or
n
ew o
nset
mitr
al re
gurg
itatio
n)
£ E
leva
ted
Trop
onin
(co
nsid
er h
aem
olys
is, r
enal
failu
re)
£ A
CS
sym
ptom
s w
ithin
48
hrs
that
occ
urre
d at
rest
, or w
ere
repe
titiv
e or
pro
long
ed (b
ut c
urre
ntly
reso
lved
)£
Pre
viou
s P
CI/C
AB
G >
6 m
onth
s £
Kno
wn
coro
nary
hea
rt di
seas
e-
E
sp if
prio
r AM
I or k
now
n co
rona
ry
l
esio
n >
50%
ste
nosi
s£
Tw
o or
mor
e ris
k fa
ctor
s of
:
H
yper
tens
ion,
fam
ily h
isto
ry,
activ
e sm
okin
g or
hyp
erlip
idae
mia
£
Chr
onic
rena
l fai
lure
(esp
ecia
lly if
kn
own
GFR
< 6
0 m
L/m
in) +
at
ypic
al A
CS
sym
ptom
s£
D
iabe
tes
+ at
ypic
al A
CS
sym
ptom
s£
A
ge >
65
year
s
£ P
rese
ntat
ion
with
clin
ical
feat
ures
con
sist
ent w
ith A
CS
with
out
in
term
edia
te- r
isk
or h
igh-
risk
feat
ures
.
£ P
ersi
sten
t or d
ynam
ic E
CG
cha
nges
of
l
ST
depr
essi
on ≥
0.5
mm
or
l
new
T w
ave
inve
rsio
n ≥
2 m
m
£ T
rans
ient
ST
elev
atio
n (≥
0.5
mm
) in
m
ore
than
two
cont
iguo
us le
ads
£ S
usta
ined
VT
£ E
CG
is n
ot n
orm
al a
nd h
as c
hang
ed
f
rom
pre
viou
s pa
in fr
ee E
CG
but
doe
s
not
con
tain
hig
h ris
k ch
ange
s.
£ E
CG
Nor
mal
or u
ncha
nged
from
pre
viou
s pa
in fr
ee E
CG
All
case
s to
be
disc
usse
d w
ith S
enio
r Med
ical
Offi
cer
Rec
omm
ende
d M
anag
emen
t on
page
2
This
tool
is in
tend
ed a
s a
guid
elin
e fo
r clin
icia
ns to
pro
vide
qua
lity
patie
nt c
are.
It is
not
inte
nded
, nor
sho
uld
it re
plac
e, in
divi
dual
c
linic
al ju
dgem
ent.
Som
e pa
tient
s w
ith c
o-m
orbi
ditie
s or
pat
ient
s no
t sui
tabl
e fo
r inv
asiv
e in
vest
igat
ions
may
be
appr
opria
tely
man
aged
med
ical
ly.
Con
trai
ndic
atio
ns a
nd c
autio
ns fo
r thr
ombo
lysi
s us
e in
STE
MI1
Abs
olut
e co
ntra
indi
catio
ns:
Ris
k of
ble
edin
g- A
ctiv
e bl
eedi
ng o
r ble
edin
g di
athe
sis
(exc
ludi
ng m
ense
s)- S
igni
fican
t clo
sed
head
or f
acia
l tra
uma
with
in 3
mon
ths
- Sus
pect
ed a
ortic
dis
sect
ion
(incl
udin
g ne
w n
euro
logi
cal s
ympt
oms)
Ris
k of
intr
acra
nial
hae
mor
rhag
e- A
ny p
rior i
ntra
cran
ial h
aem
orrh
age
- Isc
haem
ic s
troke
with
in 3
mon
ths
- Kno
wn
stru
ctur
al c
ereb
ral v
ascu
lar l
esio
n (e
g, a
rterio
veno
us m
alfo
rmat
ion)
- Kno
wn
mal
igna
nt in
tracr
ania
l neo
plas
m (p
rimar
y or
met
asta
tic)
Rel
ativ
e co
ntra
indi
catio
ns:
Ris
k of
ble
edin
g- C
urre
nt u
se o
f ant
icoa
gula
nts:
the
high
er th
e in
tern
atio
nal n
orm
alis
ed ra
tio (I
NR
), th
e hi
gher
the
risk
of b
leed
ing
- Non
-com
pres
sibl
e va
scul
ar p
unct
ures
- Rec
ent m
ajor
sur
gery
(< 3
wee
ks)
- Tra
umat
ic o
r pro
long
ed (>
10
min
utes
) car
diop
ulm
onar
y re
susc
itatio
n- R
ecen
t (w
ithin
4 w
eeks
) int
erna
l ble
edin
g (e
g, g
astro
inte
stin
al o
r urin
