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A retrospective external validation study of the HEART score among patients presenting to the emergency department with chest pain

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Abstract

Emergency physicians must be able to effectively prognosticate outcomes for patients presenting to the Emergency Department (ED) with chest pain. The HEART score offers a prognostication tool, but external validation studies are limited. We conducted an external retrospective validation study of the HEART score among ED patients presenting to our ED with chest pain from 1 January 2014 to 9 June 2014. We utilized chart review methodology to abstract data from each patient’s electronic medical record. We collected data relevant to each of the five elements of the HEART score: history, electrocardiogram (ECG) interpretation, patient age, patient risk factors, and troponin levels. We calculated the diagnostic accuracy of the HEART score (0–10) for predicting the primary outcome of major adverse cardiac events (MACE) over 6 weeks following the ED visit (coronary revascularization, myocardial infarction, or mortality). We randomly selected 10% of patient charts from which a second investigator abstracted all data to assess inter-rater reliability for all study variables. Of 625 charts reviewed, we abstracted data on 417 (66.7%) consecutive patients meeting study inclusion criteria. Thirty-one (7.4%) of these patients experienced 6-week MACE. We observed no instances of MACE within 6 weeks among subjects with a HEART score of 3 or less. The area under the receiver operator curve (AUROC) is 0.885 (95% confidence interval 0.838–0.931). Patients with a HEART score ≤3 are at low risk for 6-week MACE. Hence, these patients may be candidates for outpatient follow-up instead of inpatient admission for cardiac risk stratification.

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References

  1. Center for Disease Control and Prevention (2013) National Hospital Ambulatory Medical Care Survey: 2013 emergency department summary tables. Center for Disease Control and Prevention, Atlanta, Georgia

  2. Amsterdam EA, Wenger NK, Brindis RG et al (2014) 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 64:e139–e228

    Article  PubMed  Google Scholar 

  3. Backus BE, Six AJ, Kelder JC et al (2013) A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 168:2153–2158

    Article  CAS  PubMed  Google Scholar 

  4. Amsterdam EA, Kirk JD, Bleumke DA et al (2010) American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation 122:1756–1776

    Article  PubMed  PubMed Central  Google Scholar 

  5. Venkatesh AK, Dai Y, Ross JS, Schuur JD, Capp R, Krumholz HM (2015) Variation in US hospital emergency department admission rates by clinical condition. Med Care 53:237–244

    Article  PubMed  PubMed Central  Google Scholar 

  6. Brooker JA, Hastings JW, Major-Monfried H et al (2015) The association between medicolegal and professional concerns and chest pain admission rates. Acad Emerg Med 22:883–886

    Article  PubMed  Google Scholar 

  7. Backus BE, Six AJ, Kelder JC et al (2010) Chest pain in the emergency room: a multicenter validation of the HEART score. Crit Pathw Cardiol 9:164–169

    Article  PubMed  Google Scholar 

  8. Backus BE et al (2013) A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 168(3):2153–2158

    Article  CAS  PubMed  Google Scholar 

  9. Fesmire FM et al (2012) Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score. Am J Emerg Med 30(9):1829–1837

    Article  PubMed  Google Scholar 

  10. Poldervaart JM et al (2013) The impact of the HEART risk score in the early assessment of patients with acute chest pain: design of a stepped wedge, cluster randomised trial. BMC Cardiovasc Disord 13:77

    Article  PubMed  PubMed Central  Google Scholar 

  11. Six AJ, Backus BE, Kelder JC (2008) Chest pain in the emergency room: value of the HEART score. Neth Heart J 16(6):191–196

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Mahler SA et al (2015) The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes 8(2):195–203

    Article  PubMed  PubMed Central  Google Scholar 

  13. Weinstock MB, Weingart S, Orth F, VanFossen D, Kaide C, Anderson J, Newman DH (2015) Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Intern Med 175(7):1207–1212

    Article  PubMed  Google Scholar 

  14. Mahler SA, Miller CD, Hollander JE et al (2013) Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol 168:795–802

    Article  PubMed  Google Scholar 

  15. Goldman L, Cook EF, Johnson PA, Brand DA, Rouan GW, Lee TH (1996) Prediction of the need for intensive care in patients who come to the emergency departments with acute chest pain. N Engl J Med 334(23):1498–1504

    Article  CAS  PubMed  Google Scholar 

  16. Antman EM, Cohen M, Bernink PJ et al (2000) The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 284:835–842

    Article  CAS  PubMed  Google Scholar 

  17. Chase M, Robey JL, Zogby KE et al (2006) Prospective validation of the thrombolysis in myocardial infarction risk score in the emergency department chest pain population. Ann Emerg Med 48:252–259

    Article  PubMed  Google Scholar 

  18. Fox KA, Dabbous OH, Goldberg RJ et al (2006) Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRAC(E). BMJ 333:1091

    Article  PubMed  PubMed Central  Google Scholar 

  19. Elbarouni B, Goodman SG, Yan RT et al (2009) Validation of the global registry of acute coronary event (GRAC(E) risk score for in-hospital mortality in patients with acute coronary syndrome in Canada. Am Heart J 158:392–399

    Article  PubMed  Google Scholar 

  20. Hess EP, Agarwal D, Chandra S et al (2010) Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis. CMAJ 182:1039–1044

    Article  PubMed  PubMed Central  Google Scholar 

  21. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP et al (2007) The strengthening the reporting of observational studies in epidemiology (STROB(E) statement: guidelines for reporting observational studies. Ann Intern Med 147:573–577. doi:10.7326/0003-4819-147-8-200710160-00010

