is it just me, or has standard of care sunk?

**canoehead, BSN, RN** · Oct 17, 2011

Is it reasonable to run cardiacs everyday for a pt who c/o chest pain everyday? How many times can they be negative before you say "The heart's not the problem" Is defensive medicine the only way to go? How long does the hospital do these tests with the results all negative?

They can come in daily, or even several times a day, you still have to prove that THIS pain NOW won't kill them, per EMTALA. Most of the repeat chest painers have had some cardiac disease, and it would make sense if they had another infarct, eventually. So we have to make sure that today isn't the big one, then we can send them home.

My most frequent flyer for chest pain eventually did die of a heart attack at home. He'd come in 2-3x weekly for three years for the same workup. Yes, he had come in the night before, and yes, all the labs were negative, and then he died.

KeepItRealRN, BSN, RN · Oct 17, 2011

No it is not you. Standards are slipping.

vanburbian · Oct 17, 2011

Uggghh....

So many issues, I won't even start. Mostly already noted in previous comments.

Between rules, regulations, non user friendly EHR's that take more time to document than to treat the patient, Press-Ganey (or whichever version) satisfaction scores, and now the push to triage at the bedside so the pt is in & out even faster, it's a battlefield.

I will say the ER docs are often not concerned with tx HTN unless they can not explain it. Of course, this really is all how they present, CP vs headache vs belly pain, etc.

No O2 sat??? Something likely didn't get documented correctly.

P.S.

To answer the question, I don't honestly believe the SoC has necessarily sunk, but I do believe we are being asked to work so much more quickly, that our ability to provide the care we'd like to has become a difficult task to achieve.

As others noted, CP as CC gets cardiac enzymes drawn, always.

For those odd few who do come in every day, or even 2 to 3 times a day, and c/o CP, we may watch them for an hour or so to see if they are hemodynamically stable before we draw labs.

This is more of an attempt to see if indeed they are really having CP, or do they just need a meal, a warm and dry place to rest, or is something else going on.

Sometimes they say chest pain, then when questioned they say leg pain, then it may change again to headache, or cough, or SOB, or constipation.

At our facility, the registration people enter the chief complaint, and when we are not slammed, we change it during triage if that CC not accurate, but I am gonna guess that this sometimes gets missed.

locolorenzo22, BSN, RN · Oct 18, 2011

thank you all for the comments. Yes, the patient was admitted for chest pain, admitted to having chest pain in ER. went away shortly with the nitro paste. VS were done, as a full set, but overall the bp was the issue. I take issue with it going up and up, and nothing being done.

the er just switched to using POC cardiac enzymes, but never have had a issue with it showing up before.

Just agree overall. Good points for all. Thank you again for the input.

ukjenn231 · Oct 18, 2011

I know what you're saying. There was a patient who c/o chest pain on our floor the other night, the EKG and VS were normal but it was a new complaint of CP, not the primary diagnosis.... The RN called the doc to notify and asked if he wanted enzymes, nitro, etc and he said no, not necessary, just morphine for pain. I believe in the CYA philosophy, especially when someone is complaining of chest pain.

Guest219794 · Oct 18, 2011

they can come in daily, or even several times a day, you still have to prove that this pain now won't kill them, per emtala. most of the repeat chest painers have had some cardiac disease, and it would make sense if they had another infarct, eventually. so we have to make sure that today isn't the big one, then we can send them home.
my most frequent flyer for chest pain eventually did die of a heart attack at home. he'd come in 2-3x weekly for three years for the same workup. yes, he had come in the night before, and yes, all the labs were negative, and then he died.

nope. not true.

the pt is entitled to a medical screening exam to determine whether there is an emergency. that exam does not need to include labs, or even vitals for that matter.

