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Archive for the ‘Cardiology’ Category

Heart Failure

Heart Failure Clinical Pathway_ED_OBS through Discharge _ 1 15 14

A multidisciplinary heart failure pathway is being rolled out this week (linked above). Most of it is common practice- my take on the key points for the ED are as follows.
· BNP testing is requested as the heart failure team is using serial BNP results to gauge response to therapy and readiness for discharge.
· Strict I & O order while patient is in ED is also requested.
· Lasix should be dosed every 8 hours.
· Hold ACE / ARB while in ED.
· Consult the heart failure team for any of the following:

o Recurrent hospitalization for CHF within one year
o Elevated Troponin or Acute Coronary Syndrome
o Concurrent infection
o Worsening renal failure
o Ventricular Tachy Arrhythmia

Thank you for your attention to this important initiative.


Written by phil

March 4th, 2014 at 10:41 pm

Posted in Cardiology

Admission criteria for medical telemetry

The following describes patient groups, which are appropriate for telemetry monitoring on 11-West, 9-West, 10-West. These patients do not require specialty care provided on cardiac units. These criteria are meant as a guide and do not override clinical judgment.

1. A patient with history of CAD who presents with typical or atypical chest pain and does not have high-risk features (Ischemic EKG, low systolic blood pressure, decompensated CHF, history consistent with unstable angina) requiring a cardiac unit.
a. Patients who already have 2 consecutive negative troponins or at least one troponin 6 hours after the onset of chest pain are unlikely to benefit from telemetry

2. Patients with syncope who have high risk features for cardiac cause, including low systolic blood pressure, CHF, CAD, or advanced age(<65). 3. Medication or drug toxicity wit potential arrhythmogenic consequences. a. Examples include monitoring after overdose of a tricyclic antidepressant or digoxin or cocaine toxicity. 4. Electrolyte imbalances. a. Example includes hyperkalemia with ECG changes. 5. Patients with atrial fibrillation/flutter who are hemodynamically stable but are actively being managed for rate control. 6. Tachyarrhythmias requiring continuous intravenous therapy that can be managed by the nursing unit (e.g. IV cardizem). 7. Symptomatic bradyarrythmias. 8. Selected stable patients post procedure from heart hospital at discretion of attending (11 west only, managed by ADS nurse practitioner) 9. Any patient requiring continuous heart rate monitoring that is not otherwise specified above but is deemed medically indicated by the clinician.

Written by phil

August 28th, 2012 at 2:42 pm

Posted in Admitting,Cardiology

Recommended criteria for admission of patients to cardiac telemetry

(last update: February 27, 2008)

o High risk acute coronary syndromes characterized by a clinical history suggestive of ischemia and one or more of the following:
? Electrocardiographic evidence of acute or recent myocardial infarction
• Pathologic Q waves in two or more leads (new or not known to be old)
? Electrocardiographic evidence of acute myocardial ischemia
• ? 1mm ST depression in two or more leads (new or not known to be old)
• T wave inversions in two or more leads (new or not known to be old)
? Positive biomarker for myocardial ischemia (troponin I)
? Systolic BP < 110mm Hg ? Crackles above the lung bases ? Recent coronary intervention or coronary bypass surgery ? Worsening of established anginal pattern in the setting of known ischemic heart disease o High risk congestive heart failure (CHF) characterized by one or more of the following: ? Systolic hypotension ? Ventricular arrhythmias ? Persistent hypoxemia ? Significant hyponatremia (sodium < 130) ? Renal insufficiency (stage IV-V chronic kidney disease or acute renal failure ? stage III) ? Requirement for IV vasodilator or inotrope therapy ? Known or suspected severe aortic or mitral valvular stenosis ? CHF secondary to an acute coronary syndrome o Syncope with high suspicion for a cardiac etiology characterized by one or more of the following: ? History of CHF ? History of ventricular arrhythmia ? Acute coronary syndrome ? Significant aortic or mitral valvular stenosis ? Electrocardiograph with arrhythmia/ prolonged QT/ bundle-branch block or acute ischemia ? History of myocardial infarction ? Prior implantation of pacemaker or ICD ? Second or third degree heart block o Tachyarrhythmias requiring continuous intravenous therapy o Symptomatic bradyarrhythmias o Patients who require urgent invasive cardiac procedures o Patients who require observation immediately following invasive cardiac procedures o Patients receiving chronic infusions of vasoactive medications o Other patients who, in the judgment of the treating attending cardiologist, require specialized cardiac care Depending on the clinical scenario, individual patients meeting the above criteria for admission to cardiac telemetry may be appropriate for admission to the Cardiac Care Unit (CCU) instead.

