Triage flowchart to rule out acute coronary syndrome

Role of the nurses in partnering with mothers to give oral medication to their hospitalised child: Modification and development of a contextualised evidence-based practice guideline

Background

In paediatric wards, children are often reluctant to receive medication from nurses and eventually it is given by the parents. It is a common practice for nurses to hand the medication to mothers to give to their children, However, it is an ‘informal’ practice and lacks evidence-based guidelines.

Objectives

To develop a contextualised and adapted evidence-based guideline to support nurses to partner with mothers/carers so that they can safely give oral medication to their hospitalised child under the supervision of a competent nurse.

Method

Existing relevant guidelines were identified through searches of bibliographic databases and websites. The AGREE II: Appraisal of Guidelines for Research and Evaluation II instrument was used to appraise the quality of the identified sources. The process of guideline adaptation recommended by the South African Guidelines Excellence project was followed, and a list of adapted recommendations was developed, aligned with the legislative and regulatory frameworks for nursing in South Africa. Accessible end user documentation was developed.

Results

Six sources were screened and three sources were found to be eligible and were subjected to full appraisal. Two guidelines and one policy document were identified as suitable for adaptation. Expert consultation confirmed that the resulting adapted guideline was sound, easy to understand, and well presented for the target audience.

Conclusion

This process successfully led to the development of a modified evidence-based practice guideline to enable nurses to partner with mothers/caregivers in safely giving oral medication to their hospitalised child in lower-resourced African settings.

The diagnostic value of Red Flags in thoracolumbar pain: a systematic review

PURPOSE

Red Flags (RFs) are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal pain. The current literature wonders about the usefulness of RFs, due to high false-positive rates and low diagnostic accuracy. The aims of this systematic review are: (a) to identify and (b) to evaluate the most important RFs that could be found by a health care professional during the assessment of patients with low and upper back pain (named as thoracolumbar pain (TLP)) to screen serious pathologies.

MATERIALS AND METHODS

A systematic review of the literature was conducted. Searches were performed on seven databases (Pubmed, Web of Science, Cochrane Library, Pedro, Scielo, CINAHL, and Google Scholar) between March 2019 and June 2020, using a search string which included synonyms of low back pain (LBP), chest pain (CP), differential diagnosis, RF, and serious disease. Only observational studies enrolling patients with LBP or CP were included. Risk of bias was assessed with the Newcastle Ottawa Scale and inter-rater agreement between authors for full-text selection was evaluated with Cohen's Kappa. Where possible the diagnostic accuracy was recorded for sensitivity (Sn), specificity (Sp), and positive/negative likelihood ratio (LR+/LR-).

RESULTS

Forty full-texts were included. Most of the included observational studies were judged as low risk of bias, and Cohen's Kappa was good (=0.78). The identified RFs were: advanced age; neurological signs; history of trauma; malignancy; female gender; corticosteroids use; night pain; unintentional weight loss; bladder or bowel dysfunction; loss of anal sphincter tone; saddle anaesthesia; constant pain; recent infection; family or personal history of heart or pulmonary diseases; dyspnoea; fever; postprandial CP; typical reflux symptoms; haemoptysis; sweating; pain radiated to upper limbs; hypotension; retrosternal pain; exertional pain; diaphoresis; and tachycardia. The diagnostic accuracy of RFs as self-contained screening tool was low, while the combination of multiple RFs showed to increase the probability to identify serious pathologies.

CONCLUSIONS

Despite the use of single RF should not be recommended for the screening process in clinical practice, the combination of multiple RFs to enhance diagnostic accuracy is promising. Moreover, the identified RFs could be a baseline to develop a screening tool for patients with TLP.Implications for rehabilitationDifferential diagnosis and screening for referral are mandatory skills for each healthcare professional in direct access clinical settings, and should be the primary step for an appropriate management of a patient with signs and symptoms mimicking serious pathologies in thoracolumbar region.Clinical reasoning and decision-making processes are essential throughout all phases of a patient's pathway of care. By which, the use of single Red Flag (RF) as a self-contained screening tool should not be recommended. The combination of multiple RFs promises to increase diagnostic accuracy and could grow into an excellent screening tool for thoracolumbar pain.

External validation of an emergency department triage algorithm for chest pain patients

BACKGROUND

We aimed to externally validate an emergency department triage algorithm including five hierarchical clinical variables developed to identify chest pain patients at low risk of having an acute coronary syndrome justifying delayed rather than immediate evaluation.

