Clinical Guideline: Chest Pain Evaluation - University Report

This report presents a clinical guideline focused on the evaluation of chest pain in emergency department settings. The guideline addresses the primary health issue of ischemic heart disease and its related conditions, including sudden cardiac arrest. It outlines the need for the guideline due to th...Read More

Clinical Guideline 1
CLINICAL GUIDELINES
By (Name)
Course
Professor’s name
University name
City, State
Date of submission
Clinical Guideline
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1. Title
Criterion 6
What is the title of your guideline? (Approximately 20 words)
Chest pain evaluation in the emergency hospital room
2. Health Issue
Criterion 1
What is the primary health issue you are concerned with? Are there any related
issues? If so, what are they? (Approximately 100 words)
Ischemic heart disease is the primary health issue of concern in this guideline;
ischemic heart disease is the resultant condition of the narrowed arteries of the heart.
Narrowing of the arteries causes less oxygen and blood flow to the heart muscles; and
this results in cardiac ischemia (Armstrong, Armstrong and Rocco 2011). This
condition is also referred to as coronary heart infection or coronary artery infection;
ischemic heart infection eventually results in a heart attack. Ischemia usually causes
the angina pectoris discomfort as well as the chest pains. The SCA (Sudden cardiac
arrest) is the major problem of public health that is related to the Ischemic heart
infection (Kolli 2014).
Criterion 1
Why is this guideline needed? (Approximately 50 words)
Chest discomfort accounts for about six million yearly appointments to the emergency
sections in Australia; this makes chest pain to be among the most complaint health
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issues in Australia. Patients existing with a range of symptoms and signs reflect the
various potential etiologies of chest pain. Diseases of the abdominal viscera, lungs,
stomach, aorta, heart, pleura, mediastinum, and esophagus all result in chest pains
(Runciman, Merry and Walton 2017).
3. Context
Criterion 1
In what situation(s) could this guideline be used? (E.g., in a hospital setting, at home,
in general practice) (Approximately 100 words)
This guideline is primarily used in a hospital setting, clinicians present in the
emergency department concentrate on the instant exclusion and recognition of the
life-threatening chest pain causes. Patients having the fatal causes of chest discomfort
may seem deceptively well, showing neither physical check-up abnormalities nor vital
signs (Amsterdam et al. 2010). The guideline discusses the common and life-
threatening causes of chest discomfort and offers the best approach to the assessment
of chest pain patients in the emergency department and management of chest pains.
The guideline can also be used at home by the patient, the provision of an instruction
sheet for chest pains to all individuals who are being discharged offers algorithms for
taking medication (Jneid et al. 2012).
4. Processes used (list)
Criterion 2
List the methods (e.g., consultation with stakeholders, primary/secondary research)
that were used to formulate the guideline. (Approximately 100 words)
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The process of formulation of the chest pain evaluation in the emergency department
guideline involved:
a. discussion with the stakeholders such as the; the emergency room physicians,
other doctors, nurse educators, registered nurses, managers, regional
managers, directors and clinical nurse advisors (Goodwin et al. 2013).
b. Secondary/primary research: a literature examination was conducted to find
the research articles as well as the articles whose primary focus was the
evaluation of chest discomfort in the emergency departments.
c. Searching of various databases such as the Cochrane Library, EMBASE, and
the Catalogue of Abstracts of Reviews for Effectiveness as well as MEDLINE.
d. Use of various search terms such as “chest pain/treatment,” “chest
pain/finding” and “emergency service, clinic.”
5. Procedures used (list)
Criterion 2
List the methods (e.g., systematic review, critical appraisal) that were used to
formulate the guideline. (Approximately 100 words)
The procedures used in the development of the chest pain evaluation guideline are:
 Critical appraisal to avoid recommendations that are conflicting
 A systematic review to ensure a high methodological quality of
the recommendation, the procedure involves the designing of
an effective systematic review method by an information
specialist (Pullin and Stewart 2006).
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 Searching and retrieving of the evidence for the relevance of
the chest pain evaluation in the emergency room guideline from
various catalogs such as the database of Abstracts of Reviews
for Effectiveness of the instructions.
 Application of the GRADE system to assess the quality of the
guideline (Peffers et al. 2007).
6. Clinical Question(s) (PICO)
Criterion 3
List the clinical question(s) (formulated using PICO) that were used to develop the
guideline. (Approximately 100 words
 For patients accessing the emergency room with severe chest pains, should fentanyl or
morphine be used to manage pain based on the variation in the pain that is conveyed
using the visual scale?
 For patients in the emergency room with severe chest pains, should morphine or
hydromorphone apply in the management of pain based on the variation in the pain that is
shown by the visual scale?
 For the patients in the emergency rooms with severe chest pain but do not require
analgesia, however, demand an analgesic for the outpatient management of the pain,
should codeine-acetaminophen or oxycodone-acetaminophen be issued to the patients
with severe chest pains basing on the hostile side effects and efficacy of the patient’s
report? (Walsh et al 2013)
7. End-user(s)
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Clinical Guideline 6
Criterion 3
Who is affected both directly and possibly indirectly by this guideline?