    Article  Google Scholar 

  22. Kaji AH, Schriger D, Green S (2014) Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies. Ann Emerg Med 64(3):292–298

    Article  PubMed  Google Scholar 

  23. Hess EP, Brison RJ, Perry JJ et al (2012) Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome. Ann Emerg Med 59:115–1251

    Article  PubMed  Google Scholar 

  24. Rationale and design of the GRACE (Global Registry of Acute Coronary Events) (2001) Project: a multinational registry of patients hospitalized with acute coronary syndromes. Am Heart J 141(2):190–199

    Article  Google Scholar 

  25. Boersma E et al (2000) Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT investigators. Circulation 101(22):2557–2567

    Article  CAS  PubMed  Google Scholar 

  26. Chase M et al (2006) Prospective validation of the thrombolysis in myocardial infarction risk score in the emergency department chest pain population. Ann Emerg Med 48(3):252–259

    Article  PubMed  Google Scholar 

  27. Fleischmann KE et al (2002) Critical pathways for patients with acute chest pain at low risk. J Thromb Thrombolysis 13(2):89–96

    Article  CAS  PubMed  Google Scholar 

  28. Hess EP et al (2012) The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes 5(3):251–259

    Article  PubMed  Google Scholar 

  29. Lagerqvist B et al (2005) FRISC score for selection of patients for an early invasive treatment strategy in unstable coronary artery disease. Heart 91(8):1047–1052

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Lyon R et al (2007) Chest pain presenting to the emergency department–to stratify risk with GRACE or TIMI? Resuscitation 74(1):90–93

    Article  PubMed  Google Scholar 

  31. Than M et al (2011) A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet 377(9771):1077–1084

    Article  PubMed  Google Scholar 

  32. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Selker HP (2000) Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 342(16):1163–1170

    Article  CAS  PubMed  Google Scholar 

  33. Rusnak RA, Stair TO, Hansen K, Fastow JS (1989) Litigation against the emergency physician: common features in cases of missed myocardial infarction. Ann Emerg Med 18(10):1029–1034

    Article  CAS  PubMed  Google Scholar 

  34. Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Lauer MS (2010) 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular. J Am Coll Cardiol 56(25):e50–e103

    Article  PubMed  Google Scholar 

  35. Fesmire FM, Brady WJ, Hahn S, Decker WW, Diercks DB, Ghaemmaghami CA, Jagoda AS (2006) Clinical policy: indications for reperfusion therapy in emergency department patients with suspected acute myocardial infarction. Ann Emerg Med 48(4):358–383

    Article  PubMed  Google Scholar 

  36. Forberg JL, Henriksen LS, Edenbrandt L, Ekelund U (2006) Direct hospital costs of chest pain patients attending the emergency department: a retrospective study. BMC Emerg Med 6(1):6

    Article  PubMed  PubMed Central  Google Scholar 

  37. McCullough PA, Ayad O, O’Neill WW, Goldstein JA (1998) Costs and outcomes of patients admitted with chest pain and essentially normal electrocardiograms. Clin Cardiol 21(1):22–26

    Article  CAS  PubMed  Google Scholar 

  38. Wu WK, Yiadom MYA, Collins SP, Self WH, Monahan K (2017) Documentation of HEART score discordance between emergency physician and cardiologist evaluations of ED patients with chest pain. Am J Emerg Med 35(1):132–135

    Article  PubMed  Google Scholar 

  39. April MD, Murray BP (2017) Cost effectiveness analysis appraisal and application: an emergency medicine perspective. Acad Emerg Med 24(6):754–768. doi:10.1111/acem.13186

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Matthew Jay Streitz.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

None.

Statement of human and animal rights

For this type of study formal consent was not required. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was waived at our institution due to the chart review nature of the study.

Additional information

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, the Department of Defense, or the US Government.

Appendix

Appendix

Chest pain in the emergency department: an ambispective cohort validation of the heart score: Data dictionary

Introduction

This document comprises the study manual for the study entitled “Chest Pain in the Emergency Department: An Ambispective Cohort Validation of the Heart Score.” This is an ambispective cohort (chart review) study of adults presenting to the ED with chief complaint of chest pain, chest pressure, chest tightness, etc. This document is designed to serve as a guide for data abstractors in completing the chart reviews to ensure uniform methods for data collection and entry into the study spreadsheet.

Subjects selection—identification spreadsheet

Subjects eligible for the chart review will be identified by the principal and co-investigators through accessing ad hoc CHCS reports. Our local Essentris Administrator, Mr. Eric Hobbs, will write a program to directly abstract as much information as possible from the Essentris ED Nursing Note. The variables abstracted by Mr. Hobbs program represent the first 30 data points on the data collection spreadsheet.

Individual abstractors will gather the rest of the information for each subject from HAIMS and AHLTA. When needed, they may also access Essentris to review an admission History and Physical or a Discharge Summary. To clarify, information from this study will be gathered from four different Electronic Medical Records: CHCS, Essentris, HAIMS, and AHLTA. All four of these programs are well known to providers working within the military health care system.

All subjects eligible for inclusion in the study will then be assigned a unique study identification number starting with 1 and sequentially added until the study numbers are obtained. Subject social security numbers and medical record numbers will be recorded and affiliated with each unique study identification number and maintained in the identification spreadsheet (separate from the study spreadsheet). The medical record numbers will be temporarily provided to the chart abstractors for chart retrieval and data abstraction into the study spreadsheet (see the following section).

