What is your hospital's policy regarding Rule-Out MI's?

  1. I work in a very small rural hospital. . . and we're getting smaller!!! We're in the process of combining the med/surg unit and the ICU/CCU unit so that it's all basically one unit on the same floor. Modifications are being made so that there will be four dedicated ICU/CCU type rooms with all of the monitoring devices, etc. The hospital is also having (finally!!!) real telemetry devices so that telemetry-type patients can walk untethered and still be monitored. (Currently, the ICU/CCU lacks the tele-packs so that a telemetry patient has to be hooked up to a monitor at all times.) I believe that an additional five or so tele beds will be made available on this combined med/surg/ICU/CCU floor. Total beds will be 15!!! (This is being done in order to qualify to receive special funding which, apparently, will mean more money than what the hospital is already receiving in reimbursements. . . .I don't know. . . . I'm just a staff nurse. . . .)

    In actuality, most patients admitted to our happy little unit are telemetry-type patients. They're usually older patients with a new onset of a-fib or had a syncopal or near-syncopal episode etc. Another large population of patients are the "rule-out MI's". They are currently admitted as CCU patients until they either rule-out or remain a CCU patient if they do indeed rule-in.

    The question has been raised as to whether "rule-out" patients should be - could be - admitted as telemetry patients until they either rule-in, in which case they would become CCU patients, or rule-out and either remain as telemetry patients for further cardiac-stress testing or go home with something to help their GERD. Actually, my nurse-manager has asked me to seek input from other ICU/CCU nurses who work in similar small-hospital situations and ask, "How do you classify your 'Rule-Out MI' patients when admitted to your hospital?".

    O. K. . . . all you small-rural-community hospital type nurses (who may or may not work in the CCU/ICU). . . . I'm asking! What is your policy regarding admitting patients with the diagnosis of "Rule Out MI"? Are they considered CCU patients or are they considered telemetry patients?

    My personal opinion. . . . I think they should remain catagorized as CCU patients. What if they are admitted as telemetry patients, then rule-in as positive for an MI which would currently make them CCU patients (and are not shipped out to a bigger hospital which does cardiac caths, etc!) and all of the four ICU/CCU beds are full with real ICU/CCU patients?????

    Thank you ahead of time for your thoughtful input and suggestions.

    Regards,

    Ted Fiebke
    Last edit by Ted on Sep 26, '02
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  2. 19 Comments

  3. by   kmchugh
    Ted

    I worked in a SICU prior to going on to anesthesia, floated to CCU. Now, I see the procedures at nearly all hospitals in town. From what I have seen, all rule-out MI patients are in the CCU for at least the first 24 hours, if for no other reason than lawsuit reduction.

    Kevin McHugh
  4. by   Ted
    Thanks kevin!

    I hope our hospital keeps its policy of having "rule-outs" be admitted as CCU patients. I concerned that they're even entertaining the idea of admitting them as "tele" patients.

    Are there hospitals out there (rural or not) that admit "rule-outs" as tele patients?

    Ted
  5. by   BadBird
    In my experience all r/o MI's were either admitted to Tele or CCU depending on patient status (stable/unstable) or whatever bed is available at the time seems to be the reality of admission criteria these days. Continuous cardiac monitoring, serial CPK enzymes, Troponin. Sometimes on Tridil (ntg) drip or NTG paste, Heparin Drip. Routine lab work. EKG on admit to unit and with any chest pain.

