Does anyone else get pushback for admitting "active" chest pain

[Lex81]

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Guys,

I just wanted to see other's opinion on this. Say, 50-60 y/o guy comes in to my community ED, htn/chol w/ cp and description is of moderate concern for ACS. EKG/labs wnl, will admit to floor for 23h r/o ACS. BUT the guy is having "active" chest pain, in that he still feels the pain is present. I've given morphine and sometimes nitro in certain patients, pain is improved but persists. Now, the hospitalist is like "well did you talk to cards bc the pt is having active cp". Moreso the nurses on the floor throw a fit bc the pt has "active chest pain!".

I feel like I'm pretty up to date, and I've never come across anything that states active chest pain is an indication for closer monitoring (ICU) or transfer, which they bring up sometime as the solution. It sounds ridiculous from my perspective, but just wondering if perhaps I've missed something. Does anyone else have this issue? Is there any literature that states pt's are better served w/ higher level of care if they have active chest pain?

 

[DeadCactus]

I always get the impression that the only evidence guiding chest pain management is the data on how frequently it results in a lawsuit and the damages awarded...

 

[namethatsmell]

You know more than them. Normal EKG and neg trop is your currency. Unless there's somebody to cath cards won't likely want to hear about it (in my admittedly limited experience).

 

[The White Coat Investor]

Ongoing pain is concerning and can be one of the indicators to go to cath. But I doubt anyone will take them to path if that's the only thing....Maybe a changed EKG and ongoing pain or something.

 

[Bostonredsox]

Guys,

I just wanted to see other's opinion on this. Say, 50-60 y/o guy comes in to my community ED, htn/chol w/ cp and description is of moderate concern for ACS. EKG/labs wnl, will admit to floor for 23h r/o ACS. BUT the guy is having "active" chest pain, in that he still feels the pain is present. I've given morphine and sometimes nitro in certain patients, pain is improved but persists. Now, the hospitalist is like "well did you talk to cards bc the pt is having active cp". Moreso the nurses on the floor throw a fit bc the pt has "active chest pain!".

I feel like I'm pretty up to date, and I've never come across anything that states active chest pain is an indication for closer monitoring (ICU) or transfer, which they bring up sometime as the solution. It sounds ridiculous from my perspective, but just wondering if perhaps I've missed something. Does anyone else have this issue? Is there any literature that states pt's are better served w/ higher level of care if they have active chest pain?

I am fine with admitting him to tele. If you have had him for an hour and a half to two hours, you have 2-3 ekgs with no ischemic changes at all, a negative set of enzymes, normal vitals, and you have obviously excluded PE/dissection/PTX, etc..., ill take him to tele regardless of the active CP. I will come see him and if the story is strong, ill give cardio a ring to come see him now instead of in the am. The fact that your pts pain is alleviated with nitro concerns me a bit that maybe he is sitting on some badness. But in reality all you have is a chest pain rule out with normal EKG and enzymes. 23 hour obs on tele floor. Unrelieved PUD/GERD can cause "active chest pain" too. I don't see anything in what you've given me that warrants immediate eval by cardio prior to hospitalist admit nor a higher level of care.

 

[Birdstrike]

Guys,

I just wanted to see other's opinion on this. Say, 50-60 y/o guy comes in to my community ED, htn/chol w/ cp and description is of moderate concern for ACS. EKG/labs wnl, will admit to floor for 23h r/o ACS. BUT the guy is having "active" chest pain, in that he still feels the pain is present. I've given morphine and sometimes nitro in certain patients, pain is improved but persists. Now, the hospitalist is like "well did you talk to cards bc the pt is having active cp". Moreso the nurses on the floor throw a fit bc the pt has "active chest pain!".

I feel like I'm pretty up to date, and I've never come across anything that states active chest pain is an indication for closer monitoring (ICU) or transfer, which they bring up sometime as the solution. It sounds ridiculous from my perspective, but just wondering if perhaps I've missed something. Does anyone else have this issue? Is there any literature that states pt's are better served w/ higher level of care if they have active chest pain?

I think you're giving the people on the floor way too much credit. If you thought his "ongoing pain" smelled of burning myocardium, you wouldn't have sent him to a general floor.

Yet, nursing is very protocol driven and if you cross paths with a nurse having a bad shift, who thinks you've violated some never heard before, sacred "floor protocol" then all of a sudden your judgement is in question? I don't think so. It's funny how you can work somewhere for years and all of a sudden these rigid "protocols" pop up out of nowhere and disappear just as quick.

From the Hospitalist standpoint, that's just a classic attempted deflection. They know that if you thought the patient needed an emergent cath, you know who to call. They're not stupid. They figure it's worth casting the line to see if you bite. It might save them an admission and mean they can grab a pop tart and a coffee during a brutal shift. Let them deal with it, though, it's their job. Their job is hard, but so is yours.

