Chest pain is one of the most common reasons for presentation to the emergency department (ED), accounting for 2–6% of emergency: Diabetic Ketoacidosis Case Study, NUI, Ireland

Chest pain is one of the most common reasons for presentation to the emergency department (ED), accounting for 2–6% of emergency department attendances and 20% of emergency admissions to hospital (Fothergill et al., 1993). According to the Vital Statistics Annual Report 2019 from the Central Statistics Office (CSO), there were a total of 8,989 deaths attributed to diseases of the circulatory system. Of these, 4,163 were due to ischaemic heart disease and 1,627 to cerebrovascular disease, (Vital Statistics Yearly Summary 2019 – CSO – Central Statistics Office, 2020).

In this case study the author will present a detailed bio-psychosocial profile of a critically ill patient who presented to the emergency department with chest pain. To maintain anonymity and confidentially, as outlined under Principle Four of the Code of Professional Conduct and Ethics, (NMBI- The Code- Principle 4: Trust & Confidentiality, 2020), the pseudonym Rose will be used.

Rose is a sixty-year-old female who attended the ED where the author works as a member of the multidisciplinary team (MDT) as a nurse. Rose presented to triage with the complaint of sudden onset of central chest pain radiating up to her left shoulder and down her left arm lasting approximately two hours. There was no history of trauma and Rose had no other associated symptoms. She has a past medical history of hypercholesterolemia, high body mass index (BMI), and hypertension. Rose was assessed and triaged using the Manchester Triage System which is the tool used in the hospital Rose attended. The Manchester Triage System is a valid instrument for the first assessment of emergency patients in critical condition upon arrival (Gräff et al., 2018).

Rose was triaged as a category two, which requires a doctor to see the patient within ten minutes. Rose’s vital signs were also recorded at triage: Respiration rate – 19, Sp02 – 96% on room air, heart rate – 76bpm, blood pressure – 159/98, temperature – 36.8°C, a blood glucose level of 5.6mmols and described her pain as eight out of ten on a pain scale. Ung et al., (2015), highlighted in a literature review how nurses have a pivotal role in pain management. Pain is considered the fifth vital sign, for being as important as others are.

The effectiveness of its treatment relates to a proper evaluation since pain measurement is essential for its proper management (Santos et al., 2019). Rose was considered hemodynamically stable at triage and to comply with local hospital protocol the hospital chest pain pathway was implemented at triage which indicated that patients who presented with cardiac chest pain require an Electrocardiogram (ECG) within 10mins of ED presentation.

The introduction of the chest pain pathway resulted in fewer admissions from the ED with chest pain and the mean length of stay for all patients attending ED with chest pain was reduced by 8.3 hours (27.5 hours vs 19.1 hours) (Sweeney et al., 2020). The use of the pathway enables a large amount of information to be gathered within a limited timeframe and allows a systematic approach ensuring no steps are missed. The 12-lead ECG is an essential diagnostic tool, particularly in the management of coronary heart disease, (Jevon, 2010). Rose was transferred to a resus trolley to allow further investigations to be carried out.

Chest pain is the predominant symptom of Acute Coronary Syndrome (ACS), which presents itself initially in 75-85% of patients (Oliveira Guimarães, et al., 2018). Coronary heart disease occurs when the blood flow to the myocardium is blocked or interrupted by a build-up of atheroma in the coronary arteries. The acute coronary syndrome is an umbrella term used to describe the clinical presentation of ischaemic heart disease and encompasses unstable angina pectoris, non-ST segment elevation myocardial infarction, and ST-segment elevation myocardial infarction (O’Donovan, 2011). The main tools to determine the likelihood of ACS or MI in the ED are chest pain history, vital signs, ECG, and blood markers of myocardial injury such as a troponin level (Mokhtari et al., 2015).

Early assessment and identification of risks is vital to patient outcome. Once Rose was in a resus bay a 12 lead ECG was recorded. Kumar and Cannon, (2009) discuss how the process of myocardial ischemia is quite dynamic and a single 12-lead ECG provides only a snapshot view of this process, the guidelines recommend that patients hospitalized with ACS undergo serial ECG tracings or continuous ST-segment monitoring. Furthermore, Kumar and Cannon, (2009) highlight how troponin levels are a powerful instrument for risk stratification across the spectrum of patients presenting with symptoms of acute cardiac ischemia and together with the history, ECG, blood markers, and pain assessment a more definitive diagnosis can be made.