Data abstraction—study spreadsheet

Chart abstractors will receive a formal walk-through of chart abstraction. They will further be provided a copy of this study manual for reference during data abstraction. No less than 10% of charts will be abstracted by either Matthew Streitz or Joshua Oliver for the purpose of quality control and calculation of kappa coefficient.

This section lists in sequence the variables to be abstracted from each subject’s chart and entered into the excel spreadsheet comprising the study spreadsheet. Each variable lists a source, alternate source, and occasionally a second alternate source. There is no need to use each source. Look through the listed sources in the order, they are listed until the variable is identified. If the data are not identified, leave that field blank

Under each variable, there is a subheading of “possible variables”. With the exception of the data abstracted by Mr. Hobbs program, these variables represent the options listed in the dropdown menu for each variable in the data collection spreadsheet. Overwhelmingly, these variables are a reflection of the possible options to circle on the T sheets that our institution used at the time of this study.

Update: As of 29NOV2016, two additional variables were also added to the prospective data sheet. Follow-up with the HEART score clinic (yes, no) and if yes, how many days were followed from the initial ED visit. These variables were added before prospective data collection started. They were not initially included in the retrospective cohort as our institution was not using the HEART score at that time and the HEART score clinic did not exist as a possible follow-up option for low-risk chest pain patients that were discharged.

  1. 1.

    Subject #:

    1. (a)

      Variable: identification number.

    2. (b)

      Format: ratio (integer).

    3. (c)

      Definition: unique identification number assigned to subject as part of the subject selection process as above.

    4. (d)

      Possible variables: sequentially increasing by unit of 1.

    5. (e)

      Source:

      1. (i)

        Database: ID spreadsheet.

      2. (ii)

        Document: ID spreadsheet.

      3. (iii)

        Field: ID.

    6. (f)

      Alternative source: none.

  2. 2.

    ED_Date:

    1. (a)

      Variable: date.

    2. (b)

      Format: DD-MMM-YY (e.g., January 1st, 2013 = 01-Jan-13).

    3. (c)

      Definition: date of subject arrival in emergency department (not date of admission).

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: ED arrival date.

    6. (f)

      Alternative source: none.

  3. 3.

    Age:

    1. (a)

      Variable: subject age.

    2. (b)

      Format: ratio (integer in years).

    3. (c)

      Definition: subject age at the time of arrival in emergency department (auto-populated fields report subject’s age at the current date and, therefore, cannot be used; parameter must be calculated based on date of birth and date of presentation).

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: DOB.

    6. (f)

      Alternative source: ED daily nursing spreadsheet—admissions tab (column D).

  4. 4.

    Sex:

    1. (a)

      Variable: subject sex.

    2. (b)

      Format: nominal: M, F.

    3. (c)

      Definition: subject’s sex.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: sex.

    6. (f)

      Alternative source: ED daily nursing spreadsheet—admissions tab (column D).

  5. 5.

    ESI:

    1. (a)

      Variable: emergency severity index.

    2. (b)

      Format: nominal (1, 2, 3, 4, and 5).

    3. (c)

      Definition: triage category based on subject’s anticipated health care problems and estimated amount of resources their care will consume.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: ESI category.

    6. (f)

      Alternative source: ED daily nursing spreadsheet—admissions tab (column E).

  6. 6.

    EMS:

    1. (a)

      Variable: EMS.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: arrival to ED via emergency medical services (ambulance or fire engine).

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: history obtained from or screening RN assessment.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: historian.

  7. 7.

    Chief_complaint:

    1. (a)

      Variable: chief complaint.

    2. (b)

      Format: nominal (chest pain and shortness of breath).

    3. (c)

      Definition: concise statement describing a subject’s primary problem.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: chief complaint.

    6. (f)

      Alternative source: none.

  8. 8.

    Cholesterol:

    1. (a)

      Variable: cholesterol.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: this question is asking if the subject has high cholesterol. If the ED nursing note or T-sheet indicates a history of high cholesterol, then this data point will be answered “yes”.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    7. (g)

      Second alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  9. 9.

    HTN:

    1. (a)

      Variable: history of hypertension.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: this question is asking if the subject has high blood pressure.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    7. (g)

      Second alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  10. 10.

    DM:

    1. (a)

      Variable: history of diabetes mellitus.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: this question is asking if the subject has Diabetes regardless of type.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    7. (g)

      Second alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  11. 11.

    MI:

    1. (a)

      Variable: history of myocardial infarction.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: has the subject ever had an MI, i.e., heart attack before.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    7. (g)

      Second alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  12. 12.

    CABG:

    1. (a)

      Variable: CABG.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: has the subject ever had surgery such as CABG to re-vascularize ischemic myocardium or return blood supply to dying heart.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    7. (g)

      Second alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  13. 13.

    Stent:

    1. (a)

      Variable: stent.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: has the subject ever had a stent to re-vascularize ischemic myocardium or return blood supply to dying heart.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    7. (g)

      Second alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  14. 14.

    CVA:

    1. (a)

      Variable: history of cerebral vascular accident.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: has the subject ever had a stroke or Transient Ischemic Attach (TIA).

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    7. (g)

      Second alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  15. 15.

    CHF:

    1. (a)

      Variable: history of congestive heart failure (CHF).

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: does the subject have a history of congestive heart failure (CHF).

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    7. (g)

      Second alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  16. 16.

    CAD:

    1. (a)

      Variable: family history of coronary artery disease.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: this question is asking if the subject has a family history of coronary artery disease.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: social or family history.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: social or family history.

    7. (g)

      Second alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or family history narrative.