ary
tract
hae
mor
rhag
e)- A
ctiv
e pe
ptic
ulc
erR
isk
of in
trac
rani
al h
aem
orrh
age
- His
tory
of c
hron
ic, s
ever
e, p
oorly
con
trolle
d hy
perte
nsio
n- S
ever
e un
cont
rolle
d hy
perte
nsio
n on
pre
sent
atio
n (>
180
mm
Hg
syst
olic
or >
110
mm
Hg
dias
tolic
)- I
scha
emic
stro
ke m
ore
than
3 m
onth
s ag
o, d
emen
tia, o
r kno
wn
intra
cran
ial a
bnor
mal
ity n
ot c
over
ed in
con
train
dica
tions
Oth
er- P
regn
ancy
1 Ada
pted
from
NH
F/C
SA
NZ
Gui
delin
es fo
r the
man
agem
ent o
f acu
te c
oron
ary
synd
rom
es 2
006
Con
trai
ndic
atio
ns to
Exe
rcis
e Te
stin
g (A
CC
/AH
A G
uide
lines
)2
Abs
olut
e- R
ecur
rent
che
st p
ain
- Acu
te m
yoca
rdia
l inf
arct
ion,
with
in 2
day
s
- Hig
h-ris
k un
stab
le a
ngin
a
- Unc
ontro
lled
card
iac
arrh
ythm
ias
caus
ing
sym
ptom
s or
hae
mod
ynam
ic c
ompr
omis
e
- Sym
ptom
atic
sev
ere
aorti
c st
enos
is
- Unc
ontro
lled
sym
ptom
atic
hea
rt fa
ilure
- Acu
te p
ulm
onar
y em
bolu
s or
pul
mon
ary
infa
rctio
n
- Acu
te m
yoca
rditi
s or
per
icar
ditis
- Acu
te a
ortic
dis
sect
ion
Rel
ativ
e- C
ritic
al le
ft m
ain
coro
nary
ste
nosi
s
- Mod
erat
e st
enot
ic v
alvu
lar h
eart
dise
ase
- Ele
ctro
lyte
abn
orm
aliti
es
- Sys
tolic
hyp
erte
nsio
n >
200
mm
Hg
- Dia
stol
ic h
yper
tens
ion
> 10
0 m
mH
g
- Tac
hyar
rhyt
hmia
s or
bra
dyar
rhyt
hmia
s
- New
ons
et a
trial
fibr
illat
ion
- Hyp
ertro
phic
car
diom
yopa
thy
and
othe
r for
ms
of o
utflo
w o
bstru
ctio
n
- Men
tal o
r phy
sica
l im
pairm
ent l
eadi
ng to
the
inab
ility
to e
xerc
ise
adeq
uate
ly- H
igh-
degr
ee a
triov
entri
cula
r blo
ck
- Res
ting
EC
G w
hich
will
mak
e E
ST
inte
rpre
tatio
n di
fficu
lt (e
g LB
BB
, LV
H w
ith s
train
, Ven
tricu
lar p
acin
g, V
entri
cula
r pre
exci
tatio
n.)
2 Gib
bons
eta
l, C
ircul
atio
n 10
6:18
83,2
002
Abb
revi
atio
ns:
AC
S –
Acu
te C
oron
ary
Syn
drom
e
CA
BG
– C
oron
ary
Arte
ry B
ypas
s G
raft
ECG
– E
lect
roca
rdio
gram
EST
– E
xerc
ise
Stre
ss T
est
FMC
– F
irst M
edic
al C
onta
ct
GTN
– G
lyce
ryl
trini
trate
LBB
B –
Lef
t Bun
dle
Bra
nch
Blo
ck
LVF
– L
eft V
entri
cula
r Fai
lure
LVH
– L
eft V
entri
cula
r Hyp
ertro
phy
PCI –
Per
cuta
neou
s C
oron
ary
Inte
rven
tion
SMO
– S
enio
r Med
ical
offi
cer
STEM
I – S
T E
leva
tion
Myo
card
ial I
nfar
ctio
n
N
O W
RIT
ING
P
age
1 of
4
NO
WR
ITIN
G
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e 4
of 4
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11
10:3
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App
endi
ces
43
120511
BINDING MARGIN - NO WRITINGFa
cilit
y:
CH
EST
PAIN
PAT
HW
AYN
ON
PR
IMA
RY P
CI S
ITE
CO
MP
LETE
ALL
DE
TAIL
S O
R A
FFIX
PAT
IEN
T LA
BE
L H
ER
E
FAM
ILY
NAM
EM
RN
GIV
EN N
AME
MAL
E
FEM
ALE
D.O
.B.
