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Heart-y protocol upgrade for chest pains and coronaries

Nurses help develop best-practice for timely handling of chest pains and coronary syndromes.

What do you do to expedite assessment of chest pain and thrombolysis when a patient presents in a rural hospital, knowing the nearest cardiac catheter laboratory is more than a two-hour flight away and it takes even longer to transfer the patient out of the hospital.

Nurses from Alpine Health in north-east Victoria, along with Dr Jeffrey Robinson, medical director and GP Alpine Health, and associate professor Leslie E Bolitho from Wangaratta, have adopted a best-practice protocol for the assessment and management of chest pains and acute coronary syndrome – Hume Region Management of Chest Pains or Suspected Acute Coronary Syndromes.

This best-practice protocol is based on evidence that co-ordinated risk stratification and decision-making support for clinicians managing myocardial infarctions in rural settings leads to a reduction in the gap in mortality rates between rural and metropolitan patients in South Australia.

The protocol codifies an emergent triage score – 2, for chest pains and a suggestive presenting clinical history of Acute Coronary Syndromes. The protocol then describes three possible clinical pathways and is dynamic to allow for the evolution of management between pathways as is appropriate and necessary for the management of chest pains and acute coronary syndromes presentations.

There are three pathways in the chest pains and acute coronary syndromes protocol: 1 for observation protocol (low but not ‘no’ risk); 2 for unstable angina/non-ST elevation ACS Protocol; 3 for ST Elevation ACS Protocol.

Each protocol describes a series of clinical decision-making support steps, the prescription of important medications and the collection of pathology. A description of guidelines for patient transfer is indicated for each pathway.

In the rural setting, a nurse clinician can progress the pathway in the absence of a medical officer. This uses the strengths typical of many rural settings, including access to medical officer phone support and telehealth access to referral hospitals. The protocol has made the nursing assessment more thorough and consistent, and has helped local GPs become more confident in first-line management.

This innovative model was based on extensive research and development by Dr Philip Tideman, director of the Integrated Cardiovascular Clinical Network South Australia, to co-ordinate the emergency response for chest pains and acute coronary syndromes among several hospitals in rural and remote areas of South Australia without cardiac specialists or physicians, or timely access to larger metropolitan hospitals.

After debriefing our nurses in our health setting in Alpine Health, it was evident that we needed to become more pro-active in our assessment and follow-up care to enable the best possible outcome in our smaller rural setting. Working in collaboration with Alpine health services manager Mark Ashcroft, we initiated the debriefing and co-ordinating of nurses and doctors to establish the protocol. Bolitho led the development of the pathways. The model has made a huge difference to our assessment and treatment.

The protocol was adopted with the view of standardising the management of chest pains and acute coronary syndromes between Alpine Health and its main referral centres. It was also hoped that this protocol would be taken up at a sub-regional level and ultimately given further operational support through co-ordinated access to on-call physicians and to digital electrocardiograph transmission.

Olivia Stapleton is an associate nursing unit manager at Alpine Health.

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