Chest Pain protocols

[Lev, MSN, RN, NP]

The protocol at my hospital is to call rapid response for any acute onset or worsening chest pain. On my med surg unit this protocol is generally not followed. Why? Because the rapid response team will be annoyed that this was not "real" chest pain. Even if the nurse gets the physician assistant to the room, the nurse will generally be discouraged by the PA and not call rapid response. Usually, the nurse can get the provider to order an EKG and sometimes stat troponins and nitroglycerin PRN, occasionally they will check magnesium and potassium. I think this is a sign of poor culture and I wish it would change. Even if calling rapid response is discouraged by the providers, I think there should be an option for nurses to order an EKG, bloodwork, oxygen, nitroglycerin, and protonix IV under protocol. What happens at your facility? What are the protocols in place for chest pain?

[CardiacKittyRN]

I am on a cardiac floor so we have standing orders and don't have to call a doctor to order nitro, morphine, cardiac labs, or EKGs. If someone c/o new CP I usually get a stat EKG and give nitro sublingual x2 per our standing order; depending on how the EKG looks and if the nitro relieved the CP.. I might give morphine if unrelieved by nitro. Based on pt presentation, if it's unrelieved or EKG is funky, we then page the on call cardiologist and order a stat set of cardiac enzymes, plus a CBC, BMP, mag. On call cardiologist see the pt, if they decide it's an active MI we are instructed to call a heart alert and at that time the cath lab team is called in for emergency cath.

[thenightnurse456]

So weird that you need an order to do an ECG...

I don't think calling a rapid response for every chest pain is necessary but I do think there should be a protocol with standing orders that a nurse can implement without contacting the provider first.

[CardiacKittyRN]

I agree! It seems like a good bit of time is being wasting waiting on rapid response when the nurse could already be getting the ball rolling..

[exp626]

I work on a cardiac unit, so we don't have rapid response for CP. My manager gets annoyed when we call a rapid response for anything though, which I think is an unsupportive and unsafe culture. He doesn't say much, but he'll take it out on them by never offering to develop them professionally (relief charge duties and the like).

I can see how it would be taxing on the RRT to be called for every patient with CP, but what else can you do? I wouldn't want to be the nurse who doesn't follow protocol and my pt has an MI. Do you have a charge nurse or remote tele nurse you can enlist? Maybe they can help decide if you should call the RRT. The medical floors in my hospital will call the remote tele nurse or the intervention nurse. Otherwise I'd continue to call the RRT as instructed, and if they're unhappy you can (politely!) remind them that you're not cardiac trained and there's a policy for them to evaluate CP. You could also discuss this with your manager and see if you can get some education in evaluating CP...maybe it could be unit-wide education.

(Giving Ntg as part of a protocol can be dangerous, for example if the patient has aortic stenosis or are on sildenafil or tadalafil it can bottom out their blood pressure, so you'll most likely never see that happen.)

[MunoRN, RN]

We don't call a RR, but the RR Nurse is called to evaluate any patients with symptoms concerning for ACS outside of our cardiac floor. I work off a protocol when evaluating a patient with concerning CP or other symptoms, that includes EKG, serial enzymes if indicated (there is no purpose in doing only a set of enzymes at the onset of symptoms), CXR, and we can also have a cardiologist consult for the EKG immediately if indicated.

Oxygen should be covered by other protocols to 'administer oxygen for a sat

[Lev, MSN, RN, NP]

Usually we will get vitals and start an EKG, then get an order. There is a policy that there has to be an order for EKG to do one. I can see how ordering nitro under protocol can be dangerous. I just wish there was a more realistic policy that was easy to comply with.

[exp626]

If they have a pacemaker or preexisting left bundle branch block the EKG won't reveal anything. Several years ago a cardiologist admonished me for ordering an EKG on a pt with a pacer, saying he wouldn't sign that order.

[vintage_RN, BSN, RN]

We will do a set of vitals, do an ECG and then call the physician to notify/get orders/further instruction.

[psu_213, BSN, RN]

So weird that you need an order to do an ECG...

You technically always need an order for a EKG...if the hospital is going to get paid for that EKG. Both on the cardiac floor and the ED, the mindset is do the EKG and then get the order. (Almost) No doctor is going to "refuse" you that order.

[psu_213, BSN, RN]

Also, on the cardiac floor that was a protocol for chest pain that basically was O2, sublingual NTG x3 q5 minutes, notify physician concurrently. Obviously BP was monitored before/during/after administration, and you had to have a patent IV if NTG was being administered. I don't think EKG was on the protocol, but one was always done with new CP.