METHODS

In a single-centre cohort enrolling 29,269 consecutive patients presenting with chest pain, the performance of the algorithm was compared against the emergency department discharge diagnosis. In an international multicentre study enrolling 4069 patients, central adjudication by two independent cardiologists using all data derived from cardiac work-up including follow-up served as the reference. Triage towards 'low-risk' required absence of all five clinical 'high-risk' variables: history of coronary artery disease, diabetes, pressure-like chest pain, retrosternal chest pain and age above 40 years. Safety (sensitivity and negative predictive value (NPV)) and efficacy (percentage of patients classified as low risk) was tested in this initial proposal (Model A) and in two additional models: omitting age criteria (Model B) and allowing up to one (any) of the five high-risk variables (Model C).

RESULTS

The prevalence of acute coronary syndrome was 9.4% in the single-centre and 28.4% in the multicentre study. The triage algorithm had very high sensitivity/NPV in both cohorts (99.4%/99.1% and 99.9%/99.1%, respectively), but very low efficacy (6.2% and 2.7%, respectively). Model B resulted in sensitivity/NPV of 97.5%/98.3% and 96.1%/89.4%, while efficacy increased to 14.2% and 10.4%, respectively. Model C resulted in sensitivity/NPV of 96.7%/98.6% and 95.2%/91.3%, with a further increase in efficacy to 23.1% and 15.5%, respectively.

CONCLUSION

A triage algorithm for the identification of low-risk chest pain patients exclusively based on simple clinical variables provided reasonable performance characteristics possibly justifying delayed rather than immediate evaluation in the emergency department.

Comparison between Negative T waves characteristics in acute coronary syndrome and pulmonary embolism

BACKGROUND

Electrocardiogram (ECG) is the first available modality used in patients with chest pain and dyspnea in emergency rooms. We aimed to study differences between acute coronary syndrome (ACS) and acute pulmonary embolism (APE) in patients presented primarily with abnormal negative T waves on their admission Electrocardiogram.

METHODS

This research was a retrospective study in which 297 patients (97 patients with APE and 200 with ACS) were included. The patients were admitted to the emergency ward of a tertiary heart center between 2015 and 2017. In addition to the evaluation of distribution of negative T waves, the depth of the inverted precordial T waves was measured.

RESULTS

The mean age of patients was 62.0 ± 11.4 in ACS group and 60.7 ± 17.6 in APE group (P value = 0.563). Total negative T in V3 and V4 in ACS and APE groups was 9.1 mm and 4.2 mm respectively (P value <0.001). Total magnitude of negative T in anterior leads divided by total magnitude of negative T in inferior leads for ACS and APE groups were 15.1 ± 12.0 and 5.4 ± 3.6 respectively (P value = 0.001). ROC curves showed that total magnitude of negative T in V4 divided by negative T in V1 can be valuable. A cutoff point of 1.75 with sensitivity of 73.5% and specificity of 84.9% (95% CI 0.79-0.91 P < 0.001) could differentiate APE patients from ACS patients.

CONCLUSION

This study suggests that total magnitude of negative T in left precordial leads divided by right precordial leads can be valuable in differentiating APE from ACS.

An alternative tool for triaging patients with possible acute coronary symptoms before admission to a chest pain unit

OBJECTIVE

This study aimed to develop a triage tool to more effectively triage possible ACS patients presenting to the emergency department (ED) before admission to a protocol-driven chest pain unit (CPU).

METHODS

Seven hundred ninety-three clinical cases, randomly selected from 7962 possible ACS cases, were used to develop and test an ACS triage model using cluster analysis and stepwise logistic regression.

RESULTS

The ACS triage model, logit (suspected ACS patient)=-5.283+1.894×chest pain+1.612×age+1.222×male+0.958×proximal radiation pain+0.962×shock+0.519×acute heart failure, with a threshold value set at 2.5, was developed to triage patients. Compared to four existing methods, the chest-pain strategy, the Zarich's strategy, the flowchart, and the heart broken index (HBI), the ACS triage model had better performance.

CONCLUSION

This study developed an ACS triage model for triaging possible ACS patients. The model could be used as a rapid tool in EDs to reduce the workloads of ED nurses and physicians in relation to admissions to the CPU.

Clinical assessment of patients with chest pain; a systematic review of predictive tools

Background

The clinical assessment of patients with chest pain of recent onset remains difficult. This study presents a critical review of clinical predictive tools for the assessment of patients with chest pain.

Methods

Systematic review of observational studies and estimation of probabilities of coronary artery disease (CAD) in patients with chest pain. Searches were conducted in PubMed, Embase, Scopus, and Web of Science to identify studies reporting tools, with at least three variables from clinical history, physical examination or ECG, produced with multivariate analysis, to estimate probabilities of CAD in patients with chest pain of recent onset, published from inception of the database to the 31^st July 2015. The references of previous relevant reviews were hand searched. The methodological quality was assessed with standard criteria. Since the incidence of CAD has changed in the past few decades, the date of publication was acknowledged to be relevant in order to use the tool in clinical practice, and more recent papers were considered more relevant. Probabilities of CAD according to the studies of highest quality were estimated and the evidence provided was graded.