____
___
/ ___
____
/ __
____
_M
.O.
ADD
RES
S
LOC
ATIO
N /
WAR
D
Faci
lity: C
HES
T PA
IN P
ATH
WAY
N
ON
PR
IMA
RY P
CI S
ITE
STEM
I MA
NA
GEM
ENT
CO
MP
LETE
ALL
DE
TAIL
S O
R A
FFIX
PAT
IEN
T LA
BE
L H
ER
E
FAM
ILY
NAM
EM
RN
GIV
EN N
AME
MAL
E
FEM
ALE
D.O
.B.
____
___
/ ___
____
/ __
____
_M
.O.
ADD
RES
S
LOC
ATIO
N /
WAR
D
Rec
omm
ende
d Fu
rthe
r Man
agem
ent
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er to
dru
g pr
otoc
ols
&/o
r The
rape
utic
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delin
es
HIG
H R
ISK
A
DM
IT o
r TR
AN
SFER
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RM
EDIA
TE R
ISK
R
ESTR
ATIF
Y
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K
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CH
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GE
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tinuo
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ardi
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onito
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frequ
ent v
ital s
igns
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epea
t EC
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med
iate
ly if
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s
re
curs
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t EC
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pos
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f
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ple
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G/T
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nin
revi
ew b
y m
edic
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ffice
r
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ipla
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t the
rapy
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____
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____
____
____
____
____
____
____
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____
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nsiti
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ay is
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stin
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ay b
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duce
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vide
d th
e se
cond
sa
mpl
e is
take
n at
leas
t 6 h
ours
afte
r sym
ptom
ons
et.
Med
ical
Offi
cer:
Prin
t nam
e &
sig
n___
____
____
____
____
____
____
____
____
____
____
__ D
ate_
____
____
____
Med
ical
Offi
cer D
esig
natio
n___
____
____
____
____
____
____
____
____
____
____
____
____
___
This
tool
is in
tend
ed a
s a
guid
elin
e fo
r clin
ician
s to
pro
vide
qual
ity p
atie
nt c
are.
It is
not
inte
nded
, nor
sho
uld
it re
plac
e, in
divid
ual c
linica
l ju
dgem
ent.
Som
e pa
tient
s w
ith c
o-m
orbi
ditie
s or
pat
ient
s no
t sui
tabl
e fo
r inv
asive
inve
stig
atio
ns m
ay b
e ap
prop
riate
ly m
anag
ed m
edica
lly.
C
ardi
ac m
onito
ring
EC
G
IV
Can
nula
X 2
Rou
tine
bloo
ds
Oxy
gen
Ana
lges
ia –
Mor
phin
e
Nitr
ates
-Sub
lingu
al o
r IV
CX
R
Bet
a B
lock
ers
Con
firm
adm
inis
trat
ion
or g
ive:
A
spiri
n 3
00 m
g (s
olub
le)
Clo
pido
grel
30
0 - 6
00 m
g
(
or p
rasu
grel
&/o
r tiro
fiban
)
Eno
xapa
rin
30 m
g IV
then
bd
(or I
V h
epar
in o
r biv
aliru
din)
1
mg/
kg s
ubcu
t
(Max
100
mg)
TH
RO
MB
OLY
SIS
UN
LESS
A
bsol
ute
or u
nacc
epta
ble
rela
tive
cont
rain
dica
tions
(see
pag
e 4)
or
Pat
ient
doe
s no
t con
sent
to th
rom
boly
sis
or
D
ocum
ente
d sy
stem
for t
rans
fer t
o P
RIM
AR
Y P
CI S
ITE
in p
lace
D
iscu
ssed
with
car
diol
ogis
t:
Tim
e
:
5. T
HR
OM
BO
LYSE
Tene
ctep
lase
/ R
etep
lase
Bod
y W
eigh
t ___
__kg
Dos
e __
___
Tim
e ad
min
iste
red
:
OR
T
rans
fer t
o PR
IMA
RY P
CI S
ITE
if
app
ropr
iate
(As
per t
able
bel
ow)
D
iscu
ss fu
rther
man
agem
ent i
mm
edia
tely
with
nom
inat
ed c
ardi
olog
ist
P
riorit
ise
urge
ncy
of tr
ansf
er w
ith n
omin
ated
car
diol
ogis
t
Org
anis
e tra
nsfe
r to
PC
I-cap
able
hos
pita
l (as
per
loca
lly a
gree
d pr
otoc
ol)
R
epea
t EC
G a
t 60
min
s po
st th
rom
boly
ticMax
imum
Acc
epta
ble
Del
ay fr
om F
irst M
edic
al C
onta
ct (F
MC
):Ti
me
sinc
e sy
mpt
om
onse
tA
ccep
tabl
e de
lay
from
FM
C to
pe
rcut
aneo
us in
terv
entio
n<
1hou
rs60
min
utes
1-3
hour
s90
min
utes
3-12
hou
rs12
0 m
inut
es>1
2hou
rsN
ot ro
utin
ely
reco
mm
ende
d fr
om N
HF/
CS
AN
Z G
uide
lines
for t
he m
anag
emen
t of a
cute
cor
onar
y sy
ndro
mes
200
6
R
efer
to lo
cal
p
roto
cols
&/o
r
The
rape
utic
Gui
delin
es
1.