(Approximately 100 words)
The individuals directly affected by this guideline are:
 The emergency department doctors as they use the recommendations in the
management of etiologies of chest pain
 The other doctors as the guidelines offer the best approaches of identifying
chest pains conditions as the patients having the life-threatening causes for
chest discomfort may seem deceptively well.
 The patients as the guidelines offer the chest pain management sheet for
provision of the relevant medication uptake approaches.
The individuals indirectly affected by the guideline are the family members of
the patient as they also help in the caring of the patient and therefore the
instruction offers the best approaches for them to follow in case of an
emerging issue occurring to the outpatients (Amsterdam et al. 2010).
8. Relevance and importance of the outcome to the end-user(s)
Criterion 3
Explain how the outcome is relevant and essential to the end-user(s). Use evidence if
appropriate. (Approximately 100 words)
The importance and relevance of the guideline outcome are:
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 It offers standards against which the users (particularly the specialists in the
emergency department) can review to equate and possibly advance their
practices for quality care provision.
 It offers guidance to the emergency department physicians concerning the
undertaking of some tasks this might enable avoidance of some potential
errors therefore safe healthcare provision.
 The guideline is essential improvement of the effectiveness of the healthcare
by provision of instruction to the patient, for instance, the chest discomfort
instruction sheet that is given to the chest pain outpatients to guide them on
how to take medication, rest and approaches to follow in case of an
emergency; this reduces the cost of hospitalization, occurrence of preventable
mistakes and hostile events is also reduced (Greenhalgh, Howick and Maskrey
2014).
9. Processes used (description)
Criteria 2, 4
How did you find this evidence? (Approximately 200 words
Discussion with the stakeholders such as the; the emergency room physicians,
other doctors, nurse educators, registered nurses, managers, regional
managers, directors and clinical nurse advisors are done to find the evidence,
the discussions involve the vital nursing roles in the emergency department,
the gaps present in the current healthcare provision that require enhancement
of the functions of nursing (Speziale, Streubert and Carpenter 2011.).
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Secondary/primary research; literature research was conducted to find
information on chest pains in patients; a primary survey is then performed
which involves the initial evaluation of the patients allowing the Emergency
health responder to detect the life-threatening etiologies of chest discomfort. A
secondary survey is then conducted which involve the history and physical
examination of the patient’s chest pain complaints (MacKenzie and Ross
2013).
Searching information from various databases such as the MEDLINE for
supportive information to back up the development of the new clinical
guideline, in this case medical terminologies used when searching from the
search engines include; “chest pain/treatment”, “chest pain/finding” and
“emergency service, clinic” this helps in finding relevant literature data to
back up the statistical data obtained during the primary and secondary survey.
10. Procedures used (description)
Criteria 2, 4
The systematic review which involves searching of various databases such as,
the Cochrane Library, EMBASE, and the Catalogue of Abstracts of Reviews
for Effectiveness as well as MEDLINE, the search should involve a variety of
databases to reduce the incidence of selection bias. The quality of the
systematic review of the chest pain evaluation in emergency room guideline
can be improved through the appropriate formulation of the systematic review
methodology by an information specialist (Higgins and Green 2011).
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Critical appraisal of the guideline, a survey is conducted to affirm the
relevance and the truth in the guideline stated, this survey is conducted by
carrying out interviews with the emergency department physicians as well as
the chest pain patients.
The use of the GRADE tool that ensures the quality of the evidence-based
guidelines, the methodology of GRADE is specifically well-tuned to a medical
approach that is evidence-based by specifying the creation of well-structured
PICO clinical questions which then focus on the development of the clinical
guidelines (Polit and Beck 2008.). Grade also adopts a reliable approach that
rates the evidence quality around the prioritized and predefined outcomes of
importance into four groups; very low, low, moderate and high.
11. Considerations
Criterion 4
What did you consider when making these recommendations? Who or what is
affected? (E.g. benefits, harms, values, preferences, resource use, acceptability)
(Approximately 200 words)
The recommendations of the chest pain evaluation has various benefits which
are; the reduced stay in hospitals, as well as decrease in the annual rates of visits to
hospitals, therefore, decrease in the hospitalization costs, effective detection of the
life-threatening etiologies of chest pain, therefore, reduced mortality rates and
effective and quality healthcare provision to the patient (Tagami et al 2012).
The harm of this recommendation is the accelerated diagnostic procedures
conducted, comprising of various markers for cardiac injury and electrocardiograms
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exposes the patient and even the physicians conducting the process to radiations that
might be if negative effect to the body.
This guideline resource use is quite high as the chest pain evaluation process
requires advanced equipment such as the markers of cardiac injury to ensure the
effectiveness of the assessment, however, it is greatly acceptable for application in the
emergency department as it has more positive outcomes for both the patients and the
physicians and the major positive outcome is the decrease in rates of annual visits to
the emergency units therefore reducing hospitalization costs.
