BS Chest pain bridge order/dc requirements

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bravotwozero

bravotwozero

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So, the 'chest pain co-ordinator' (still not sure if she is an RN, or just a plain paper pusher admin) is saying that we need to put in a crap ton of bridge orders and dc instructions in order for the hospital to maintain its accreditation as a CHEST PAIN CENTER, per the American College of cardiology. See attached images.

If i'm admitting someones, I have to put them on PRN Nitro - bad idea for lots of reasons. What if they develop an inferior wall STEMI?

If I am discharging someone, I have to order an outpatient stress test scheduled within 72 hours of discharge! There's a lot more crap in there, please see the attachments.

Thoughts? Are you guys being made to do this at other chest pain centers? I want that chest pain co-ordinator's head on a platter right now, and demand proof that the ACC actually requires this. There are other hospitals in the same system that I work at that are accredited chest pain centers, that don't require any of this....

Any suggestions on how (or IF) I should fight this?
 

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bravotwozero said:
So, the 'chest pain co-ordinator' (still not sure if she is an RN, or just a plain paper pusher admin) is saying that we need to put in a crap ton of bridge orders and dc instructions in order for the hospital to maintain its accreditation as a CHEST PAIN CENTER, per the American College of cardiology. See attached images.

If i'm admitting someones, I have to put them on PRN Nitro - bad idea for lots of reasons. What if they develop an inferior wall STEMI?

If I am discharging someone, I have to order an outpatient stress test scheduled within 72 hours of discharge! There's a lot more crap in there, please see the attachments.

Thoughts? Are you guys being made to do this at other chest pain centers? I want that chest pain co-ordinator's head on a platter right now, and demand proof that the ACC actually requires this. There are other hospitals in the same system that I work at that are accredited chest pain centers, that don't require any of this....

Any suggestions on how (or IF) I should fight this?
Click to expand...
Sounds like fake news to me. Chest pain accreditation guidelines are based on ACC/AHA STEMI and NSTEMI-ACS recommendations and guidelines. No where in the the NSTE-ACS guidelines does it talk about PRN nitrate orders for admitted patients with suspected ACS. As far as the 72 hour stress test follow up, the NSTE-ACS guidelines state that it is reasonable (rather than necessary) for stress test within 72 hours. Also, I imagine you could get around it by diagnosing “chest wall pain” or “atypical chest pain” in individuals where these diagnoses are appropriate to save some headache on those you’re discharging.
 
bravotwozero said:
So, the 'chest pain co-ordinator' (still not sure if she is an RN, or just a plain paper pusher admin) is saying that we need to put in a crap ton of bridge orders and dc instructions in order for the hospital to maintain its accreditation as a CHEST PAIN CENTER, per the American College of cardiology. See attached images.

If i'm admitting someones, I have to put them on PRN Nitro - bad idea for lots of reasons. What if they develop an inferior wall STEMI?
Click to expand...

HAHAHA it says
EKG Q4 x2
then
PRN EKG.

What are you supposed to do with that?

Should say PRN nitroglycerin too. Nitro is helpful in some cases.

bravotwozero said:
If I am discharging someone, I have to order an outpatient stress test scheduled within 72 hours of discharge! There's a lot more crap in there, please see the attachments.

Thoughts? Are you guys being made to do this at other chest pain centers? I want that chest pain co-ordinator's head on a platter right now, and demand proof that the ACC actually requires this. There are other hospitals in the same system that I work at that are accredited chest pain centers, that don't require any of this....
Click to expand...

I work at an accredited chest pain center, don't have to do some of this stuff.

I can see that it's annoying to order an outpatient stress test for someone, but hell they are getting it. As long as there is a way for their PCP or Cardiologist to follow-up on the results, and not the ED, I think it's OK.

bravotwozero said:
Any suggestions on how (or IF) I should fight this?
Click to expand...

You can write that person and just say there is a typo with the "PRN EKG and Nitroglycerin. Should say PRN nitroglycerin." See what they say.
 
This sounds really ****ing stupid. And if you're not getting paid more for this crap why do it?
 