Results

Twelve papers were included out of the 19126 references initially identified. The methodological quality of all of them was high. The clinical characteristics of the chest pain, age, past medical history of cardiovascular disease, gender, and abnormalities in the ECG were the predictors of CAD most commonly reported across the studies. The most recent papers, with highest methodological quality, and most practical for use in clinical settings, reported prediction or exclusion of CAD with area under the curve 0.90 in Primary Care, 0.91 in Emergency department, and 0.79 in Cardiology. These papers provide evidence of high level (1B) and the recommendation to use their results in the management of patients with chest pain is strong (A).

Conclusions

The risk of CAD can be estimated on clinical grounds in patients with chest pain in different clinical settings with high accuracy. The estimation of probabilities of CAD presented in these studies could be used for a better management of patients with chest pain and also in the development of future predictive tools.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0196-4) contains supplementary material, which is available to authorized users.

An online tool for nurse triage to evaluate risk for acute coronary syndrome at emergency department

Background. To differentiate acute coronary syndrome (ACS) from other causes in patients presenting with chest pain at the emergency department (ED) is crucial and can be performed by the nurse triage. We evaluated the effectiveness of the ED nurse triage for ACS of the tertiary care hospital. Methods. We retrospectively enrolled consecutive patients who were identified as ACS at risk patients by the ED nurse triage. Patients were categorized as ACS and non-ACS group by the final diagnosis. Multivariate logistic analysis was used to predict factors associated with ACS. An online model predictive of ACS for the ED nurse triage was constructed. Results. There were 175 patients who met the study criteria. Of those, 28 patients (16.0%) were diagnosed with ACS. Patients with diabetes, patients with previous history of CAD, and those who had at least one character of ACS chest pain were independently associated with having ACS by multivariate logistic regression. The adjusted odds ratios (95% confidence interval) were 4.220 (1.445, 12.327), 3.333 (1.040, 10.684), and 12.539 (3.876, 40.567), respectively. Conclusions. The effectiveness of the ED nurse triage for ACS was 16%. The online tool is available for the ED triage nurse to evaluate risk of ACS in individuals.

Clinical value of chest pain presentation and prodromes on the assessment of cardiovascular disease: a cohort study

OBJECTIVES

The recognition of coronary artery disease (CAD) among patients who report chest pain remains difficult in primary care. This study investigates the association between chest pain (specified, unspecified or musculoskeletal) and prodromes (dyspepsia, fatigue or dyspnoea), with first-ever acute CAD, and increased longer term cardiovascular risk.

DESIGN

Cohort study.

SETTING

Anonymised clinical data recorded electronically by general practitioners from 140 primary care surgeries in London (UK) between April 2008 and April 2013.

PARTICIPANTS

Data were extracted for all patients aged 30 years and over at the beginning of the study period, registered in the surgeries.

MAIN OUTCOME MEASURES

Clinical data included chest pain, dyspepsia, dyspnoea and fatigue, first-ever CAD and long-term cardiovascular risk (QRisk2). Regression models were used to analyse the association between chest pain together with prodromes and CAD and QRisk2≥20%.

RESULTS

354,052 patients were included in the study. 4842 patients had first-ever CAD of which 270 reported chest pain in the year before the acute event. 257,019 patients had QRisk2 estimations. Chest pain was associated with a higher risk of CAD. HRs: 21.12 (16.68 to 26.76), p<0.001; 7.51 (6.49 to 8.68), p<0.001; and 1.84 (1.14 to 3.00), p<0.001 for specified, unspecified and musculoskeletal chest pain. Dyspepsia, dyspnoea or fatigue was also associated with a higher risk of CAD. Chest pain of all subtypes, dyspepsia and dyspnoea were also associated with an increased 10-year cardiovascular risk of 20% or more.

CONCLUSIONS

All patients with chest pain, including those with atypical symptoms, require careful assessment for acute and longer term cardiovascular risk. Prodromes may have independent diagnostic value in the estimation of cardiovascular disease risk.

The efficacy and safety of a chest pain protocol for short stay unit patients: A one year follow-up

BACKGROUND

The Alfred Emergency Short Stay Unit initiated a chest pain protocol for patients presenting with chest pain to risk stratify for acute coronary syndrome (ACS). A 30-day follow-up of patients discharged with low-or-intermediate risk of ACS demonstrated no deaths or ACS.