This guideline is more useful to the patient whose life is saved by the
recommendations of the guideline through the effective detection of the life-
threatening etiologies of chest pain (Budoff et al 2006).
12. Recommendations
Criteria 4, 5
What are your recommendations? Are some of your recommendations more important
than others? Why? Show direct links to supporting evidence. (Approximately 200
words)
In this chest pain evaluation in the emergency room guideline, the
recommendation is all individuals especially those above the age of 30 years are
required to visit the clinical center annually for chest pain analysis (Tagami et al
2012).
In other clinical guidelines,
a) Guideline; the process of screening of breast cancer in women
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Recommendation; every woman above the age of 40 is requested to visit the
clinical center for the examination of her breasts. Mammography in every two to one
year is essential to all women aging from 50 years to 70 years.
b) Guideline: screening for reduced visual Acuity
Recommendation: all children getting into school particularly at the age of 3-4
years require vision screening.
The recommendation for chest pain assessment at the emergency room is more
important this is because the causative elements of chest pain can lead to quick death
and the patients having the life-threatening causes for chest discomfort may seem
deceptively well, therefore, the process requires keen interest and another reason is
that most patients visiting the hospitals have chest pain problems, therefore, need for
the chest evaluation program (Budoff et al 2006).
13. References
Criteria 4, 6
What sources did you use to develop this guideline?
Amsterdam, E.A., Kirk, J.D., Bluemke, D.A., Diercks, D., Farkouh, M.E., Garvey,
J.L., Kontos, M.C., McCord, J., Miller, T.D., Morise, A. and Newby, L.K., 2010.
Testing of low-risk patients presenting to the emergency department with chest pain: a
scientific statement from the American Heart Association. Circulation, 122(17),
pp.1756-1776.
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Armstrong, E.J., Armstrong, A.W. and Rocco, T.P., 2011. Integrative Cardiovascular
Hypertension, Ischemic Heart Disease, and Heart Failure. Principles of
Pharmacology: The Pathophysiologic Basis of Drug Therapy, p.437.
Budoff, M.J., Achenbach, S., Blumenthal, R.S., Carr, J.J., Goldin, J.G., Greenland, P.,
Guerci, A.D., Lima, J.A., Rader, D.J., Rubin, G.D. and Shaw, L.J., 2006. Assessment
of coronary artery disease by cardiac computed tomography: a scientific statement
from the American Heart Association Committee on Cardiovascular Imaging and
Intervention, Council on Cardiovascular Radiology and Intervention, and Committee
on Cardiac Imaging, Council on Clinical Cardiology. Circulation, 114(16), pp.1761-
1791.
Goodwin, N., Sonola, L., Thiel, V. and Kodner, D., 2013. Co-ordinated care for
people with complex chronic conditions. Key lesson and markers for success
Greenhalgh, T., Howick, J. and Maskrey, N., 2014. Evidence based medicine: a
movement in crisis?. Bmj, 348, p.g3725
Higgins, J.P. and Green, S. eds., 2011. Cochrane handbook for systematic reviews of
interventions (Vol. 4). John Wiley & Sons.
Jneid, H., Anderson, J.L., Wright, R.S., Adams, C.D., Bridges, C.R., Casey, D.E.,
Ettinger, S.M., Fesmire, F.M., Ganiats, T.G., Lincoff, A.M. and Peterson, E.D., 2012.
2012 ACCF/AHA focused update of the guideline for the management of patients
with unstable Angina/Non–ST-elevation myocardial infarction (updating the 2007
guideline and replacing the 2011 focused update). Circulation, 126(7), pp.875-910.
Kolli, K.K., 2014. Diagnosis of coronary artery disease using pressure drop
coefficient (Doctoral dissertation, University of Cincinnati)
MacKenzie, A. and Ross, F., 2013. Nursing in primary health care: policy into
practice. Routledge.
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Peffers, K., Tuunanen, T., Rothenberger, M.A. and Chatterjee, S., 2007. A design
science research methodology for information systems research. Journal of
management information systems, 24(3), pp.45-77.
Polit, D.F. and Beck, C.T., 2008. Nursing research: Generating and assessing
evidence for nursing practice. Lippincott Williams & Wilkins.
Pullin, A.S. and Stewart, G.B., 2006. Guidelines for systematic review in
conservation and environmental management. Conservation biology, 20(6), pp.1647-
1656.
Runciman, B., Merry, A. and Walton, M., 2017. Safety and ethics in healthcare: a
guide to getting it right. CRC Press.
Speziale, H.S., Streubert, H.J. and Carpenter, D.R., 2011. Qualitative research in
nursing: Advancing the humanistic imperative.
Tagami, T., Tosa, R., Omura, M., Yokota, H. and Hirama, H., 2012. Implementation
of the fifth link of the chain of survival concept for out-of-hospital cardiac arrest.
Critical Care, 16(1), p.P266.
Walsh, B., Cone, D.C., Meyer, E.M. and Larkin, G.L., 2013. Paramedic attitudes
regarding prehospital analgesia. Prehospital Emergency Care, 17(1), pp.78-87.
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