xtxrn, ASN, RN · Oct 18, 2011

in defense of the er, and i don't work er, they frequently have the same pts, present several times a week with the same complaint.
apparently the er is very familiar with this pt. is it possible she had a complete cardiac workup the same day or the day before?
it would have been nice if the er had given the pt her scheduled bp meds. but the er is not the doctors office or the clinic.
it would have been nicer if the pt had taken them herself

ok..bear with me ...there's a point to this

or, if you don't care to know about anything personal that isn't all rosy about everything nursey, skip this... you've been warned :clown:

i absolutely understand what you're saying....however- as someone with chronic medical conditions that resulted in a lot of transfers to the ed from work, then after being disabled, when i was following my pcp's parameters, one particular ed was horrendous in its "assumptions" that it was "just" the epilepsy or dysautonomia (witnessed/documented, for more than 20 years- including 5-day video eeg), i was a wasted bed (their words) that i was non-compliant and never followed up with my pcp, when i virtually had a standing appointment. plus post-ed visits.

however, when symptoms changed a bit (and i wasn't sure what was going on, either) they started to refuse to even double check bps, which was the parameter my pcp had me going to the ed for (got severely low). there were also medication interactions that hadn't been addressed (and took some figuring out - time wise, as to when things got worse after what meds). :confused: they assumed i was just showing up due to nothing else to do- which was pretty p-poor of them to even suggest; it was horrible going there.

well, an md who refused to examine me (or recheck the bp after ems got me dumped off, and i wasn't all stirred up from that movement), and sent me home was blowing off pulmonary emboli...that were discovered 10 days later (acute, sub-acute, and chronic...many, and not from just a day or so before; thanks for the permanent lung scars - way to go :yeah: ).

i didn't have the sob, cyanosis, low sats, pain on inspiration or other "normal" pe s/s... mine were more of the syncopal and hypotensive symptoms (which were part of the dysautonomia i deal with all the time) - over time- until my right lung had clots in all 3 lobes and the r pa, and were "enough" to push into my heart, causing transient ischemia to the apex, with mi symptoms. if i hadn't gone to a different ed (as instructed by my pcp's nurse- who was part of the crappy ed's "group") i'd be dead. end of story. :mad:

my pcps nurse saved my butt by realizing that the lousy ed really was sub-standard (and they'd had one of the decent mds there tell my pcp that he'd seen them be nasty to me). :up:

frequent fliers die still die from preventable causes. and yes, they are annoying at times, and it's frustrating to deal with someone who doesn't follow up.

it's also frustrating to have ed staff assume that of everyone who is seen a lot. and i've heard so many people tell me horror stories of their own from that place.... they actually posted their pg satisfaction %..... 60% (what a treasure to modern medicine ) i refused to answer the pg surveys from there- i'd already dealt with the lip service from "customer relations" and that was a disgusting joke. only not funny....

after getting meds straightened out, my ed visits went down by about 95%- and "fecal hole" place is off my list completely (the pe miss was just one of a laundry list of screw ups- and once established at the other medical group/hospital, i could stop going to the abusive place unless ems couldn't get bypass approval - that's only happened once) they had nothing to do with getting meds straightened out- i figured it out on my own, and brought it up with my doc; tias from hypotension r/t medication interactions shouldn't happen).

and yes, i understand that most eds/ed nurses/docs aren't like that- but there are really nasty facilities that have no business dealing with live people.

if the op is describing something that is a constant problem with ed admissions, then that's pretty lousy. if it's a fluke situation, then maybe the ed was totally slammed, and doing the best they could. idk. none of us do. i've gotten patients from the ed at a couple of places i worked that were a mess- but that wasn't their norm. most did the best they could. :twocents:

i especially appreciated it when the ed nurse giving report could tell me "hey, we didn't get x,y, z done, but we have 2 bad mvas with family all over the place, and 2 of the 7 criticals not expected to leave the ed, and 3 of the others being flown to _______". that told me a lot. and i was happy to pick up whatever i could to help them out. as much as i've had lousy experiences as an ed patient, i've had a lot more good experiences getting patients from the ed as a nurse. if the supervisor told the ed that the floors were swamped, then the ed would do more "floor stuff" before sending them up (teds, bucks, foley for the hips, etc).

jme and o... :) what's that thing they talk about in the lovely customer service "lectures"??? that nobody talks about the good stuff, but 10 people will hear about the bad- and those 10 will tell their friends. fwiw, it's nice to send thank yous when things go well :) people hear enough about the trash stuff. :twocents: i do have a lot more good experiences on both sides of the side rails than the bad :)