AIMS

The purpose of this study was to evaluate the long-term safety of the chest pain protocol, a one year follow-up was undertaken.

METHODS

A questionnaire was designed for the one-year follow-up and it was administered via a telephone interview by emergency nurses to document adverse cardiac events and health care utilisation.

RESULTS

From 297 patients, 224 (75%) were contacted 12 months following discharge. There was one death from stroke (0.4%; 95% confidence interval (CI): 0.01-2.5%) and another from an unknown cause. Five patients had been diagnosed with atrial fibrillation (2.2%; 95% CI: 0.7-5.1%), two patients had an acute myocardial infarction (0.9%; 95% CI: 0.03-2.1%) and four were diagnosed with angina (1.8%; 95% CI: 0.9-3.2%). Nearly half (n=103, 46%; 95% CI: 39.5-52.5%) had returned to the emergency department (ED) for various conditions including 42 patients with further chest pain. Ninety-six patients (43%; 95% CI: 39.3-52.7%) had specialist referrals and 124 investigations were performed. Thirty-four patients had cardiology referrals (15%; 95% CI: 10.7-20.5%) and 25 patients had gastroenterology referrals (11%; 95% CI: 7.3-16.0%). Diagnostic cardiac tests were performed on 38 patients: coronary angiography (n=10), 24-hour Holter monitoring (n=17), 24-hour blood pressure (BP) monitoring (n=4), thallium scans (n=5), exercise stress test (n=1) and CT scan (n=1).

CONCLUSION

Patients had a low risk of adverse events 12 months after discharge but substantial continuing health care utilization was observed. Complete assessment by health care professionals prior to discharge may help mitigate representations.

The challenge of triaging chest pain patients: the bernese university hospital experience

Accurate diagnosis of the causes of chest pain and dyspnea remain challenging. In this preliminary observational study with a 5-year follow-up, we attempted to find a simplified approach to selecting patients with chest pain needing immediate care based on the initial evaluation in ED. During a 24-month period were randomly selected 301 patients and a conditional inference tree (CIT) was used as the basis of the prognostic rule. Common diagnoses were musculoskeletal chest pain (27%), ACS (19%) and panic attack (12%). Using variables of ACS symptoms we estimated the likelihood of ACS based on a CIT to be high at 91% (32), low at 4% (198) and intermediate at 20.5–40% in (71) patients. Coronary catheterization was performed within 24 hours in 91% of the patients with ACS. A culprit lesion was found in 79%. Follow-up (median 4.2 years) information was available for 70% of the patients. Of the 164 patients without ACS who were followed up, 5 were treated with revascularization for stable angina pectoris, 2 were treated with revascularization for myocardial infarction, and 25 died. Although a simple triage decision tree could theoretically help to efficient select patients needing immediate care we need also to be vigilant for those presenting with atypical symptoms.

Evaluation of the ACT Intervention to Improve Nurses’ Cardiac Triage Decisions

Emergency department (ED) nurses are in a key position to initiate life-saving recommendations for myocardial infarction, which include a physician-read electrocardiogram (ECG) within 10 min of ED arrival. Using a quasi-experimental, one-group pretest—posttest design, the authors evaluated the preliminary effectiveness of the Aid to Cardiac Triage (ACT) intervention to improve ED nurses’ cardiac triage decisions. Charts of all women who received an ED ECG 3 months before ( n = 171) and after ( n = 184) the intervention and who were at least 18 years of age were reviewed. A 1-hr educational session was conducted to improve nurses’ ( n = 23) cardiac triage decisions. Postintervention, the proportion of women receiving an ECG within 10 min of ED arrival improved, as did the odds of women receiving a timely ECG. Preliminary evaluation of the ACT intervention indicates its effectiveness at improving ED nurses’ cardiac triage decisions and obtaining a 10-min physician-read ECG.

Undisclosed cocaine use and chest pain in emergency departments of Spain

Aims

Illicit cocaine consumption in Spain is one of the highest in Europe. Our objective was to study the incidence of undisclosed cocaine consumption in patients attending in two Spanish Emergency Departments for chest pain.

Methods

We analysed urine samples from consenting consecutive patients attending ED for chest pain to determine the presence of cocaine, and other drugs, by semiquantative tests with fluorescence polarization immunoassay (FPIA).

Results

Of 140 cases, 15.7 presented positive test for drugs, and cocaine was present in 6.4%. All cocaine-positive patients were younger (p < 0.001); none was admitted to Hospital (p = 0.08). No significant differences in ED stay or need for hospitalization were found between cocaine-positive and negative patients.

Conclusion

This finding in chest pain patients who consented to urine analysis suggests that the true incidence of cocaine use leading to such ED visits may be higher.