What is your chest pain hospitalization criteria?

[Angry Birds]

What is your chest pain hospitalization criteria?

Who are you admitting and who are you discharging?

What’s the latest criteria? I think I might be behind on this. I work in a place where I can admit a corpse if I wanted to. Want to get a feel how it is in other places.

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[TooMuchResearch]

I discharge the vast majority of patients with chest pain these days.

 

[Tenk]

Pretty much need a trop bump with a good story at this point.

 

[southerndoc]

What is your chest pain hospitalization criteria?

Who are you admitting and who are you discharging?

What’s the latest criteria? I think I might be behind on this. I work in a place where I can admit a corpse if I wanted to. Want to get a feel how it is in other places.

• HEART 0-3: discharge with referral to PCP (single hsTrop if pain >3 hours)
• HEART 4-6: discharge with two hsTrops if delta <7 (hsTrops checked 3 hours apart regardless of duration of symptoms; looking at moving to 2 hours)
  • we enter an order in Epic and the cardiology APP schedules patient for an appointment within 2 weeks
  • if delta 7 or greater +/- heparin
• HEART 7-10: admit to hospitalist
  • they will consult cardiology
  • +/- heparin depending on clinical situation or if delta 7 or above

• Confirmed PE without known DVT, sPESI <1 and not bilateral/multiple, hypoxemic, etc. -- DC with Eliquis starter pack after first dose of Eliquis in ED

 

[DocEspana]

• HEART 0-3: discharge with referral to PCP (single hsTrop if pain >3 hours)
• HEART 4-6: discharge with two hsTrops if delta <7 (hsTrops checked 3 hours apart regardless of duration of symptoms; looking at moving to 2 hours)
  • we enter an order in Epic and the cardiology APP schedules patient for an appointment within 2 weeks
  • if delta 7 or greater +/- heparin
• HEART 7-10: admit to hospitalist
  • they will consult cardiology
  • +/- heparin depending on clinical situation or if delta 7 or above

• Confirmed PE without known DVT, sPESI <1 and not bilateral/multiple, hypoxemic, etc. -- DC with Eliquis starter pack after first dose of Eliquis in ED

Slightly different version of this, but mostly what southerndoc posted. All of these are using hsTrop because thats all my various EDs carry nowadays.

Heart 0-3
Trop x1 then DC if the onset+maximum pain are both >3 hours ago
trop x1 then DC if your "H" portion of the HEART score was 0
trop x2 then discharge if your pain was <3 hours ago and your "H" component was 1 or 2

Heart 4-6
Trop x2 q2 hours +/- cardiac CT if I'm still suspicious if your "H" component was 0. Trop not rising = DC with close follow up. Trop rising >5 = admit
Trop x2 q2 hours if your "H" component is 1 or 2. just going to admit these. Often I dont even get the second troponin because the hospital doesnt push back if the EKG isnt terrifying

HEART 7 or more
Just admitting after whatever the initial lab workup is.

 

[xaelia]

I assume "chest pain hospitalization" applies to r/o ACS –

No specific protocol for such at our institution in NZ anymore; we used to use EDACS to dictate which patients were evaluated by the cardiology registrar, but we've discarded it in favor of relying primarily on troponin-based clinical evaluation.

Admits are basically:
- Obvious NSTEACS that rules in
- Surprise! elevated troponin (your SCAD/pericarditis/myocarditis young people)
- Known (or highly suspected) CAD with a story for true crescendo angina/exertional symptoms/dynamic ECG changes (frequently has mildly elevated baseline trop levels)
- Unrelenting chest discomfort requiring IV opiates despite normal troponins and negative CT chest (v. infrequent)

 

[Zebra Hunter]

I assume "chest pain hospitalization" applies to r/o ACS –

No specific protocol for such at our institution in NZ anymore; we used to use EDACS to dictate which patients were evaluated by the cardiology registrar, but we've discarded it in favor of relying primarily on troponin-based clinical evaluation.