    If titrating a tridil drip then patients are usually CCU. After 3 negative enzymes some times patients have stress test, if negative then they are worked up for GI probs. such as hiatel hernia. If pain continues some are taken to cath lab. It all depends on the doctors and it seems that the insurance companies will dictate what tests will and will not be done.
  6. by   prn nurse
    The first cardiac enzymes and the first EKG would generally give you the info you need to know where the patient goes.
    If the patient had chest pain earlier, presents to the ER and all the tests and history are done, the ONE question the ER doc and admitting doc wants to know is: How much is the troponin? Troponin is the one indicator for MI.
    If the troponin is 0.0-0.9 the patient can easily be placed in tele. Those values would indicate no cardiac involvement at this time.
    The patient is then placed in tele and monitored , and serial cardiac enzymes are then ordered X 3 eight hours apart. An EKG is done at the same time. So, you have the initial cardiac enzymes , CPK, CKMB, TROPONIN, drawn in ER, and 3 more sets.
    The initial troponin result decides everything. And this lab test takes 20 minutes to do, so you know on admission if your patient is experiencing an MI. If he is tele or CCU bound.
    In such a small unit, will you have a tele tech who sits & watches the monitors?
    I would guess the same person is watching the tele and the CCU patients monitors?
    The primary difference I see, (its' wake up time for me, I'm on my 1st coffee...so I might miss something) is the skill/experience level of the nurses in tele and CCU. The difference in CCU & Tele is the CCU nurses are quicker to pick up on a irregularity, quicker to call the doc, and experienced in starting drips and monitoring the patient on drips. Most patients in the CCU are confirmed via troponin levels as MI's and of course , once confirmed , handled with more observation and intervention and hopefully the nurseatient staffing is better than tele.
  7. by   kaycee
    Originally posted by prn nurse
    The first cardiac enzymes and the first EKG would generally give you the info you need to know where the patient goes.
    I disagree here. We have had many an MI come into the ER with minimal or no EKG changes and the first set of enzymes neg, including the troponin.
    We base the adm on the whole picture. If the pt is stable and pain free and has no family hx and everything looks normal they will go to tele. Also pt's that presents with new onset Afib or nonspecific chest pain and are stable usually go to tele.
    Anyone with persistent pain, extensive cardiac or family hx and is the least bit unstable goes to CCU.
    Also in some ER's there are chest pain centers that have from 6-8 monitored beds. They are staffed by an ER nurse and they do serial enzymes and EKG's for 24hrs and if normal they stress them and if ok send home. These pts are very stable and in some ERs would be sent home, or admitted for 23hr obvs.
  8. by   willie2001
    I also work in a small rural hospital.

    We admit R/O MI patients to our Med/Surg floor on telemetry if they are pain free and their first set of cardiac enzymes are normal as well as their EKG. If their status changes, they start to have pain or their enzymes go up or their EKG changes, they will go to ICU or transferred to a larger facility for an angiogram. We will not do Nitro drips on med/surg. We will however do IV amiodorone and IV Cardizem on Med/Surg for atrial fibrillation.
    Last edit by willie2001 on Sep 26, '02
  9. by   prn nurse
    I agree with everything you posted kaycee.

    An MI can & does present to the ER with normal cardiac values.

    The question was :
    "Are R/O MI's considered CCU or Tele?

    Looking at the total picture is a given.
    All I am saying is: (Looking at the total picture)
    If the patient presents to the ER, & the total picture is stable, and the 1st set of enzmes and EKG are normal, yes, he is sent to tele.



    As long as the enzymes are negative, and he is stable, he fits into the "ruling Out" category and is eligible for Tele.

    That isn't saying he isn't a pending MI. It says he is stable "right now." With any change, he can be transferred to CCU.

    I've had lots of new MI's on a tele unit, some MI's are mild.They were never transferred to CCU.

    Yes, an MI can present to the ER with negative trop. But,(yes there are exceptions to everything--- trying to answer Ted's simple question here), most MI's in progress (evolving MI's) will not be stable and will be SOB, diaphoretic, experiencing pain, nausea and vomiting, pallor, v/s changes.....and yes, this patient would be a CCU candidate.

    And yes, there are people who suffer major "silent" MI's, but these are the exception, not the rule.