CO
NFI
RM
IN
DIC
ATIO
NS
for
REP
ERFU
SIO
N
C
hest
pai
n >
30 m
in a
nd <
12
hrs
P
ersi
sten
t ST
segm
ent e
leva
tion
of ≥
1 m
m in
two
or m
ore
c
ontig
uous
lim
b le
ads
or S
T se
gmen
t ele
vatio
n of
≥ 2
mm
in
two
cont
iguo
us c
hest
lead
s or
pre
sum
ed n
ew L
BB
B p
atte
rn
Myo
card
ial i
nfar
ct li
kely
from
his
tory
2.
GEN
ERA
L M
AN
AG
EMEN
T
3.
AD
MIN
ISTE
R
AN
TITH
RO
MB
OTI
CTH
ERA
PY
4.C
HO
OSE
R
EPER
FUSI
ON
MET
HO
D
Med
ical
Offi
cer:
Prin
t nam
e &
sig
n___
____
____
____
____
____
____
____
____
____
____
__ D
ate_
____
____
____
Med
ical
Offi
cer D
esig
natio
n___
____
____
____
____
____
____
____
____
____
____
____
____
___
This
tool
is in
tend
ed a
s a
guid
elin
e fo
r clin
icia
ns to
pro
vide
qua
lity p
atie
nt c
are.
It is
not
inte
nded
, nor
sho
uld
it re
plac
e, in
divi
dual
clin
ical
ju
dgem
ent.
Som
e pa
tient
s w
ith c
o-m
orbi
ditie
s or
pat
ient
s no
t sui
tabl
e fo
r inv
asiv
e in
vest
igat
ions
may
be
appr
opria
tely
man
aged
med
ical
ly.
N
O W
RIT
ING
P
age
2 of
4
NO
WR
ITIN
G
Pag
e 3
of 4
Dis
cuss
with
card
iolo
gist
/S
MO
}
NB
: ** I
f str
ess
test
is n
ot
avai
labl
e w
ithin
72
hrs
of
disc
harg
e, tr
eatm
ent p
lan
shou
ld b
e gu
ided
by
nom
inat
ed
SMO
/Car
diol
ogis
t
Pha
rmac
olog
ical
stre
ss te
st o
r C
T co
rona
ry a
ngio
grap
hy m
ay b
e in
dica
ted
Tim
e of
dia
gnos
tic E
CG
:
¶SMRÊ(Îg|Ä SMR080071
NS
W H
EA
LTH
NO
N P
RIM
AR
Y P
CI S
ITE
CP
AS
SE
SS
ME
NT
.indd
2
12/0
5/20
11
10:3
2:22
AM
App
endi
ces
44
Membership GMCT Cardiac Network
• Prof Peter Fletcher
• Ms Karen Lintern
• Ms Bride Carr
Emergency Care Taskforce
• Dr Rod Bishop
• Dr Adam Chan
Critical Care Network
• Dr Garry Tall
Rural Critical Care Network
• Dr. Patricia Saccasan Whelan
• Ms Megan Tuipulotu
NSW Ambulance
• Mr Paul Stewart
Quality & Safety Branch
• Ms Christine Hapustein
Nursing & Midwifery Office
• Mr James Wedeswieler
Health System Performance Improvement Branch
• Mr Daniel Comerford
• Mr Neil Rickwood
Additional members
• Mr Lindsay Savage
• Dr Carolyn Hullick
• Dr Matthew Bragg
Project contact: James Dunne [email protected]
Chest Pain Patient Journey — Working Party
APPENDIX G
NSW Health
73 Miller St
North Sydney 2060