MEDICAL EXAMPLE EXPLANATION EMERGENCY HELP YOUR TEXT HERE CT SCAN HEALTHCARE NURSE

EXAMINE EXAMPLE EXPLANATION EMERGENCY HELP YOUR TEXT HERE CT SCAN HEALTHCARE NURSE

Pathways are OK, in fact most are OK. Risk scores are OK, and in fact most are OK. Troponins are a good test, and in fact most are OK

RISK ASSESSMENT

• PE assessment

• Pre Test Probability

• Add a test if indicated

• Cardiac should be the same

• EDACS does this TIMI, HEART, most others mix clinical and testing

• Risk Assess

• Add the tests Troponins and ECGs

• Disposition is based on the Risk Assessment and Tests Combined

EDACS has been derived and validated for use in EDs to assess risk of ACS in undifferentiated patients presenting with Chest pain Interpretation of test is best done by MDCALC: If the person has ALL of the following: • EDAC

The HEART score was derived and validated as a risk assessment score to be used in Emergency Departments Low Risk is 0-3 in association and a repeat troponin increases its sensitivity. Low Risk and normal serial ECGs and Troponins can be DC to home with follow up with GP.

Trop Tests vary. Generally do two tests. Positive tests are a high unexplained initial level for any test OR a change (delta) over time. ( for Hs 2 hrs ) A negative test is no significant change over time and in normal range. Any test > normal is Not Low Risk.

Not High or Low Risk Further stratification required Inconclusive/Intermediate risk

Repeat Hs test at 0 and 2 hrs +/- repeat 2 hrs (delta) POCT/Ss test at 0 and 6 hrs (Appdx 2) • Initial Trop

not elevated AND

• Negative delta

Management (Appdx 3) • Aspirin • Discuss with senior ED MO +/- • Discuss with cardiologist • Intermediate or inconclusive risk patients carry higher risk for cardiac and non cardiac problems and may require admission for further testing • Discharge only with clear plan and defined testing strategies

Hs Trop 1st ___ 2nd ___ Delta < ____ -ve > ____ +ve If ____ to ____ then repeat 2 more hrs ( appdx 2) POCT/Ss are positive above their cut point _____

(Appdx 1)

+ve -ve

*High Sensitivity Test Hs, Standard Sensitivity Test Ss

• Initial Trop elevated

• Alert senior MO

• Repeat ECG

Appdx 1 Risk Assessment Scores in the ED setting. Scoring systems have been used regularly in the clinical assessment of Undifferentiated Chest Pain and ACS in the ED setting. The examples provided here have been validated for use in Accelerated Diagnostic Pathways in EDs in Australasia. The key approach to using Risk Scores is the clinical assessment and then the addition of tests (Troponins and ECGs) and using the two to drive patient disposition. To apply rules and scores you must be able to adequately clinically assess the patient. Seek help when you cannot do this. Your first priority is to asses for any High Risk features and if found start basic supportive measures as required and admission under physicians as per local practices. If the patient is not High Risk they can be assessed for Low Risk as outlined. Troponin testing strategies depend on your hospital tests and local clinicians interpretation of those and perception of Risk. Low Risk patients can be discharged to home with two normal Troponins and ECGs and may not need further objective testing, this decision should be made with senior ED MO or cardiologist. Patients who are not Low Risk or High Risk have serial ECGs and Troponins and decisions for this group depend on a spectrum of clinical presentation. The decisions will depend on seniority of decision makers and based on a combination of risk and Troponin levels, (for example below detection, in normal range or above normal range), along with availability of follow up cardiology services. Accelerated Diagnostic Pathways and Low Risk scoring systems are used in conjunction with Hs Troponins. Use of Low Risk scores with POCT or Ss tests is done at the discretion of local senior clinicians and within a local pathway.

Appdx 2 Troponin Testing High sensitivity Troponin testing is now common in many NSW EDs. These can be either Troponin T or I tests and although the absolute numbers vary they have similar test characteristics and a low coefficient of variation. This means the level you see or measure is most likely to be correct. This means less risk of false negatives and false positives. This does not mean it is a substitute for clinical assessment. Troponin testing is done as part of a strategy to further assess patients who present with symptoms suspicious of Acute Coronary Syndrome. High Sensitivity Troponins (Hs). These tests are done at presentation and 2 hrs post the first test to assess for a change or delta. Hs Troponin tests have a lower limit of detection and a 99th centile level for each test used. This is usually given as the “normal range” by your laboratory. An initial test above the 99th centile may be normal and a level within the normal range may be abnormal. It is suggested that 2 tests 2-3 hrs apart are done to assess for a change or delta. Strategies for using one test only at a designated cut off time or in association with scoring systems are used and validated and you should use these at the discretion of your senior governing ED and Cardiology services. One or two tests below the lower limit of detection have been used in decision rules and further stratify risk, these rules can be used on an institution case basis according to current evidence which is evolving. For Hs Troponins the delta is positive which is a change > 30 % of the 99th centile (upper limit of normal). For Hs Troponins the delta is negative which is a change of < 30% of the lower limit of detection ( lower limit of normal) For changes in between we suggest a test at a further 2 hrs. A test becomes positive if the total change is > 30% of the 99th centile. (Reichlan) Your pathways should reflect this by indicating the values in your hospital which are positive and negative and test repeated. Example Roche HsTrop T . Normal range is 5ng/L-14ng/L. (Lower limit of detection is 5 and 99th centile is 14ng/L) Test positive when delta is >5 ng/L Test negative when delta is < 3 ng/L Repeat test further 2 hrs if delta is 3-5 ng/L The change from 0 to 4 hrs becomes the delta and [positive or negative as above • Single tests done at the discretion of senior ED MO. • The same test must be used for any delta Trop measurement to detect rise and fall.

