Evidence Based Practice

1. Evidence Based Practice Treatment of Chest Pain in the Emergency Department John Cates, RN Northeastern State University EBP Symposium April 23, 2010 jcatesrn@suddenlink.net

2. WHAT IS EVIDENCE BASE PRACTICE (EBP)? DEFINITION: The process involving the examination and application of research findings or other reliable evidence that has been integrated with scientific theories

3. EVIDENCE BASED PRACTICE Researched based information Clinical Expertise Patient Preferences

4. WHAT IS THE NURSES ROLE IN EBP? Identify clinical problems Participate in EBP changes Serve as change agents or opinion leaders Establish a vision for the organization

5. WHAT IS THE EBP PROJECT? A clinical problem or area of concern that requires a solution that can be described, explained or predicted to improve nursing practice.

6. CHEST PAIN

7. CHEST PAIN Chest pain is one of the most common problems in the emergency room

8. CHEST PAIN PRESENTATION Pain (Heaviness) in chest which may radiate to neck, jaw, shoulder, upper back, abdomen Shortness of breath Nausea and/or vomiting Diaphoresis

9. OTHER SIGNS AND SYMPTOMS Abdominal pain Heartburn Lightheadedness Dizziness Fatigue

10. CHEST PAIN IN WOMEN Signs and symptoms are similar to men but may be atypical Prevalence is usually lower until the age of 70 Consequences are often more severe

11. CHEST PAIN IN CHILDREN Usually there is an underlying cause such as: Musculoskeletal Pulmonary Gastrointestinal Cardiac Psychogenic IT IS IMPORTANT TO GATHER A THOROUGH FAMILY HISTORY AND ASK THE RIGHT QUESTIONS!!!

12. RISK FACTORS Smoking Obesity Hypertension Diabetes Prior Cardiac History Family History

13. RESEARCH A study by Wright et al. (2006) showed that triage nurses can identify pleuritic chest pain and start relevant evaluation and treatment. 175� participants were chosen after meeting certain criteria. The study concluded that triage nurses identified pleuritic chest pain 92.7 percent of the time. This suggests that triage nurses are more sensitive in recognizing cardiac chest pain as opposed to pleuritic chest pain.

14. RESEARCH Another study by White et al. (2008) suggests using a CTA or CT angiography to diagnose cardiac chest pain in the emergency department. The CTA gives the physician a better picture of the heart and is of valuable clinical significance in diagnosing a cardiac problem in 95 percent of the study cases.

15. RESEARCH A study by Steele et al. (2006) was to determine if relief of chest pain with nitroglycerin (NTG) can be used as a diagnostic test to help differentiate cardiac chest pain and non-cardiac chest pain. Of those patients who experienced relief with NTG, 34 percent had defined cardiac chest pain and 66 percent had non-cardiac chest pain.

16. RESEARCH (CONT) For those who had no relief with NTG, 25 percent were found to have cardiac chest pain and 75 percent were found to have non-cardiac chest pain. There were 35 AMIs, based on troponin levels in the study population. Of those diagnosed with AMI, 20 experienced relief with NTG and 15 did not obtain relief. There were 9 deaths, and 3 in the group that did respond to NTG and 6 in the group that did not. A telephone follow-up at 4 weeks was conducted with a 95 percent contact rate.

17. EMERGENCY DEPARMENT PROTOCOL A simple and thorough assessment and use of a written protocol can have a drastic and desired effect for patient�s outcomes.

18. PROTOCOL Obtain an EKG within 10 minutes upon arrival Initiate assessment for fibrinolytic therapy Administer oxygen Obtain IV access and draw blood for lab Administer pain medication per protocol

19. PROTOCOL (CONT) Aspirin on arrival Aspirin allergy Coumadin prescribed as pre-arrival medication Beta blocker within the first 24 hour Beta blocker allergy Bradycardia, CHF, 2nd or 3rd degree AV block, shock Door to Drug and Door to Needle times Clinical reasons are acceptable i.e. CT to R/O ICH, BP control, family consultation re: risks, benefits System reasons are NOT acceptable i.e. equipment related, staff related, awaiting consult

20. PROTOCOL Everyone remember the gold standard? MONA

21. NOT THESE MONA�S

22. MONA Morphine Oxygen Nitroglycerin Aspirin

23. DEVELOP A PLAN Talk to administration Form a policy and procedure Possibly develop clinical guidelines Educate and encourage the staff Provide In-Services Encourage feedback

24. INTERVENTIONS ASSESS! Ask about history of chest pain Identify risk factors Document Identify allergies Notify physician Administer appropriate medications as ordered Continue to monitor the patient

25. EVALUATION Measured by monitoring the incidence of chest pain. Inpatient Assessment prior to discharge Continued Assessment after discharge Follow-up phone call Patient Satisfaction Survey

26. POSTIVE ASPECTS Decreased length of stay Decreased costs for the facility Increased patient satisfaction Increased family satisfaction Increased patient outcome Quality Care

27. Conclusion The overall aim is to provide quality care by accurately assessing and treating chest pain and providing quality care. In addition, the patient would have increased satisfaction and overall positive outcome. The role of the nurse in the emergency department is crucial. By providing evidence based research, nurses can improve the care that patients receive.

28. QUESTIONS? THANK YOU FOR YOUR TIME