The hospital actually employs doctors to do that. Guess who’s responsibility it is. Hint: it’s not yours. I deal with plenty of nonsense, but bridge orders isn’t part of any of them.

Let her know you’ll happily start doing this when you start to interpret the stress tests, start rounding on the floor, seeing the patients in clinic and performing the caths.
 
Bravo, that's horses***. We are an accredited chest pain center and I don't have to do any of that. I'm not keen on bridging orders (I do make exceptions) for obvious medicolegal reasons and I'm sure as hell not ordering an outpatient test that I don't intend on following up with the results. When I d/c my low risk pt's and recommend an outpatient stress, we have someone else that sets them up with the cards appt in 4-5 days for the stress test but I never have to order it and I'm always careful to document "f/u with output cardiologist for potential utility of further outpatient testing" or something to that effect.

Get the opinion of your colleagues and let your director know. That would need to be escalated for me and probably a deal breaker if it was enforced in its entirety.
 
Based on literally no science and old white haired dude consensus. Sort of like the amiodarone vs lidocaine debate. I would prefer to practice actual evidence based medicine. **** the AHA and their BS ACLS requirements.
 
Let me provide my Patented Method for Dealing with Medical Bureaucracies:

My inspiration was a Bugs Bunny Cartoon (at least I think it was him, that was too long ago.) Bugs was being confronted by two bullies. He managed to get the two bullies fighting each other and slipped off to the side; while there was a cloud of them fighting, he was off to the side munching a carrot.

This should be your ideal.

You have an idiot. As long as that idiot keeps to himself everything is fine. However, eventually she will start to do stupid things that hurt you, The good news is that these stupid things also negatively impact someone else's job.

Years ago we had an infection control nurse who wanted to shut down the entire hospital because two employees (in jobs w/o patient contact) had kids in daycare with diarrhea. Now I could have argued with this person until I was blue in the face and nothing would change. Instead, I sent a quick email to our CFO ("Hey Bob. Infection control says they have an issue and want to shut down the hospital for a week or so. That is going to blow your revenue projections.") The problem disappeared two hours later and we never heard a peep from her again. I was at home planting my carrots.

Now for this case. Let me give you a hint that is absolute heresy: If you are a physician working in a medical bureaucracy, trial lawyers are your best friend. They are the perfect boogy-man who can get you almost anything you want. Hopefully, you have an EM physician who is on a first name basis and on good terms with the c-suite. If not, log out of this site and do not come back until you have fixed this. You cannot trust anyone in healthcare who wears a suit to work. (If you are at Mayo, this may not strictly apply.) You cannot trust a two year old. You do not leave the latter to his own devices, why would you not keep a close eye on the former?

Now this person writes an email to the VP/CLO/General Counsel along these lines: "Hey Bob, I want to give you a heads-up. XXXX wants to XXXX this exposes us to liability because XXXXX. Saint Holy Moses in Poughkeepsie got hit with a judgement of $20M on a case of XXXX."

Now I can tell you exactly what will happen when he reads this email:
1) He has a vision of being in court when the jury announces a $20M verdict against the hospital.
2) He has a vision of being fired by the Board of Directors for losing a $20M verdict.
3) He has a vision of working a document review job for $20/hour every night in a sweatshop.

He will then storm off to confront this coordinator ... while you are munching on carrots.

Disclaimers:
It worked for me, it may not work for you. I was lucky. Do not rely on the advice of anyone on the internet you do not personally know on any significant matter. Instead of fighting each other they may gang up on you. If you do not have the relationship and/or established communication attempting to communicate in this manner may be very badly received. On these lines, I started with Bugs Bunny, I will end with Klinger on MASH; "Sometimes, to grow a beautiful rose, you have to shovel a lot of manure."
 
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Dr.McNinja said:
Based on literally no science and old white haired dude consensus. Sort of like the amiodarone vs lidocaine debate. I would prefer to practice actual evidence based medicine. **** the AHA and their BS ACLS requirements.
Click to expand...

If cardiologists day don’t give nitro in inferior wall STEMI, no amount of evidence will persuade a jury or judge. I don’t do it because I’ve seen it happen way more often than other STEMIs.
 