Rose’s ECG showed no ischemic changes but Rose remained a category 2 according to the Manchester Triage system, due to her severe pain and risk factors of hypercholesterolemia, high BMI, and hypertension. Rose was attached to a cardiac monitor and verbal consent was gained for intravenous access and blood samples and sent to the laboratory for urgent processing as per hospital policy.

Carrying out a holistic nursing assessment is a vital nursing skill and when a patient comes into the ED it acts as a baseline which allows nurses to make informed decisions on patient care. Objective and subjective data is gained through observing and engaging in conversation with the patient. The two nursing diagnoses for Rose were chest pain and fear/anxiety. Rosie’s main nursing diagnosis was chest pain, which she rated 8/10. This gave Rose a pain scale of ‘severe’ on the numerical pain scale tool.

The zero-to-ten pain scale is the gold standard of care for pain assessment (Tandon et al., 2016). Pain quality and intensity are based on patients’ self-report. Pain is what the patient says it is. Ford, (2019) highlights how the holistic assessment and management of pain is important and to observe for supporting information using appropriate and varied assessment approaches, for example, guarding shallow breaths, and facial grimacing. Rose’s severe pain was reported to her medical doctor who prescribed a glyceryl trinitrate spray (GTN) sublingually for Rose to alleviate her chest pain.

Nitroglycerin, administered sublingually or as a spray to patients with ischaemic chest pain, dilates blood vessels, reducing venous return to the heart and thereby reducing myocardial workload and oxygen demand thus, improves myocardial perfusion (Pope, 2006). The nitroglycerin spray was administered to Rose ensuring safe medication management in compliance with the NMBI guidelines of safe medication administration (NMBI – Medication Management: NMBI guidance, 2020).

It is important after administration of analgesia to reassess the patient’s pain using the pain scale. On reassessment, Rose’s pain was now a six out of ten which according to the numerical pain scale is classified as moderate pain, and the same was reported to the medical doctor responsible for Roses’s care. (Parodi, 2015), highlights the importance of effective pain relief in patients with myocardial infractions.

Not only for compassionate reasons, but analgesia has a physiological effect as well, thereby reducing cardiac workload. Routinely, intravenous morphine would be used for chest pain tolerant to glyceryl trinitrate therapy and used in a step-wise fashion. Morphine is a strong opiate-based drug and has been used in the treatment of chest pain in patients with acute myocardial infractions for decades. However, morphine administration is to be used with caution due to side effects (de Waha et al., 2015). Nausea is a common side effect experienced by patients and metoclopramide hydrochloride is used regularly alongside intravenous morphine administration. The medical doctor responsible for Rose chose these two drugs to help alleviate symptoms.

New data published by (Puymirat et al., 2016) disputes intravenous morphine use as it may hinder anti-platelet absorption given orally. But further research needs to be carried out to alter international gold standards at this time for pain relief in patients with chest pain experiencing acute myocardial infarctions. Rose was administered morphine and metoclopramide hydrochloride and on reassessment of her pain, she now rated it as 1/10 and described it as a discomfort rather than a pain.

Rose’s second nursing diagnosis was fear/anxiety. Fear and anxiety are heightened with emergency department attendance and therefore it is vital that the patients receive emotional support and reassurance. Carter et al,. (2015) discuss how some ED practices may be increasing patients’ anxiety and fear. There is evidence that ED practitioners do not provide patients with enough information to put them at ease. The ED is a fast-paced and busy environment. It serves as the first point of care for most individuals in their medical evaluation for potentially life-threatening cardiac events.

At times the ED is a chaotic and potentially stressful environment for patients awaiting care. For patients being evaluated for an acute cardiac event, this environment may couple with the fear of experiencing a severe cardiac illness (Homma et al., 2016). Patients who present to the ED with symptoms indicative of acute coronary syndrome experience a great deal of stress. Evaluation for non-ST elevation myocardial infarction (NSTEMI) or unstable angina in the ED can be accompanied by feelings of fear, vulnerability, and loss of control (Edmondson et al., 2013). Research conducted by Rozanski & Kubzansky (2005) discussed that there is an influence of the clinical condition of coronary heart patients on their psychological status.

This was further highlighted by Wittchen et al. (2011) who mentioned that patients who are treated in the hospital are likely to experience mental disorders such as anxiety and depression due to their fear of death. Therefore, it is vital that nurses act quickly to provide reassurance and support to the patient. Using the nursing process Rose’s level of anxiety was assessed. Accurate information about the situation was provided and it reduced Rose’s fear.