Written by phil

August 28th, 2012 at 2:40 pm

Posted in Admitting,Cardiology

Coronary CT

We now (apparently) have the ability to do an unlimited number of coronary CT scans.

Potential advantages over stress testing includes:
1. Much quicker

2. Allows for same day discharge

3. Can identify early CAD (not just obstructive disease)

4. Less radiation for the patient

5. Can simultaneously look for PE and aortic dissection

Please consider coronary CT for all of your chest pain patients without known CAD and no contraindications to contrast.

1. Order can be placed in EPIC by searching for “CT coronary” (choose the option with angiography)

2. During business hours (8-5) page Aileen to let her know you’ve ordered the study (this page will be going away soon).

a. If it’s not business hours but is a weekday you can still order the test and it will be done in the morning

b. Currently no weekend availability but this will be coming as will overnight testing

3. Give an oral dose of beta blocker to get the heart rate close to 60 (this isn’t essential if you don’t feel comfortable)

If you want to look at additional structures (i.e. pulmonary vasculature or aorta) place separate orders for these structures as well.

Any questions let me know,


Written by phil

May 25th, 2012 at 4:00 pm

Posted in Cardiology

Cath Lab Handoff

Attached is a copy of our handoff procedure to Cath Lab. This came about as a result of an RCA. It is brief and easy to read; please familiarize yourself with it. The part that physicians and PAs should especially know about is:

The Cardiac Cath Lab’s designated provider will locate the ED provider at the time the patient is ‘consented ‘for a catheterization. At this time provider to provider hand-off will take place.

Thank you all



• The Emergency Department RN will call the Cardiac Catheterization Lab to speak to a RN or provider in order to give hand-off information regarding the patient they will be receiving.

• The Emergency Department RN will document the hand-off in the EPIC/ SBAR dedicated area only.

• The Cardiac Cath Lab’s BA will call the Emergency Department’s charge nurse prior to picking up the patient in order to confirm identification of the patient using the patient’s name and DOB.

• The Cardiac Cath Lab’s designated provider will locate the ED provider at the time the patient is ‘consented ‘for a catheterization. At this time provider to provider hand-off will take place.

• The Cath Lab provider will document the hand-off in the pre-cath note only.

March 2012

Written by reuben

March 10th, 2012 at 12:29 am

Posted in Cardiology

Core Measures Update

Hey guys

Actual pay for performance is starting in six months and the most recent report card does not look as good as it could (i.e. if we were paid on our current performance the hospital would lose several million dollars).

We are primarily responsible for 3 metrics

1. Door to balloon for STEMI- on this we are doing well.

2. Blood cultures prior to antibiotics for pneumonia patients

a. This we are not doing as well partially because our previous strategy (no cultures for simple CAPNA) conflicted with the dogma of the admitting teams (cultures on everyone)

b. That said… given the increasing number of resistant organisms, ID is requesting cultures before any IV antibiotics on admitted patients

c. This strategy does have the advantage of simplifying the expected behavior so please…

d. If you are providing IV antibiotics to a patient you are admitting get blood cultures first. 2 sets. Every time.

3. Appropriate antibiotics for pneumonia patients

a. We do pretty well with this

b. The only piece we often miss is atypical coverage in the ICU PNA patients

c. Give azithromicin to both community and hospital associated pneumonia patients

Again, this is a very visible issue at the level of the C Suite.
Thanks for the help.


Written by reuben

February 14th, 2011 at 4:35 pm

Posted in Cardiology,ID


If EMS calls ahead with a case they believe is a STEMI and when you review their ECG you find no STEMI (approx 70% of activations thus far) please document in chart that EMS ECG not STEMI.

Written by phil

May 18th, 2009 at 5:41 pm

Posted in Cardiology

Corrective Action Plans

We have had several ED cases with poor outcomes over the past year that triggered root cause analysis and resulted in corrective action plans.  The following corrective actions directly or indirectly involve our ED practice. The department may be monitored by the state for compliance with these plans.

