Standing orders for chest pain

[wellstar]

Does anyone have standing orders or a practice guidline for pts with chest pain at thier facility?

It seems to me that pts get faster care for chest pain if they out in the community than if they are already in the hosp. If 911 is called they get O2, S/L Nitro, aspirin and an EKG as soon as the EMTs arrive. In the hosp they have to wait until the MD calls back and the nurse gets orders.

Please let me know what the procedure is at your facility and what literature supports your practice.

[jstar126]

I am only a CNA in a chest pain unit at a hospital but I know that we have standing orders. Pts come up from the ER with the orders signed. Then then attending MD is called and he comes to see the patient and writes additional orders.

[TachyBrady]

On our telemetry unit, when a pt has chest pain, we automatically apply oxygen, do an EKG, and give up to 3 NTG (as long as BP is okay). Then we call the doctor for further orders, i.e. enzymes, meds, etc. We do this regardless of whether we have prior written orders or not.

We do have formal Chest Pain Standing Orders that some doctors use on admission but most do not use them because they are too indepth and presumptious (not sure if that is the right word. they tell the doctor what to do and doctors don't like to be told what to do!).

I'm not really sure how you'd go about finding literature to support standing orders. Maybe do a search or visit some nursing sites??? or maybe someone here has some ideas.

[RN_04]

On our telemetry unit, when a pt has chest pain, we automatically apply oxygen, do an EKG, and give up to 3 NTG (as long as BP is okay). Then we call the doctor for further orders, i.e. enzymes, meds, etc. We do this regardless of whether we have prior written orders or not.

It's exactly the same on our telemetry unit. We do vitals, oxygen, EKG and NTG. We also call the house physician to evaluate the pt and get orders for enzymes and meds. A call is placed to the primary physician to update him/her and get any further orders. This works better for the patient instead of waiting for a doctor to call back.

[Indy, LPN, LVN]

Hmm. I think the ACLS protocols support fast NTG, ASA, O2, etc. Wouldn't that be support enough?

[zookeeper]

We have a couple different pathways called CCC's which I think stands for Collaborative Care Continuim (sp). There is one for low risk MI and one for hi risk MI. In ED they do MONA, serial EKG's, cardiac profiles, etc. Within 30 min. of arrival. Once on the floor, if doc continues the CCC (most do) he orders the type of stress he wants for the next day, that is if profiles are neg, also nitropaste, lipid profile, EKG in AM, etc. are all on the pathway. (These are all just check marks on a list.) If profiles are pos they fall off that pathway and go to ACS pathway at Dr's discretion, which has things on it like integrillin, Lovenox, IV nitro, echo. There's room, of course, for the Dr to modify so they're not feeling like it's cookbook medicine. A lot of these things are national reportable indicators though and our hospital developed these pathways for that reason. In fact there was a guy at Harvard University who, this year, was doing a paper on quality care and our hospital came up in his research. He ended up doing his paper on us We are the top hospital in Indiana due directly to developing these pathways. Here is the link to our hospital's feedback from that paper. There was a big write up in our local paper too about the same time, but I can't get the wording right to find the archived article. http://www.reidhosp.com/news/releases/20060214-best.html Our hospital also hired people to do chart review to make sure nothing was missed and to do Pt call backs.

[ZASHAGALKA, RN]

Hmm. I think the ACLS protocols support fast NTG, ASA, O2, etc. Wouldn't that be support enough?

ACLS is intended as a protocol for dealing w/ emergency, resusitation situations. To use those protocols outside of a 'code' would not be appropriate. They aren't designed to replace MD orders; they are there as 'emergency' protocols.

CP, by itself, is not a resusitation emergency. There is an algorithm for 'ischemic CP' but, outside of an emergency situation, that algorithm must be subject to MD approval. If you look at the CP algorithm, it is dealing w/ pre-hospital/ED care. It is not a 'standing order' for admitted pts.

That being said, most cardiac pts I see have standing admit orders that cover EKG and MONA (morphine, O2, ntg, asa) for CP

~faith,

Timothy.

[TachyBrady]

Zookeeper and Timothy,

Do all of your telemetry admissions come with CCCs/Standing Orders regardless of their diagnosis? If not, what do you do for a pt admitted with CHF or new Afib that develops chest pain on their 2nd or 3rd day? I think this is what the OP is asking. If there are no SO, it is a time waster to call and get orders vs taking it upon ourselves to do the O2, EKG, and NTG.

Thanks

[ZASHAGALKA, RN]

I work in Critical Care and so all of our pts are on 'monitors'. Most of them have a protocol for CP in their chart.

If they don't, we can do EKGs and O2 by protocol. And we would normally call very quickly.

If a doc is not being responsive, then we have other options: we can call a 'code' for any reason that we feel we need an MD emergently. In addition, all of our pts not seen by cardiology have to have consults from our pulmonologists, who double as our 'intensivists'. And, they also, as a group, function as our 'chiefs of staff' for critical care.

So.

If we don't get a quick MD response, we can either immediately call our intensivists (for all but cardiology pts, and they tend to have CP standing orders) or call a code and get an ER doc up to see someone, or, if a cardiologist doesn't answer, we can still call our intensivists in their capacity as 1 up the chain of command (critical care Chief of Staff).

~faith,

Timothy.

[zookeeper]

Only CP r/o MI are on a CCC.

On our tele floor if someone develops CP we have standing orders that we can give SL ntg x3, O2, and do an EKG. If we're doing all this we're usually on the phone pretty quickly to the doc getting further orders to treat the cause. The standing orders we have in place are the result of going through a committee and the signing thereof by that particular section chief or by the medical director.

[TachyBrady]

When you say "standing orders" or "protocol", are these actual written order sets that go on the pt's chart after the fact? If our pts do not have chest pain standing orders, we do the O2, EKG, NTG and nothing is placed in the pt's chart... we just do it automatically and it is not covered by any written order.

Thanks for your replies. I've only worked in Telemetry and in one hospital my whole nursing career so it is interesting for me to see how others do it.

[ZASHAGALKA, RN]

It's a preprinted standard order that is ordered and placed on the chart.

We also have 'protocols' that cover certain situations, and can be placed on the chart, if those situations are triggered: example - electrolyte replacement protocol which allows the admin of say, K+ if it falls below 3.4

Standard orders are already on the chart. If a protocol is activated, we not only place it on the chart, we write it down as an order: example -

5/29/06 1800 Potassium 40 MEQ PO x 1 now and repeat K+ level in am

per Electrolyte Replacement Protocol

signed off by me, here.

Our protocols are approved by the Medical Committee and are considered to be orders on all pts unless specifically contra-manded.

If you do something of a medical scope (order a med, o2, etc), whether there is an order on the chart or not, that action must be documented on the order sheet and the origin of the order should be noted. Otherwise, you set yourself up for legal problems.

~faith,

Timothy.