  17. 17.

    Pulse:

    1. (a)

      Variable: first heart rate.

    2. (b)

      Format: ratio (integer in beats per minute).

    3. (c)

      Definition: value of heart rate taken as part of initial vital signs.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: HR.

    6. (f)

      Alternative source: none.

  18. 18.

    SBP:

    1. (a)

      Variable: first systolic blood pressure.

    2. (b)

      Format: ratio (integer in mm Hg).

    3. (c)

      Definition: value of systolic blood pressure taken as part of initial vital signs.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: BP (first value).

    6. (f)

      Alternative source: None.

  19. 19.

    DBP:

    1. (a)

      Variable: first diastolic blood pressure.

    2. (b)

      Format: ratio (integer in mm Hg).

    3. (c)

      Definition: value of diastolic blood pressure taken as part of initial vital signs.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: BP (second value).

    6. (f)

      Alternative source: none.

  20. 20.

    TEMP:

    1. (a)

      Variable: first temperature.

    2. (b)

      Format: interval (degrees Fahrenheit).

    3. (c)

      Definition: value of temperature taken as part of initial vital signs.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: temp.

    6. (f)

      Alternative source: none.

  21. 21.

    TEMP_SRC:

    1. (a)

      Variable: source for first temperature.

    2. (b)

      Format: nominal: A (axillary), O (oral), R (rectal), and T (temporal).

    3. (c)

      Definition: value of temperature taken as part of initial vital signs.

    4. (d)

      Possible Variables: Data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: temp.

    6. (f)

      Alternative source: none.

  22. 22.

    RR:

    1. (a)

      Variable: first respiratory rate.

    2. (b)

      Format: ratio (integer in breaths per minute).

    3. (c)

      Definition: value of respiratory rate taken as part of initial vital signs.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: RR.

    6. (f)

      Alternative source: none.

  23. 23.

    SAO2:

    1. (a)

      Variable: first oxygen saturation.

    2. (b)

      Format: ratio (percentage).

    3. (c)

      Definition: value of oxygen saturation taken as part of initial vital signs.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: SaO2.

    6. (f)

      Alternative source: none.

  24. 24.

    Pain:

    1. (a)

      Variable: pain.

    2. (b)

      Format: nominal (1, 2, 3, 4, and 5).

    3. (c)

      Definition: subject’s subjective self-assessment of pain on a scale of 1–10.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: pain intensity scale.

    6. (f)

      Alternative source: none.

  25. 25.

    GLU:

    1. (a)

      Variable: blood sugar.

    2. (b)

      Format: interval (1, 2, 3, 4, and 5).

    3. (c)

      Definition: measurement of first blood glucose.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: lab result under flowsheet dropdown menu.

      3. (iii)

        Field: GLU.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: encounter note.

      3. (iii)

        Field: Gluc.

    7. (g)

      Second alternative source:

      1. (i)

        Database: CHCS.

      2. (ii)

        Document: LAB results under RCR menu, select renal function panel, or complete metabolic panel.

      3. (iii)

        Field: glucose.

  26. 26.

    BNP:

    1. (a)

      Variable: brain natriuretic peptide.

    2. (b)

      Format: interval (1.2).

    3. (c)

      Definition: an enzyme released by the ventricles of the heart in response to stretching. It is used to assess and trend congestive heart failure.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: BNP.

    6. (f)

      Alternative source:

      1. (i)

        Database: CHCS.

      2. (ii)

        Document: lab results under RCR tab.

      3. (iii)

        Field: BNP.

  27. 27.

    TROP1:

    1. (a)

      Variable: first troponin.

    2. (b)

      Format: interval (<0.01).

    3. (c)

      Definition: troponin is a protein involved in muscle contraction that is released into the blood stream when muscle is injured. This troponin is specific to myocardium (heart muscle). This value represents the first troponin measured while evaluating a subject for Chest Pain.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: troponin.

    6. (f)

      Alternative source:

      1. (i)

        Database: CHCS.

      2. (ii)

        Document: lab results under RCR tab.

      3. (iii)

        Field: Troponin.

  28. 28.

    TROP_TIME1:

    1. (a)

      Variable: time at which the first troponin is drawn/sent to lab.

    2. (b)

      Format: interval (13:55).

    3. (c)

      Definition: the time that the first troponin is ordered is important to know to track the time between the first and delta troponin.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: troponin.

    6. (f)

      Alternative source:

      1. (i)

        Database: CHCS.

      2. (ii)

        Document: lab results under RCR tab.

      3. (iii)

        Field: troponin.

  29. 29.

    TROP2:

    1. (a)

      Variable: second troponin.

    2. (b)

      Format: interval (<0.01).

    3. (c)

      Definition: See definition of “1st Trop”. This will be the second troponin value ordered in the ED. It will usually be drawn about 3 h after the initial, however, records the value regardless. This is sometimes referred to as a delta troponin in the ED.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: troponin.

    6. (f)

      Alternative source:

      1. (i)

        Database: CHCS.

      2. (ii)

        Document: lab results under RCR tab.

      3. (iii)

        Field: troponin.

  30. 30.

    TROP_TIME2:

    1. (a)

      Variable: time at which the second troponin is drawn/sent to lab.

    2. (b)

      Format: interval (13:55).

    3. (c)

      Definition: the time that the second troponin is ordered is important to know to track the time between the first and delta troponin.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: troponin.

    6. (f)

      Alternative source:

      1. (i)

        Database: CHCS.

      2. (ii)

        Document: lab results under RCR tab.