I think anyone is going to have an incredibly tough time producing evidenced based literature (more than just opinion), that would tease out an outcome difference between patients with ongoing chest pain, with non-ischemic ekg's and negative enzymes, based on what level of care they went to. The vast majority of these patients are going to rule out, and therefore where they go makes little difference in outcome.

The one thing I would say is, for these patients that are suspicious, bother you and keep having pain, make sure you do your serial EKGs while they're in your department. Ongoing chest pain with evolving ekg's becomes a very big deal and is some whose life you can save and who you can get to the cath lab before they lose any myocardium at all.

That being said, I think this downstream griping and whining, is just a normal part of hospital based medicine as an EP and should be taken with a grain of salt.

 

[NERDY]

Can you send low risk chest pain to the obs unit?

 

[dotcb]

Get at least 2 ekgs, 1 trop neg, at least 2 attempts at pain control, admit. That's it. You're done. Admit them to whatever floor you usually admit R/O ACS.

 

[Bostonredsox]

Get at least 2 ekgs, 1 trop neg, at least 2 attempts at pain control, admit. That's it. You're done. Admit them to whatever floor you usually admit R/O ACS.

This is exactly what I want to see when I'm called for a chest pain obs. Throw in a chest X-ray for me too though.

 

[iish]

Get at least 2 ekgs, 1 trop neg, at least 2 attempts at pain control, admit. That's it. You're done. Admit them to whatever floor you usually admit R/O ACS.

This may sound like a newb question, but I am newb so I will ask it anyways. What intervals do you get the 2 EKGs at? At my shop I only see repeat EKGs when there is an acute change to the pt's condition, not when they have persistent pain.

 

[mauricekenter]

2nd EKG comes with the 2nd troponin unless the patient has chest pain that changes or comes back.

 

[dotcb]

This may sound like a newb question, but I am newb so I will ask it anyways. What intervals do you get the 2 EKGs at? At my shop I only see repeat EKGs when there is an acute change to the pt's condition, not when they have persistent pain.

If the pain persists despite treatment, I'd get a second EKG before calling the admission.

It pads the "they're having ongoing chest pain" concern.

Which I much prefer over - "Sounds like it might not be cardiac chest pain. I think you need to rule them out for PE with testing before I'll admit them." Another stall/turf strategy...

 

[Groove]

Ah yes, the "chest pain" CHESS game with medicine. I admit that I get pushback sometimes on these. Prob because I admit almost 100% mod risk factor chest painers, regardless of whether it seems like costochondritis. The hospitalist never knows how many low risk chest painers I send out all the time which is the irony of it all.

Moderate risk factors. 2 EKG's, attempt to control pain. Gestalt. Next up is dependent on your shop.

Groove's Strategy

1) - Call hospitalist and sell it as risk factors in need of ACS rule out, suspicious "cardiac" sounding chest pain is resolved, leaving a seemingly "non cardiac" component, MSK, what have you... Needs obs. I almost dread this one because it almost guarantees the "So, does he have active chest pain? Did you talk to cards?" I mean, what can you really say? Technically, it's active chest pain. The guy probably has chest wall pain and you simply can't take the risk of sending him home with a MI with those risk factors but I find it almost impossible to weasel my way through any sane sounding persuasion for obs unless the medicine guy on call just knows me or I know he'll admit anyway.

2) - Call cards for a quickie "Hey, mod risk chest painer, no EKG changes, neg trops, think it's MSK but he's got risk factors, was thinking of admitting to medicine for obs and if they have any problems, they can consult you from floor." Almost guarantees a vigorous "That sounds great! <Click>". Followed by my buffed medicine consult with power drive punch line to the sell..."oh btw... ran it by cards who thinks it's a good idea for medicine obs and said if you have any problems, call them for a floor consult". They have nowhere to go unless they want to call cards themselves and they never do. I find this one easiest.

3) - If I get any pushback from medicine, I simply refuse to send the guy home with mod risk factors and in need of a rule out. I don't have the luxury of CPU where I work presently. Rare occasion I'll simply say "Fine, I'd appreciate a formal consult from the ED, eval and discharge of the patient." I don't have this happen very much because honestly... medicine is more trying to manipulate out of what they know is a valid obs admission.

Generally speaking, I find it easiest to just call an active chest pain to cards first to cover yourself. It makes everything go much more smoothly and expedites the obs admission.

I say stick to your guns. If anyone gets sued, it's going to be you. I get downright paranoid sometimes these days when I hear some of the guys talking about lawsuits for the most benign stuff. Can you imagine missing an MI and sending it out? Yikes. I pray it never happens to me.