McNinja... I wish I worked in ivory tower sovereign immunity land and had your cahoonas, but until then... l would be lynched by every cardiologist and trial lawyer in the land if I started a nitro drip on my hypotensive inferior MI. They wouldn't care what I quoted. Neither would the jury... Remember, malpractice cases aren't juries of your peers, they are laypersons having to take a crash course in medicine 101 and AHA/ACC guidelines are going to sound pretty authoritative to them. I might wait for a few more validation studies before I started discarding those guidelines. That's me though.... my balls are more like reinforced tire rubber. Resilient, but still a bit squishy with enough force applied.

@Vandalia , great advice.
 
Not even reading the attachments. I have worked at and currently work at CP centers that accepts from everywhere in the region. Never heard of this.

This is the continued BS that began with Pneumonia protocol to Sepsis protocol to Stroke protocol.

We are seeing the beginning of the CP protocol.

I am happy I will be transitioning to more FSEDs where as physicians we actually practice real medicine.
 
I'm not discarding guidelines. Don't give it to hypotensive patients to begin with. But there are plenty of studies showing that inferior MIs aren't more likely to get hypotensive with nitro than any other MI. And no recent ones showing it does.
Of course, there's no mortality benefit at all with nitro anyway, so you can just not give it at all.
And I don't have sovereign immunity.
 
Groove said:
McNinja... I wish I worked in ivory tower sovereign immunity land and had your cahoonas, but until then... l would be lynched by every cardiologist and trial lawyer in the land if I started a nitro drip on my hypotensive inferior MI. They wouldn't care what I quoted. Neither would the jury... Remember, malpractice cases aren't juries of your peers, they are laypersons having to take a crash course in medicine 101 and AHA/ACC guidelines are going to sound pretty authoritative to them. I might wait for a few more validation studies before I started discarding those guidelines. That's me though.... my balls are more like reinforced tire rubber. Resilient, but still a bit squishy with enough force applied.

@Vandalia , great advice.
Click to expand...

As vivid the description of your balls is, I think I could have lived without that. Thanks, lol.
 
Dr.McNinja said:
I'm not discarding guidelines. Don't give it to hypotensive patients to begin with. But there are plenty of studies showing that inferior MIs aren't more likely to get hypotensive with nitro than any other MI. And no recent ones showing it does.
Of course, there's no mortality benefit at all with nitro anyway, so you can just not give it at all.
And I don't have sovereign immunity.
Click to expand...

Correct. Why mentally masturbate about things which make no difference? Kayexlate, Octreotide, Protonix drips, and supplemental oxygen (for normal O2) come to mind.
 
Again, it's contraindication per AHA/ACC NSTEMI/STEMI guidelines to use with right sided MI.

I could probably pick over a hundred journal articles similar to this one (2013) from the cardiology literature on inferior MI management stating something similar "it is critically important to avoid drugs that cause venodilation and a decrease in RV filling (eg, nitrates...)

We all know that inferior MIs have higher rates of bradycardia and hypotension, just look at the territory, and depending on what study you reference, can range from 25-50%. I don't even need journal articles to tell me that, and I know you don't either... When you have an inferior STEMI come in tell me you aren't already worried and anticipating potential cardiogenic shock? How many of those pt's have you personally seen go from normotensive with HR 90s to hypotensive with HR 40s? All of us have hopefully seen plenty of these. Why even argue about giving these people nitrates? These people need volume and inotropes ready to go at the first sign of decompensation. The last thing they need is you taking away their preload with something that makes absolutely no difference in their mortality. Why even argue about this? I don't see the point.

