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When is chest pain something more?

WILLMAR -- When someone arrives in Rice Memorial Hospital's emergency room in the throes of a severe heart attack, everyone knows what to do: Assess the patient as rapidly as possible and, if necessary, call for a helicopter and get him or her transferred to a cardiac catheterization lab within 90 minutes or less.

For patients who come to the emergency room with low-risk chest pain, however, the treatment picture has been less clear.

Should they be hospitalized or should they be sent home? What sorts of tests should they receive? How should they be monitored? What if the patient has a normal EKG but a worrisome family history for heart disease?

Ruling out a heart attack among these patients has always been a bit of a diagnostic dilemma, said Dr. Norris Anderson, the hospital's medical director for care improvement.

"We can't be absolutely 100 percent certain it's not their heart," he said.

Recognizing there was a gap, a hospital team sat down last year to develop a new process for how patients with low-risk chest pain are managed. The new set of orders has been in place since last April.

Chest pain brings several million Americans to the emergency room each year. Most of them are at low risk of having an actual heart attack and probably don't need an aggressive, expensive workup. However, a small fraction of heart attack patients -- somewhere between 2 percent and 4 percent -- are sent home too soon because their heart attack goes unrecognized.

"There's a fairly significant number of patients who come into the emergency room with chest pain. There's always a risk," said Dr. George Gordon, chief medical officer at Rice Hospital and a part-time emergency physician.

The new protocol "really offers the option to that physician to say, 'My comfort level is not strong enough to send you home but we're not going to push this to the extreme,'" Gordon said.

Patients with low-risk chest pain are now being hospitalized for 24 to 48 hours for monitoring. They all undergo a cardiac stress test, and they might have further tests if needed.

June Boie, assistant director in critical care in the emergency room and intensive care unit, said that since this pathway was introduced almost a year ago, about 30 patients have qualified. Eight of them ended up being moved to a higher level of care because their cardiac stress tests showed an abnormality, she said.

Both patients and families appear to like the way the process is working, she said. "They have been able to get into the system and out swiftly."