      3. (iii)

        Field: troponin.

  31. 31.

    Creatinine:

    1. (a)

      Variable: creatinine.

    2. (b)

      Format: interval (1.2).

    3. (c)

      Definition: creatinine is a breakdown product of muscle and is used to assess kidney function as it is produced at a relatively constant rate and excreted in the urine unchanged.

    4. (d)

      Possible variables: data extracted from ED nursing note by a program written by our local Essentris administrator Mr. Eric Hobbs.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: creatinine.

    6. (f)

      Alternative source:

      1. (i)

        Database: CHCS.

      2. (ii)

        Document: after selecting RCR on the main menu, select LAB, then RFP or CMP for date of the ED visit.

      3. (iii)

        Field: creatinine.

  32. 32.

    Abstractor:

    1. (a)

      Variable: abstractor.

    2. (b)

      Format: nominal.

    3. (c)

      Definition: name of abstractor—Mike April, Matt Streitz, Joshua Oliver, Jessica Zack, Richard Wood, and Yevgeniy Maksimenko.

    4. (d)

      Possible variables: Mike April, Matt Streitz, Joshua Oliver, Jessica Zack, Richard Wood, and Yevgeniy Maksimenko.

    5. (e)

      Source:

      1. (i)

        Database: abstractor

      2. (ii)

        Document: abstractor.

      3. (iii)

        Field: abstractor.

    6. (f)

      Alternative source: none.

  33. 33.

    Residence:

    1. (a)

      Variable: residence.

    2. (b)

      Format: nominal: assist (assisted living facility), home, nursing (nursing facility), and rehab (rehabilitation facility).

    3. (c)

      Definition: subject’s place of primary residence at the time of emergency department arrival.

    4. (d)

      Possible variables: home, nursing facility, undomiciled, and unknown

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: screening RN assessment.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: history narrative (section on social history).

  34. 34.

    Transfer

    1. (a)

      Variable: transfer.

    2. (b)

      Format: nominal: (yes, no).

    3. (c)

      Definition: transfer from another hospital. Not a long-term care facility as in item 7.

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: screening RN Assessment.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: history narrative (history of the present illness).

  35. 35.

    Admission:

    1. (a)

      Variable: admission to SAMMC.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: patient was admitted to SAMMC (has Discharge Summary in Essentris).

    4. (d)

      Possible variables: admitted, discharged.

    5. (e)

      Source:

      1. (i)

        Database: first line for looking up patients.

      2. (ii)

        Document: first line for looking up patients.

      3. (iii)

        Field: column E: HOSPNO. If the hospital number is the same as the ED_REGNO, the subject was discharged. If they were admitted, they would have been given a unique hospital number (HOSPNO) that differs from their ED registration number (ED_REGNO).

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note and discharge summary.

      3. (iii)

        Field: “history obtained from” or “screening RN assessment”.

  36. 36.

    Onset:

    1. (a)

      Variable: duration of symptoms.

    2. (b)

      Format: ordinal (ratio) 1.5, 24, and 96.

    3. (c)

      Definition: the amount of time subject has been having symptoms measured in hours.

    4. (d)

      Possible variables: <30 min, >30 min, 1, 2, 3 h, and 4, 5, >6 h

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: onset/duration.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: screening NR assessment.

  37. 37.

    Timing:

    1. (a)

      Variable: timing.

    2. (b)

      Format: nominal (yes, no, better, worse, and other).

    3. (c)

      Definition: the following variables between 37 and 43 are related to the timing of chest pain such as sudden onset, still present, or intermittent episodes. The variable to be entered will be binary such as yes/no or better/worse. The exception will be “other” allowing a free text descriptor to be entered. Of note, these variables are characterizing the subjects HPI not reassessments of interventions. For example, the “better/worse” variable is assessing if the subject feels better or worse at initial presentation to the ED than they did at the onset of their symptoms. Further variables such as “constant” and waxing/waning” assess if the symptoms are constant or intermittent and if the symptoms are increasing or decreasing. It may helpful to reference a T-sheet to better understand how these data will abstracted. T-sheets can be found on the L drive; detailed instructions leading you to their location can be found at the end of this document.

    4. (d)

      Possible variables: yes, no, or free text entry under “other”.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: timing.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: screening RN assessment.

  38. 38.

    Sudden onset.

  39. 39.

    Gradual onset.

  40. 40.

    Still present.

  41. 41.

    Better/worse.

  42. 42.

    Constant.

  43. 43.

    Waxing/waning.

  44. 44.

    Other.

  45. 45.

    Context:

    1. (a)

      Variable: context.

    2. (b)

      Format: nominal (sleep, rest, emotional upset, activity, exertion, etc.).

    3. (c)

      Definition: the setting and activity level the subject was at the onset of symptoms.

    4. (d)

      Possible variables: sleep, rest, emotional upset, activity/exertion, and recent flight.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: context.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: screening RN assessment.

  46. 46.

    Quality:

    1. (a)

      Variable: quality.

    2. (b)

      Format: nominal (pressure, tightness, like prior MI, etc.).

    3. (c)

      Definition: this is the how a subject describes their chest pain in their own words.

    4. (d)

      Possible variables: pressure, tightness, indigestion, burning, dull, aching, sharp, stabbing, like prior MI.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: quality.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: screening RN assessment.

  47. 47.

    Radiation:

    1. (a)

      Variable: radiation.

    2. (b)

      Format: nominal (location such as head, neck, back, or no).

    3. (c)

      Definition: this question is asking if the subject’s chest pain is radiating to another location. If yes, document the location. If no, document no.