The author used nonclinical language to communicate clearly with Rose and repeating small amounts of important information not only helped to strengthen the nurse-patient relationship but also help reduce Roses’s fear and anxiety about not only the situation but also the immediate environment. The author allowed Rose to express any worries she might have and provide the emotional support and reassurance Rose needed. Having Roses’s husband John with her also provided Rose with emotional support.

The diagnosis for Acute Coronary Syndrome is based on the history of cardiac ischemia, ie the chest pain Rose experienced ECG changes and elevated biomarkers which troponin was used. The NICE guidelines indicate that all patients who are assessed as having a mild to moderate risk of ACS should have a troponin blood test carried out. Rose’s troponin level was noted by her medical doctor to be elevated at 140ng/l. According to local hospital policy 14ng/l or greater is considered abnormal. Troponin levels in the blood drive an NSTEMI diagnosis (Cramer et al., 2018). Since 2000, cardiac troponin is the preferred biomarker for diagnosis and ruling out of acute myocardial infarction (Alan and Lynch, 2020).

An NSTEMI is diagnosed in patients determined to have symptoms consistent with ACS and troponin elevation but without ECG changes (Basit et al., 2020). The medical doctor decided it was appropriate to treat Roses as having an NSTEMI event.  Rose was informed of the diagnosis and the treatment allowing her to make informed decisions about her care. Chummun et al., (2009) discuss the principles of care for ACS which is early reperfusion, use of antiplatelet therapy and anticoagulants, controlling risk factors, and secondary prevention.

Rose was administered Asprin 300mg, Clopidogrel 300mg, and Enoxoparin 1mg/kg and referred to the medical team for further management. Clopidogrel acts synergistically with aspirin to inhibit platelets by inhibiting different receptor-mediated pathways and has been shown to reduce mortality and recurrent ischemia (Chummun et al,. 2009). Angiolillo et al., (2007) disused how there is a delayed onset of action with a loading dose of 300mg of clopidogrel and a loading dose of 600 mg produces a more rapid onset of action, a higher level of platelet inhibition, and a greater reduction in platelet activation, compared with 300 mg.

Once admitted Rose was transferred to the Coronary Care Unit (CCU) in the hospital where she received ongoing cardiac monitoring. This continuous monitoring allows any changes to Roses’ condition be detected immediately and in rapid response. It was recommended that Rose undergo serial data, repeat ECG and repeat troponin levels, taken 6 hours after the initial result. A referral was sent to the cardiology team and Rose was to be reviewed by the team the following day. It was suggested that Rose undergo an exercise stress test when suitable.

The nurse suggest to the physician if Rose would benefit from involvement from other members of the multi-disciplinary team, such as the dietician. Given that Rose had an increased BMI the nurse felt she would benefit from an education session and help Rose to make informed decisions about her food choices and exercise. Lewis et al., (2009) discuss how having a high BMI increases the hearts cardiac output which can in turn lead to high blood pressure and heart disease. The author followed up on Rose’s care the following week and learned that she was transferred to the regional cardiac catherization lab and had a cardiac stent inserted.

On reflection of this case study the author has noted some areas of practice that may require further research for patients presenting with NSTEMI. The use of a higher loading dose of clopidogrel may benefit patients as it has a quicker onset and provides greater reperfusion leading to less long term complications for the patient, however more research is need on this. The author also feels that investigation into the introduction of an Advanced Nurse Practitioner (ANP) to the ED.  This role was developed in St James’s Hospital in 2005 as an essential role in the development of a designated Chest Pain Assessment Unit (CPAU).

The ANP provides rapid cardiology consults to the ED and CPAU. Furthermore St Vincents University Hospital audit results showed that majority of all patients (82%) were discharged after a short stay. Sixty-five per cent of those patients had undergone exercise treadmill testing and there were no deaths or non-fatal myocardial infarctions at 30 days post discharge in the audit group. These types of audit results provide evidence those initiatives such as these, which are ANP-led under supervision of the cardiology department. To add to this St Luke’s Hospital, Kilkenny has developed a care pathway which involves the CNS educating staff in the administration of first dose thrombolysis agent in the ED or Medical Assessment Unit. The introduction of this initiative has decreased the ‘door to needle time’ from 29 minutes in 2004 to 23 minutes in 2007.

To conclude, the use of a triage system along with the chest pain pathway tool resulted in Rose being diagnosed correctly and within an appropriate time frame. These actions allowed for Rose to receive the recommended treatment and care. This case study outlines the importance of early detection, diagnosis and intervention leads to improved patient outcomes. The author believes that while this approach proved successful the use of an ANP and further research into the pharmacological management is needed. This case study also highlights the effectiveness of a multi-disciplinary approach to patient care and how it improved patient care.