• New onset adult seizures, syncope, and chest pain will all be treated as if potential cardiac ischemia:  ECG within 15 minutes.

• Initial dosing of hydromorphone is 0.5 -1.4 mg, initial dosing of Morphine is 4 mg.

• Higher doses of pain medications may be given if there is a note in the chart documenting the medical reasoning for choosing a higher dose.

• More than 3 doses of IV pain medication in 3 hours should prompt a pain consult for consideration of PCA pump, or medical reasoning why there is no consult.

• All transfers of patients with thoracic aneurysm or dissection should be discussed with the MSH ED attending before transfer from another institution.

• CT surgery will use AMION for on call and chain of command contacts.  Non-compliance should be reported to Scot Hill.

• Consultants should respond by phone within 10 minutes, and be present within 30 minutes.  Non-response should trigger a call to the next higher level in the chain of command.

Written by phil

April 8th, 2009 at 7:16 pm

Coronary Calcium Scores

Beginning today we will be getting coronary artery calcium (CAC) scores
on some of our CPU patients who consent to participate in a study. For
you, this means you may have a research assistant approach you and ask
that a CAC study be ordered on a given patient. This is a non-contrast
CT of the heart that involves minimal radiation or time. It can be
ordered in the “ED Attending Only” order section in IBEX.

Thanks up front for your help- any questions let me know.


Written by phil

January 29th, 2009 at 12:49 am

Posted in Cardiology

Acute Coronary Syndrome (ACS) Guidelines

The TIMI Guided ACS Protocol is now available here as well as the MI Flowsheet.

Written by phil

January 16th, 2009 at 9:34 pm

Posted in Cardiology


If a patient arrives with LVAD; Call Director on call 24/7-212-241-1000 immediately.

  • Plug in external battery pack into AC outlet
  • No chest compressions

Left Ventricular Assist Device

What is a left ventricular assist device (LVAD)?

The left ventricle is the large, muscular chamber of the heart that pumps blood out to the body. A left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that’s surgically implanted. It helps maintain the pumping ability of a heart that can’t effectively work on its own.

These devices are available in most heart transplant centers.

When is an LVAD used?

This device is sometimes called a “bridge to transplant.” People awaiting a heart transplant often must wait a long time before a suitable heart becomes available. During this wait, the patient’s already-weakened heart may deteriorate and become unable to pump enough blood to sustain life. An LVAD can help a weak heart and “buy time” for the patient.

How does an LVAD work?

A common type of LVAD has a tube that pulls blood from the left ventricle into a pump. The pump then sends blood into the aorta (the large blood vessel leaving the left ventricle). This effectively helps the weakened ventricle. The pump is placed in the upper part of the abdomen. Another tube attached to the pump is brought out of the abdominal wall to the outside of the body and attached to the pump’s battery and control system. LVADs are now portable and are often used for weeks to months. Patients with LVADs can be discharged from the hospital and have an acceptable quality of life while waiting for a donor heart to become available.

LVAD SetupLVAD Setup

Written by phil

November 21st, 2008 at 2:34 pm

Posted in Cardiology,JCAHO

Cardiology Update

1. there are no curbside consults to fellows for potential acute mi cases.  if there is any suspicion, any suspicion, call amac to activate the system, ie: 7 am to 10 pm m-f amac calls directly to the cath lab; after 10 pm amac calls the cath attending cell phone.
2. if you have a patient with an acute mi, call amac to activate the system, ie: 7 am to 10 pm m-f amac calls directly to the cath lab; after 10 pm amac calls the cath attending cell phone
3. if you want to directly call the cath lab, thats ok, but also let amac do their thing
4. for acute mi, conversation with the cath attending should be ed attending (preferred) or senior resident to the cath attending – no junior resident nor intern should be presenting to the cath attending – one more time – conversation with the cath attending should be ed attending (preferred) or senior resident to the cath attending – no junior resident or intern should be presenting to the cath attending
5. if you have a nonacute cardiac patient and need to discuss with eps ccu or cath fellow, call amac and be explicit exactly who you want – this is only for nonemergent patients.  if amac has not idea who is on, tell them to go to “amion” and on the far right click on “amion” and then password is “mscardio”
6. when you call an attending for an admission please make sure you have a clear concise assessment and plan

Written by admin

November 11th, 2008 at 2:34 pm