    4. (d)

      Possible variables: L arm, R arm, both arms, shoulder, back, jaw, and neck.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: radiation.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: screening RN assessment.

  48. 48.

    Associated symptoms.

  49. 49.

    Variable: associated symptoms.

  50. 50.

    Format: nominal (yes, no, fatigue).

  51. 51.

    Definition: the variables 47–55 will fall into this category. 47–54 will be yes/no answers. If there is an associated symptom not listed, it can be free texted into “other”. A note about terminology. While it is understood that the proper medical term for chest pain with breathing is pleurisy, the data are being extracted from a T-sheet. The T-sheet uses the lay term, “hurts to breath”. It may helpful to reference a T-sheet to better understand how these data will abstracted. T-sheets can be found on the L drive, and detailed instructions leading you to their location can be found at the end of this document.

  52. 52.

    Possible variables: for N/V, the variables will be nausea, vomiting, both, or neither. The remaining variables listed under this block are either yes or no.

  53. 53.

    Source:

    1. (i)

      Database: HAIMS.

    2. (ii)

      Document: T-sheet.

    3. (iii)

      Field: associated symptoms.

  54. 54)

    Alternative source:

    1. (i)

      Database: Essentris.

    2. (ii)

      Document: ED nursing note.

    3. (iii)

      Field: screening RN assessment.

  55. 55.

    N/V.

  56. 56.

    Sweating.

  57. 57.

    Shortness of breath.

  58. 58.

    Hurts to breath.

  59. 59.

    Palpitations.

  60. 60.

    Cough.

  61. 61.

    Weakness.

  62. 62.

    Dizziness.

  63. 63.

    Other.

  64. 64.

    Worsened by

    1. (a)

      Variable: worsened by

    2. (b)

      Format: nominal (exertion, deep breaths, change in position, movement, nothing, etc).

    3. (c)

      Definition: factors that have made symptoms worse.

    4. (d)

      Possible variables: nothing, deep breaths, movement, and change in position.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: worsened by

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: RN assessment.

  65. 65.

    Relieved by

    1. (a)

      Variable: relieved by

    2. (b)

      Format: nominal (food, rest, antacids, change in position, nothing, etc).

    3. (c)

      Definition: factors that have relieved the symptoms.

    4. (d)

      Possible variables: nothing, sitting up, rest, antacids, NTG, O2, and ASA,

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: relieved by

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: RN assessment.

  66. 66.

    ECG

    1. (a)

      Variable: ECG (electrocardiogram).

    2. (b)

      Format: nominal (NSR, ST depression, and BBB)

    3. (c)

      Definition: this will be the staff ED physician’s interpretation or diagnosis of the ECG. A large but not all inclusive lists of ECG diagnoses and a link to example ECGs is provided in Appendix 1. It may be helpful to have this list printed out when abstracting data.

    4. (d)

      Possible variables: ECGs were coded with a number ranging from 1 to 34 based on information that can be found on the last page of this document.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: ECG interpretation sheet.

      3. (iii)

        Field: ECG checkboxes and narrative.

    6. (f)

      Alternative source: none

  67. 67.

    FmHx of CAD:

    1. (a)

      Variable: family history of coronary artery disease.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: has anyone in the subjects’ family been diagnosed with CAD?

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: family history of CAD.

    6. (f)

      Alternative source: none.

  68. 68.

    Hx smoking

    1. (a)

      Variable: history of cigarette smoking.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: does the subject smoke.

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: AHLTA.

      2. (ii)

        Document: vital signs review.

      3. (iii)

        Field: tobacco use.

  69. 69.

    Hx obesity:

    1. (a)

      Variable: history of obesity or body mass index (BM(I) >30.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: is the subject obese? You are not expected to calculate this. If it is not listed or not already calculated, do not do so and leave black or enter unavailable.

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: AHLTA.

      2. (ii)

        Document: vital signs.

      3. (iii)

        Field: BMI.

  70. 70.

    Hx arrhythmia:

    1. (a)

      Variable: history of arrhythmia.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: does the subject have a history of abnormal heart rhythms such atrial fibrillation (A-fib), atrial flutter, Wolff–Parkinson–White (WPW), or heart block?

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  71. 71.

    Hx pacemaker:

    1. (a)

      Variable: history of pacemaker.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: does the subject have a pacemaker?

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history or past surgical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  72. 72.

    Hx ACID:

    1. (a)

      Variable: Hx of automated internal cardiac defibrillator.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: does the subject have an automated internal cardiac defibrillator (AICD)?

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: past medical history.

    6. (f)

      Alternative source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: history and physical.

      3. (iii)

        Field: HPI or PMH narrative.

  73. 73.

    CXR:

    1. (a)

      Variable: primary chest X-ray diagnosis.

    2. (b)

      Format: nominal (normal, pneumonia, pneumothorax, atelectasis, and effusion).

    3. (c)

      Definition: the radiologist’s primary read of the chest X-ray. We freely admit that this is highly subjective and prone to bias. Unless a chest X-ray is completely normal, it rarely has only one finding. It will be up to the abstractor to decide which finding is primary unless it is made clear by the radiologist’s interpretation.

    4. (d)

      Possible variables: no acute cardiopulmonary findings, PNA, PTX, Atelectasis, wide mediastinum, pleural effusion, MSK findings, and other findings.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: imaging report.

      3. (iii)

        Field: narrative summary.

    6. (f)

      Alternative source:

      1. (i)

        Database: Impax.

