The OHSU Suspected

Acute Coronary Syndrome

Clinical Guideline

C L I N I C A L N O T E B O O K

Authors: Kathryn Johnson, RN, MS, CNS, CCRN, and

Laura Criddle, RN, MS, CCNS, CEN, Portland andScappoose, Ore

Section Editor: Renee Semonin Holleran, RN, PhD, CEN,CCRN, CFRN, CTRN, FAEN

Kathryn Johnson is Cardiac Clinical Nurse Specialist, Oregon Health &Science University, Portland, Ore.

Laura Criddle, Oregon ENA State Council, is Clinical Nurse Specialist,Premier Jets/Lifeguard Air Ambulance, Hillsboro, Ore.

For correspondence, write: Kathryn Johnson, RN, MS, CNS, CCRN,Oregon Health & Science University, 3181 SW Sam Jackson Park Rd,Mail Code: UHS32, Portland, OR 97229; E-mail: johnskat@ohsu.edu.

J Emerg Nurs 2007;33:47-9.

Available online 30 November 2006.

0099-1767/$32.00

Copyright n 2007 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2006.08.016

February 2007 33:1

Earn Up to 9.5 CE Hours. See page 91.

n emergency departments across the United States,

Ichest pain is a ubiquitous chief complaint, account-

ing for an estimated five million visits each year.1 Al-

though most people with a myocardial infarction are

identified easily, other patients presenting with chest pain

or non-specific symptoms associated with acute coronary

syndrome (ACS), (eg, shortness of breath; discomfort in

one or both arms, neck, back, jaw, or stomach; gastro-

intestinal upset; lightheadedness) can be challenging to di-

agnose and treat appropriately.

At Oregon Health & Science University (OHSU), a

multidisciplinary team was formed to help physicians and

nurses provide a consistent, evidence-based approach to the

identification, risk stratification, and treatment of patients

with suspected cardiac ischemia. Included on this com-

mittee were physician and nurse representatives from both

the cardiology and emergency departments. Through col-

laboration, this team was able to develop and implement

initiatives to improve management of the suspected ACS

patient. The most notable development arising from this

partnership was the evidence-based ‘‘Suspected Acute Coro-

nary Syndrome Clinical Guideline’’ (Figure). This algo-

rithm facilitates rapid evaluation of the potential ACS

patient and directs both physicians and nurses to imple-

ment the appropriate interventions. Although developed

at OHSU, the algorithm is founded on the guidelines

put forth by the American College of Cardiology (ACC)

as well as other evidence based literature2-7 and it can

be adapted readily by other institutions. This algorithm

delineates an easy-to-follow, detailed, systematic, and

timely approach to the management of patients with sus-

pected ACS.

JOURNAL OF EMERGENCY NURSING 47

FIGURE

The OHSU Suspected Acute Coronary Syndrome Clinical Guideline. (Note: The ACS Pathway is an inpatient

documentation tool.) Developed by Kathryn Johnson, RN, MS, CNS, CCRN, Joaquin Cigarroa, MD, and

Crispin Davies, MD.

C L I N I C A L N O T E B O O K / J o h n s o n a n d C r i d d l e

The Suspected Acute Coronary Syndrome Clinical Guide-

line is in effect currently throughout the OHSU medical

center. Nevertheless, it is initiated most commonly in the

emergency department, where the majority of patients with

chest pain are identified. Since its implementation several

48 J

months ago, we have seen care of the suspected ACS patient

enhanced by increased staff adherence to evidence-based

practices, including compliance with the ACC recommen-

dation of performing a 12-lead EKG within 10 minutes

(door-to-EKG time). Additionally, in our efforts to meet

OURNAL OF EMERGENCY NURSING 33:1 February 2007

C L I N I C A L N O T E B O O K / J o h n s o n a n d C r i d d l e

the ACC target door-to-balloon time of less than 90 min-

utes for ST elevation myocardial infarction patients, we

have improved our outcome by almost 100%. This algo-

rithm has dramatically improved our ability to treat pa-

tients rapidly, when each minute matters.

REFERENCES

1. Burt CW. Summary statistics for acute cardiac ischemia andchest pain visits to United States EDs, 1995-1996. Am J EmergMed 1999;17:552-9.

2. Antman E, Anbe D, Armstrong P, Bates E, Green L, Hand M,et al. ACC/AHA guidelines for the management of patientswith acute ST-elevation myocardial infarction: A report of theAmerican College of Cardiology/American Heart AssociationTask Force on Practice Guidelines (committee to revise the 1999guidelines for the management of patients with acute myocardialinfarction). Available from URL: www.acc.org/clinical/guidelines/stemi/index.pdf. Accessed February 6, 2006.

3. Braunwald E, Antman E, Beasley J, Califf R, Cheitlin M,Hockman J, et al. ACC/AHA 2002 guidelines for the manage-ment of patients with unstable angina and non-ST segment ele-vation myocardial infarction: A report of the American Collegeof Cardiology/American Heart Association Task Force on Prac-tice Guidelines (committee on the management of patients withunstable angina). J Am Coll Cardiol 2002;36:970-1062.

4. Ferguson JJ, Califf RM, Antman EM, Cohen M, Grines CL,Goodman S, et al. Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronarysyndromes managed with an intended early invasive strategy:primary results of the SYNERGY randomized trial. J Am MedAssoc 2004;29:45-54.

5. Ryder RE, Hayes TM, Mulligan IP, Kingswood JC, Williams S,Owens DR. How soon after myocardial infarction should plasmalipid levels be assessed? Br Med J 1984;289:1651-3.

6. Sabatine MS, Antman EM. The thrombolysis in myocardial in-farction risk score in unstable angina/non ST segment eleva-tion myocardial infarction. J Am Coll Cardiol 2003;41(Suppl S):89S-95S.

7. Scirica BM, Cannon CP, Antman EM, Murphy SA, MorowDA, Sabatine MS, et al. Validation of the thrombolysis in myo-cardial infarction (TIMI) risk score for unstable angina pectorisand non-ST-elevation myocardial infarction in the TIMI III reg-istry. Am J Cardiol 2002;90:303-5.

Submit descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in a reference file or notebook to:

Renee Semonin Holleran, RN, PhD, CEN, CCRN, CFRN,CTRN, FAEN, Section EditorSubmit Clinical Notebook manuscripts online at http://ees.elsevier.com/jen/

February 2007 33:1 JOURNAL OF EMERGENCY NURSING 49