• of Care Testing (POCT) is currently Standard Sensitivity (Ss)

Appx 2 continued. Point of of Care Testing (POCT) is currently Standard Sensitivity (Ss). This test is used very differently to Hs tests and is currently being investigated for use in accelerated pathways but is still used in a simpler fashion in NSW. A risk assessment should always be done and High Risk patients treated accordingly. Patients who have Low Risk and a normal first Troponin require a repeat test in 6 hrs. The test is currently called positive above a certain “cut point” and if above that point then they are considered ACS and admitted accordingly. If below the cut point then the repeat test is to see if the level rises above the cut point irrespective of delta (change) size. You cannot compare one test to any other as the delta may be meaningless. If another test ( for example a Hs) test is likely to be done later or at another place then serum should be held at the time of first testing so a delta Troponin can be assessed subsequently.

Appdx 3 Disposition Decisions High Risk patients are assessed as high risk on arrival or can become high risk at any time during there time in the ED. Patients who are assessed as Low Risk may be assessed as part of a local hospitals Accelerated Pathway and discharged after 2 Troponins and ECGs which are considered normal. Further more advice may be given at discharge for Low Risk patients about the risks and benefits of further testing. This will be influenced in particular by Hs Tests which are below the Limit of Detection (LOD). In general no further testing but GP follow up is recommended for Low Risk patients who meet criteria for DC. ( AHF guides) Patients who are neither High or Low Risk are more complex and require a certain level of expertise to get the right/safe decision. In general the lower the level of seniority in the ED the more likely that these patients will be managed as inpatients or in ED Short Stay Units. The addition of serial Troponins and ECGs to the Inconclusive/Intermediate Risk patients doesn’t change their overall baseline risk but does contribute to immediate decision making. For example a patient who is just outside Low Risk criteria and has two Troponins below LOD will have a much lower risk than a patient who is just short of High Risk and two trops just below the 99th Centile ( upper limit of normal range). Making these decisions should be done by or in close conjunction with a senior ED MO In larger centres that will often be on floor ED Physicians or Registrars and smaller places could be off site ED Specialists or referral Physicians, Cardiologists or their representatives the Medical Registrar. Follow up if discharged in this group must involve a clear plan and structure to defined testing as discussed with senior decision makers, if this cannot be done then should admitted by default.

How Hard Can It Be

Trop

onin

Lev

el

Days

High Sensitivity Troponin

LOD 99th

Centile

Trop

onin

Lev

el

Days

High Sensitivity Troponin

99th Centile

LOD

LOD 99th

Centile

For Hs Troponins the delta is positive which is a change > 30 % of the 99th centile (upper limit of normal). For Hs Troponins the delta is negative which is a change of < 30% of the lower limit of detection ( lower limit of normal) For changes in between we suggest a test at a further 2 hrs. A test becomes positive if the total change is > 30% of the 99th centile. (Reichlan) Your pathways should reflect this by indicating the values in your hospital which are positive and negative and test repeated.

Trop Tests vary. Generally do two tests. Positive tests are a high unexplained initial level for any test OR a change (delta) over time. ( for Hs 2 hrs ) A negative test is no significant change over time and in normal range. Any test > normal is Not Low Risk.

Not High or Low Risk Further stratification required Inconclusive/Intermediate risk

Repeat Hs test at 0 and 2 hrs +/- repeat 2 hrs (delta) POCT/Ss test at 0 and 6 hrs (Appdx 2) • Initial Trop

not elevated AND

• Negative delta

Management (Appdx 3) • Aspirin • Discuss with senior ED MO +/- • Discuss with cardiologist • Intermediate or inconclusive risk patients carry higher risk for cardiac and non cardiac problems and may require admission for further testing • Discharge only with clear plan and defined testing strategies

Hs Trop 1st ___ 2nd ___ Delta < ____ -ve > ____ +ve If ____ to ____ then repeat 2 more hrs ( appdx 2) POCT/Ss are positive above their cut point _____

(Appdx 1)

+ve -ve

*High Sensitivity Test Hs, Standard Sensitivity Test Ss

• Initial Trop elevated

• Alert senior MO

• Repeat ECG

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