      2. (ii)

        Document: portable chest X-ray from day of presentation.

      3. (iii)

        Field: narrative summary.

  74. 74.

    Mortality in 6 weeks

    1. (a)

      Variable: mortality within 6 weeks of ED presentation.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: did the subject die of any cause within 6 weeks of being seen in the ED?

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: death note.

      3. (iii)

        Field: narrative.

    6. (f)

      Alternative source:

      1. (i)

        Database: AHLTA.

      2. (ii)

        Document: subject encounter.

      3. (iii)

        Field: any subject encounter after 6 weeks will answer this question.

    7. (g)

      Second alternate source:

      1. (i)

        If this question cannot be answered, you will need to access public death records. To apply for said access, our local IRB will need to approve of our protocol as it stands. The process will be clarified as it is established.

  75. 75.

    CABG in 6 weeks:

    1. (a)

      Variable: revascularization within 6 weeks of ED presentation.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: did the subject have a CABG or Stent placed within 6 weeks of being seen in the ED?

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: AHLTA.

      2. (ii)

        Document: cardiology or CT surgery appointment.

      3. (iii)

        Field: any subject encounter after 6 weeks will answer this question.

    6. (f)

      Alternate source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: SURG operative note, CT surgery POD, and Cath lab procedure note.

      3. (iii)

        Field: narrative.

  76. 76.

    STENT in 6 weeks:

    1. (a)

      Variable: revascularization within 6 weeks of ED presentation.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: did the subject have a CABG or stent placed within 6 weeks of being seen in the ED?

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: AHLTA.

      2. (ii)

        Document: cardiology or CT surgery appointment.

      3. (iii)

        Field: any subject encounter after 6 weeks will answer this question.

    6. (f)

      Alternate source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: SURG operative note, CT surgery POD, and Cath lab procedure note.

      3. (iii)

        Field: narrative.

  77. 77.

    MI in 6 weeks:

    1. (a)

      Variable: myocardial infarction (MI) within 6 weeks of ED presentation.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: did the subject have an MI within 6 weeks of being seen in the ED? If unable to determine will be listed as missing data.

    4. (d)

      Possible variables: yes, no

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: daily progress notes following admission.

      3. (iii)

        Field: narrative.

      4. (iv)

        Possible variables.

    6. (f)

      Alternative source:

      1. (i)

        Database: AHLTA.

      2. (ii)

        Document: subject encounter.

      3. (iii)

        Field: any subject encounter after 6 weeks should answer this question.

  78. 78.

    Aspirin 24 h:

    1. (a)

      Variable: aspirin use within the last 24 h.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: Aspirin within 24 h. This information can be found on the T-sheet in HAIMS. It is an option to circle under medications that reads “Aspirin within 24 h”. These data will be used to calculate a TIMI score. We acknowledge that in the original TIMI paper, the variable was aspirin within the last 7 days (refer to citation #13 in the protocol). However, for the purposes of this paper, if the chart indicated aspirin within 24 h, then “yes” will be entered as a data point.

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: screening: RN assessment or medications given.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: all T-sheets have a place under medications, where aspirin can be circled. The T-sheets for chest pain, syncope, and CPR actually have “Aspririn within 24 h”.

  79. 79.

    Severe angina:

    1. (a)

      Variable: severe angina, 2 or more episodes w/n 24 h.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: In the original TIMI paper, severe angina was described as 2 or more episodes of angina in 24 h (refer to citation #13 in the protocol). This will be difficult to assess directly on the chart review; however, there are many descriptors on the chest pain T-sheet that should allow us to approximate. One of the variables that can be circled is “intermittent”. This is a variable that is already being abstracted as part of this study. If the T-sheet in HAIMS indicates intermittent chest pain, we will conclude that the subject had at least two episodes of chest pain and meets the definition. Admittedly, if the chart indicates that symptoms started more than 24 h ago, we will have no way of knowing if the chart meets the 24 time constraint defined be TIMI. We freely admit that this is a limitation of our study.

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note, history, and physical.

      3. (iii)

        Field: screening RN assessment, history, and physical narrative.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: context.

  80. 80.

    Cardiac arrest:

    1. (a)

      Variable: cardiac arrest on admission.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: was the subject without a pulse on arrival to the ER or was cardiopulmonary resuscitation (CPR) in progress on arrival?

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: RN assessment.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet, Staff addendum.

      3. (iii)

        Field: if the title of the T-sheet is cardiopulmonary resuscitation, look no further. Otherwise, look under context or the narrative of the staff addendum.

  81. 81.

    Rales:

    1. (a)

      Variable: rales.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: rales sound like crackles when auscultating lungs on a pulmonary exam. It is a sign of fluid overload or heart failure.

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: crackles listed under the pulmonary exam, and JVD listed under cardiac.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: Rales under respirator, and JVD under neck.

  82. 82.

    JVD:

    1. (a)

      Variable: jugular venous distention.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: JVD is an abnormal distention of jugular veins in your neck. It is a sign of fluid or heart failure.

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note.

      3. (iii)

        Field: crackles listed under the pulmonary exam, and JVD listed under cardiac.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: rales under respirator, and JVD under neck.

  83. 83.

    Cardiogenic shock:

    1. (a)

      Variable: cardiogenic shock.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: cardiogenic shock will be defined as a systolic blood pressure of less than 90 mm mercury. This definition is taken from the 2014 AHA/ACC guidelines for the management of NSTEMI (refer to citation #12 in the protocol) which in turn references the SHOCK trial (refer to citation #14 in the protocol). While the SHOCK trial also used variables such as pulmonary wedge pressure and left ventricular ejection fraction, these variables would not be practical to include in a decision-making tool in the ED. They would also be very cumbersome to include on a chart review this large, if they were available at all.