It's an interesting study, but fairly isolated from what I can see. It will take a lot more than that for me to change my practice or for most practicing cardiologists for that matter, which is really what matters in the end since they dictate most of your CPU/STEMI protocols.
 
southerndoc said:
It's not no NTG for inferior STEMI's, it's use with caution in inferior STEMI's. RVI's shouldn't get NTG. RVI decreases preload from decreased right ventricular contraction. That decreased preload plus the decreased preload with NTG is where the hypotension comes from.
Click to expand...
the article in question said:
In the comparison between inferior STEMI and inferior STEMI thought to involve the right ventricle, the authors report no difference in hypotension (systolic BP < 90 mmHg) following NTG administration...
Further, in the subgroup of patients who suffered an inferior wall STEMI, those with ECG evidence of right ventricular involvement were no more likely to suffer 30 mmHg or greater reductions in SBP following NTG administration than those without...
Despite the lack of strong evidence, AHA warns that NTG should be used with caution (if at all) in patients with ECG evidence of inferior wall STEMI when one suspects right ventricular involvement [4]. However, when right ventricular infarction is confirmed, NTG is generally contraindicated [4]. The results of this study challenge those concerns.
Click to expand...
Look, I'm not saying everybody needs it. Actually, probably nobody needs it. But at the same time we shouldn't be afraid of it. In fact, if it's harmful at all, it's equally harmful across all subgroups of MI.
 
Dr.McNinja said:
Look, I'm not saying everybody needs it. Actually, probably nobody needs it. But at the same time we shouldn't be afraid of it. In fact, if it's harmful at all, it's equally harmful across all subgroups of MI.
Click to expand...

I don't worry about NTG in inferior STEMI's unless RVI is documented and their BP is <140. Even with RV involvement, a BP >140 is unlikely to become hypotensive if closely monitored. I don't require my paramedics to have an IV to give NTG and I don't scold them for giving it in inferior MI's as long as their initial BP is OK.
 
I certainly don't put anyone with an inferior wall STEMI on a nitro drip. I might give them one tab if their BP is high...but i generally avoid it. If I know they are going to the cath lab very quickly, I'll give them 50-100 mcg fentanly instead. Just so they don't have to sit around in agony.

Must be terrible to have chest pain enough to cause a STEMI.
 
thegenius said:
I certainly don't put anyone with an inferior wall STEMI on a nitro drip. I might give them one tab if their BP is high...but i generally avoid it. If I know they are going to the cath lab very quickly, I'll give them 50-100 mcg fentanly instead. Just so they don't have to sit around in agony.

Must be terrible to have chest pain enough to cause a STEMI.
Click to expand...

Huh, I consider the nitro drip to be safer than sublingual tabs, as it's more titratable. Am I missing something?

...

On an avatar-related note - you check out the new documentary Long Strange Trip yet? It's pretty legit.
 
Last edited:
WilcoWorld said:
Huh, I consider the nitro drip to be safer than sublingual tabs, as it's more titratable. Am I missing something?
Click to expand...

Nope....it's safer albeit more of a hassle. The nurses seem to have nitro tabs in their pocket when a STEMI / chest pain comes in, but getting a drip ordered, then they go to the pixis, setting it up, the infuser beeps, blah blah...takes much longer. Then it's started at 5-10 mcg/min which is such a small dose it's just pissing in the wind. Then by the time you actually get therapy from the nitro drip the cardiologist is there to take them to the cath lab.

I'm pretty liberal with nitroglycerin for ischemic chest pain. I'm aware that it does nothing for "important clinical outcomes", but we often just think only about that and not making the patient feel better. We should do something to take away their pain. Opiates make outcomes worse (increases infarct size). Nitro reduces pain, and provided you don't make them hypotensive should not make outcomes worse. So I make a bedside judgement and given a tab of nitro if I think the patient can tolerate it. Occasionally I will ask the RN to cut a pill in half.

Interestingly I've had the most problems with nitro paste vs nitro SL or gtt. I hate using nitro paste and if I do....it's like 1/2 inch for someone's BP who is 180 and I know they can go to the floor (usually the hospitalist asks for it.) Even then I rarely do that.

WilcoWorld said:
On an avatar-related note - you check out the new documentary Long Strange Trip yet? It's pretty legit.
Click to expand...

I think so...is that the 4 or 6 part series? On Netflix or Amazon? I remember the last episode was the saddest, where we heard from Jerry's wife how he acted in the mid 90's before he died. Very sad. But overall a good documentary. Makes you wanna be a hippie during that time going from show to show in the 70s, instead of arguing with patients daily why you are not going to give them dilaudid or carisoprodol.
 
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