Admits are basically:
- Obvious NSTEACS that rules in
- Surprise! elevated troponin (your SCAD/pericarditis/myocarditis young people)
- Known (or highly suspected) CAD with a story for true crescendo angina/exertional symptoms/dynamic ECG changes (frequently has mildly elevated baseline trop levels)
- Unrelenting chest discomfort requiring IV opiates despite normal troponins and negative CT chest (v. infrequent)

This is exactly my practice, as well.

 

[Porfirio]

Heart score </= 3 delta trop home
Heart score >/= 4 admit unless hospitalist says no then cards says no

Cards rarely says no and forces hospitalist admission.

Extremely high med mal risk - I use to be more liberal with chest pains home. But families expect 72 hrs of immortality after seeing me.

 

[Rekt]

Slightly different version of this, but mostly what southerndoc posted. All of these are using hsTrop because thats all my various EDs carry nowadays.

Heart 0-3
Trop x1 then DC if the onset+maximum pain are both >3 hours ago
trop x1 then DC if your "H" portion of the HEART score was 0
trop x2 then discharge if your pain was <3 hours ago and your "H" component was 1 or 2

Heart 4-6
Trop x2 q2 hours +/- cardiac CT if I'm still suspicious if your "H" component was 0. Trop not rising = DC with close follow up. Trop rising >5 = admit
Trop x2 q2 hours if your "H" component is 1 or 2. just going to admit these. Often I dont even get the second troponin because the hospital doesnt push back if the EKG isnt terrifying

HEART 7 or more
Just admitting after whatever the initial lab workup is.

Cardiac CT? As in calcium scoring?

 

[DocEspana]

Cardiac CT? As in calcium scoring?

No. Coronary artery CTA. It's the (not super) new thing the cardiologists love in active chest pain. My understanding is calcium scoring is for the asymptomatic.

 

[RustedFox]

Old? Smokey? Buttery?
A combination of these things?
Admit.

 

[southerndoc]

No. Coronary artery CTA. It's the (not super) new thing the cardiologists love in active chest pain. My understanding is calcium scoring is for the asymptomatic.

I'm curious what your ED CT flow is to be able to do this. Patients have to be medicated with NTG and sometimes metoprolol so a nurse has to go with them.

Even with my ED having 4 CT scanners, we still have 3+ hour delays getting CTs.

 

[thegenius]

What is your chest pain hospitalization criteria?

Who are you admitting and who are you discharging?

What’s the latest criteria? I think I might be behind on this. I work in a place where I can admit a corpse if I wanted to. Want to get a feel how it is in other places.

I discharge two negative high sensitivity troponins 98% of the time. EKG really has to be super crappy or ominous to admit.
I discharge HEART score <= 4 100% of the time with negative HS-troponins. If 5, I think a little. If it's 6 or higher I tend to admit, but I even send those home a small percentage of the time.

The thing with these high heart scores is they all tend of already have CAD, stents, and have had prior angiograms and prior MPS. So they are well differentiated. There isn't much to uncover.

Kaiser has better, more accurate HEART score data and basically the 30 day risk of MACE is much lower than we were taught in residency (roughly 2%) and even lower than the original HEART score derivation data.

It's not even clear that low risk people with heart scores 3 or less should even get stress testing anyway.

 

[xaelia]

The thing with these high heart scores is they all tend of already have CAD, stents, and have had prior angiograms and prior MPS. So they are well differentiated. There isn't much to uncover.

This is the real problem with HEART – it got pushed out there as a predictive score, and, lo, it's not bad!

But prediction is not prescription – the sheer fact someone is at baseline higher risk for an adverse event does not prescribe a specific protective intervention. There is nothing magical about a night in the observation unit preventing a poor outcome – you need some sort of clinical action. I think it's pretty reasonable to send home just about anyone once you've called around and established there isn't any further inpatient management that will move the needle on a diseased heart.