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: Essentris.

      2. (ii)

        Document: ED nursing note, history and physical.

      3. (iii)

        Field: vital signs.

    6. (f)

      Alternative source:

      1. (i)

        Database: HAIMS.

      2. (ii)

        Document: T-sheet.

      3. (iii)

        Field: vital signs.

  84. 84

    Follow-up in heart score clinic (only prospective data):

    1. (a)

      Variable: follow-up.

    2. (b)

      Format: nominal (yes, no).

    3. (c)

      Definition: did the patient follow-up in the HEART score clinic?

    4. (d)

      Possible variables: yes, no.

    5. (e)

      Source:

      1. (i)

        Database: AHLTA.

      2. (ii)

        Document: specialty care clinic.

      3. (iii)

        Field: clinic name under the previous encounters tab in AHLTA.

      4. (iv)

        The HEART score clinic in AHLTA is called “specialty care clinic” in AHLTA. If a subject has: 1. been seen in the ED for a chief complaint of chest pain and 2. been discharged and then has a subsequent encounter in the 3. “specialty care clinic”, investigate further. This is most likely a HEART score clinic follow-up.

    6. (f)

      Alternative source: none.

  85. 85.

    Days from the initial ED visit to follow-up? (only prospective data)

    1. (a)

      Variable: days from the initial ED visit to follow-up.

    2. (b)

      Format: continuous (1, 2, 3, 4, 5, 6…..).

    3. (c)

      Definition: days to follow-up after being seen in ED for chest pain.

    4. (d)

      Possible variables: 1–60.

    5. (e)

      Source:

      1. (i)

        Database: AHLTA.

      2. (ii)

        Document: specialty care clinic.

      3. (iii)

        Field: date, count the days from initial encounter. Consider the first recoded date. Use ED_Date in column B to make this calculation.

    6. (f)

      Alternative source: none.

The following ECG diagnoses are provided to help abstractors identify hand written diagnosis found on HAIMS database. This list was taken from the “ACC/AHA Clinical Competence Statement on Electrocardiography” published in the Journal of American College of Cardiology in 2001. As of the start of this study, this is their most recent update. The intention of said publication was to “Detail the minimum knowledge necessary to demonstrate competent 12 lead ECG interpretations.” At the top of the list, you will find a link to a website with an example of each ECG diagnosis listed. This research project is no way related and has no financial relationship to said website or the University of Utah School of Medicine.

http://ecg.utah.edu/acc_aha

  1. 1.

    Normal ECG or normal sinus rhythm (NSR).

  2. 2.

    Sinus bradycardia.

  3. 3.

    Sinus arrhythmia.

  4. 4.

    Sinus arrest or pause.

  5. 5.

    Sino-atrial exit block.

  6. 6.

    Premature atrial contraction (PAC).

  7. 7.

    Ectopic atrial rhythm.

  8. 8.

    Multifocal atrial rhythm or tachycardia (MAT).

  9. 9.

    Atrial fibrillation.

  10. 10.

    Atrial flutter.

  11. 11.

    Junctional escape rhythm.

  12. 12.

    Junctional tachycardia.

  13. 13.

    Paroxysmal supraventricular tachycardia.

  14. 14.

    Premature ventricular contractions (PVCs).

  15. 15.

    Accelerated ventricular rhythm.

  16. -

    Uniform.

  17. -

    Polymorphous.

  18. -

    Torsades.

  19. 16.

    Ventricular fibrillation.

  20. 17.

    Ventricular escape rhythm.

  21. 18.

    First degree atrio-ventricular (AV) block.

  22. 19.

    Second degree type 1 AV block; aka Wenchebach; and aka Mobitz type 1.

  23. 20.

    Second degree type 2 AV block and aka Mobitz 2

  24. 21.

    Third degree AV block.

  25. 22.

    Complete bundle branch block (BBB).

  26. 23.

    Incomplete BBB.

  27. 24.

    Left anterior fascicular block (LAFB).

  28. 25.

    Left posterior fascicular block (LPFB).

  29. 26.

    Left ventricular hypertrophy (LVH).

  30. 27.

    Right ventricular hypertrophy (RVH).

  31. 28.

    ST elevation (STEMI).

  32. 29.

    ST depression.

  33. 30.

    T-wave inversions.

  34. 31.

    Hyperacute T-waves.

  35. 32.

    Prolonged QT.

  36. 33.

    Paced rhythm.

  37. 34.

    Sinus tachycardia.

Instructions for finding T-sheets (two options)

  1. 1.

    It may be easiest to walk down to the ED and pick up a physical copy of a T-sheet. A chest pain T-sheet can be found in any POD.

  2. 2.

    An electronic copy can be found on the L drive.

    • Step 1: go to start menu and select “computer”

    • Step 2: select ”L Drive”

    • Step 3: select “DEM admin—clerks”

    • Step 4: select “T-systems templates ICD-10 complaint”

    • Step 5: select any T-sheet you want, but “33 Chest Pain” would be most helpful.

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Streitz, M.J., Oliver, J.J., Hyams, J.M. et al. A retrospective external validation study of the HEART score among patients presenting to the emergency department with chest pain. Intern Emerg Med 13, 727–748 (2018). https://doi.org/10.1007/s11739-017-1743-4

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  • DOI: https://doi.org/10.1007/s11739-017-1743-4

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