    To answer Ted's inquiry, the doctors will use the troponin as the indicator (along with the history and total picture-- a given) to decide which patient goes to tele and which to CCU. The vast majority of stable patients presenting with a R/O MI diagnosis and negative enzymes will be sent to Tele.

    If they are stable and have an elevated Trop, they will usually go to CCU. Because the MI is "evolving" and you don't know how bad or how fast it will change and you want to start interventions stat.
  10. by   RNinICU
    Originally posted by prn nurse
    The first cardiac enzymes and the first EKG would generally give you the info you need to know where the patient goes.
    If the patient had chest pain earlier, presents to the ER and all the tests and history are done, the ONE question the ER doc and admitting doc wants to know is: How much is the troponin? Troponin is the one indicator for MI.
    If the troponin is 0.0-0.9 the patient can easily be placed in tele. Those values would indicate no cardiac involvement at this time.

    The initial troponin result decides everything. And this lab test takes 20 minutes to do, so you know on admission if your patient is experiencing an MI.
    .
    B]
    An MI can and does present to the ER with normal cardiac values. Looking at the total picture is a given.
    So which is it? Someone says you are wrong, and so you change your mind?

    Ted, it basically comes down to what is going on with the patient. We often put a R/O MI on telemetry. If the patient develops chest pain, or becomes unstable, then they are transferred to CCU. Our telemetry unit cannot do Tridil drips, so a patient requiring IV nitro will always come to CCU. Most of the answers here are accurate. Sometimes it also depends on the physician. One of our cardiologists sends all of his R/O MIs to CCU, and some of the others only send them ther if they are unstable.
  11. by   ceecel.dee
    Our small, rural hospital admits all R/O's to CCU until 3 sets of enzymes come back as normal, regardless of patient symptoms or stability.
  12. by   Sleepyeyes
    I work a MS/Tele unit, and I really am loving it. Teamwork is the key here, and you want to have a close-knit group of nurses/techs. I also have to think that your hospital will do some pretty good training with all this?? We have courses in EKG and Crit care, etc. for free.

    On presenting to the ER, an EKG, complete blood work (cbc, bmp, pt/inr and cardiac enzymes X3 q8h ( i think) are done along with a chest xray. A consult is put in to the cardio doc and this doc is in touch with the ER about that pt at the time of admit. They usually add orders for Cardiac tests such as a 2DE, TEE, stress or US for the morning. Most of our orders get in from the pcp's so fast that they come up with the patient, complete, so they don't miss any meds during their stay.
    So you can see why doctor communication and response plays such a big role in the success of any tele unit.
    We often have R/O MI pts. They're monitored and if they become symptomatic, we have standing tele orders (ntg 0.4 mg sl q 5 min X 3 & notify MD, for example) and tylenol for that nitro headache.
    Docs must see their pts q24hours and more often than not, if we hafta call a doc at 3 am, we get the covering doc directly and don't even hafta wait for a callback. (Another reason I LOVE MY HOSPITAL!!!!) We must call the doc asap for a + troponin.
    I don't know what the criteria are for dx-ing stable/unstable r/o MI, but i think that depends on the admitting ER doc. We have one who plays it safe and admits the 24-yo with a panic attack as well as the 78-yo with significant cardio hx who needs to be on a nitro drip. We also have a lot of CHF'ers and PE's on our unit.
    We have a max of 8 (usually between 5-7) patients on our unit per RN for 11-7 shift and we work with a PCT.

    If a pt codes on our unit, they're immediately stabilized and sent to the Unit. If they have a lot of stuff going on and they make us nervous, we can usually get the doc to agree to send them if we can give reasons. It happened twice last couple of weeks.
  13. by   fab4fan
    I work in a very small community hosp. ED. Depends on the sx., enzymes. If troponin is indetermin., usually tele., unless they are having CP and get started on ntg gtt...then they go to ICU.

    Of course, if troponin is +, ICU.
  14. by   prn nurse
    <SIGH>

    Did I change my mind?? I don't see it.

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