/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/delegationpractice-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/,

/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/name-97342-en.cckm

201711332

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Inpatient Delegation Protocols

Chest Pain Control - Adult - Inpatient [138]

Chest Pain Control - Adult - Inpatient [138] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


Delegation Protocol Number: 138

Delegation Protocol Title:
Chest Pain Control - Adult - Inpatient

Delegation Protocol Applies To:
Registered Nurses (RNs) caring for adult inpatients at UW Health. This protocol does not apply to
Registered Nurses in procedural areas.

Target Patient Population:
Adult inpatients experiencing new onset of chest pain and other warning signs of a heart attack.

Delegation Protocol Champion:
Anne O’Connor, MD – Department of Medicine, Cardiology

Delegation Protocol Reviewers:
Stephanie Kraus, CNS - Cardiology
Vonda Shaw, MS, MPH – Manager, Preventive Cardiology & Heart Station
Margaret Murray, CNS - Cardiac Surgery and Cardiac Transplant
Jessica Weber, CNS - General Surgery and Transplant
Betsy Laessig-Stary, CNS- Surgical Specialities
Kristen Stine, CNS - Overnight Care at The American Center
Ellie Burgenske, CNS - Neurosciences
Shelly VanDenbergh, CNS- General Medicine
Amy Shepard, RN- STEMI and Shock Coordinator

Responsible Department:
Department of Medicine - Cardiovascular

Purpose Statement:
The purpose of this protocol is to delegate authority from the attending physician to Registered Nurses
(RNs) to place orders to evaluate new onset chest pain.

Who May Carry Out This Delegation Protocol:
RNs caring for adult inpatients experiencing chest pain and who are trained in the use of this protocol.

Training on this protocol consists of training registered nurses in the recognition of chest pain, warning
signs of a heart attack and how to place the order for the items in the protocol.

Guidelines for Implementation:
1. This protocol is initiated when a patient is experiencing new onset chest pain or discomfort or other
warning signs of a heart attack include discomfort in other areas of the upper body including or both
arms, back, neck, jaw or stomach; shortness of breath, sweating, nausea or lightheadedness.


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


2. Contraindications to this protocol consist of:
2.1. Adult patients admitted to the American Family Children’s Hospital
2.2. OR and PACU patients
2.3. Inpatients in procedure areas such as the Cath Lab, Radiology and GI Procedure Center
2.4. Inpatients being treated off the unit and who are not accompanied by an inpatient RN trained
in the use of this protocol.
2.5. Palliative Care Service and patients receiving end of life care. (This protocol does not apply to
patients who have Do Not Resuscitate or No CPR orders.)
3. The RN places an order for:
3.1. 12 Lead ECG (stat, once).
3.1.1. When the ECG order is signed, it will automatically generate a page to the ECG tech (page
contents includes the ECG priority of stat, patient name and patient location). If the ECG
tech has not responded in 10 minutes, then page the tech at pager 8497.
3.1.2. If the ECG cart is readily available and the RN or tech is trained to use it, the RN or tech can
obtain the ECG.
3.2. Cardiac monitoring (telemetry) with intermittent frequency for 12 hours (if not already in place)
3.3. Peripheral IV (if not currently in place)
3.4. Oxygen 2 liters by nasal cannula for oxygen saturation of less than 92%
4. The RN immediately notifies the patient’s primary team that the chest pain protocol was used and
that the stat 12 Lead ECG obtained via the protocol needs to be reviewed. RN documents the
notification of the team.
Order Mode: Cosign Required, Protocol/Policy

References:
1. O’Gara, P.T., Kushner, F.G., Ascheim, D.D., Casey, D.E., Chung, M.K, et al. (2013). 2013 ACCF/AHA
guideline for the management of ST-elevation myocardial infarction. Journal of the American
College of Cardiology, 61(4), e78-e140.
2. http://www.heart.org/HEARTORG/Conditions/HeartAttack/WarningSignsofaHeartAttack/Warning-
Signs-of-a-Heart-Attack_UCM_002039_Article.jsp.
3. Policy #1.31 Caring for Adult & Pediatric Patients Requiring Cardiac
Monitoring https://uconnect.wisc.edu/policies/clinical/uwhc-clinical/department-specific/nursing-
patient-care/cardiovascular-and-infusion/131.policy
Collateral Documents/Tools: NA

Approved By:
UWHC Nursing Practice Committee: March 2016
UW Health Clinical Knowledge Management Council: March 2016
UWHC Medical Board: April 2016

Effective Date: April 2016

Scheduled for Review: April 2018
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org