A&E OBSERVATION WARD MULTIDISCIPLINARY CLERKING PROFORMA
NON-TRAUMATIC CHEST PAIN
Patient Name:
Date
Time of arrival
Unit Number:
Known Allergies:
Obs Ward management OR A&E?
Inclusion criteria (for Obs
Ward)

Episode of chest pain, which has now resolved which is possibly cardiac in
origin with a non-diagnostic ECG and no other diagnosis is apparent.
Exclusion criteria
(manage in A&E and refer
appropriately if any apply)







Any ECG changes consistent with ischaemia/infarction
Haemodynamic instability (dysrhythmia or hypotension)
Known history of IHD on anti-anginal treatment
Currently under active Cardiology follow-up
Obvious history suggestive of alternative diagnosis (Pneumothorax, PE)
Persisting pain
Social Circumstances prevent discharge within 24 hours
Initial assessment
Time
Pulse
Blood
Pressure
RR
O2 Sat
Temp
.
GCS
EWS
Pain score on arrival
Next of Kin details
………………………
Pain assessment
0
2
4
6
8
10
________________________________________________
no pain
worst pain imaginable
This patient can be managed in:
………………………
………………………
Obs Ward
If unable to send patient to Obs Ward please document why (e.g. no space, patient
too ill etc…):
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Chest Pain to exclude Acute Cardiac Ischaemia (ACI)
Management in A&E
Assessment by Doctor.
Review history, examination and ECG.
Check inclusion / exclusion criteria and chest pain pathway
Investigations in A&E: Observations and ECG
Management on Obs Ward
ONLY PATIENTS WITH NORMAL ECG AND WHO ARE PAIN FREE ARE TO BE ADMITTED
TO A&E OBS WARD.
IV access and aspirin.
FOLLOW THE PATHWAY OVERLEAF
Once the low risk patients are on A&E Obs Ward investigate as per the pathway. (Overleaf)
Criteria for Discharge
Cardiac markers normal
No change in ECGs
No further pain
Follow up arranged (GP or cardiology)
Criteria for Admission (at any time)
Recurrent pain suggestive of ACS
ECG changes suggestive of ACS
Cardiac marker abnormalities suggesting ACS (Troponin-I normal range <0.04 g/l)
Criteria for Admission (final review)
Any of the above
Alternative diagnosis and further tests required
Social circumstances.
Obs Ward – chest pain investigation pathway
Presents within 0-12 hours of
Chest Pain
Patients with chest pain >12
hours ago
Investigations
Investigations
On admission:
FBC/U&E/Glucose
ECG (1 hour after A&E ECG
minimum)
On admission
FBC/U&E/Glucose/Troponin
ECG
4 Hours post admission
ECG
12 hours post chest pain
Troponin
ECG
DISCHARGE IF:
Cardiac Markers are normal
No ECG Changes
No Further Chest Pain
ADMIT IF
FURTHER EPISODES OF CHEST PAIN
ANY ECG CHANGES
POSITIVE CARDIAC MARKERS
Guidelines for final assessment of probability of Ischaemic Heart Disease (IHD)
Following a negative Troponin patients should be categorised according to probability of stable IHD.
Low Probability
No indication for further follow-up. Can be discharged to GP.
Medium Probability
Require cardiology follow-up with Exercise testing, but this is not urgent.
Refer to Rapid Access Chest Pain Clinic and will aim to be seen within 4
weeks.
Start aspirin 75mg daily.
High Probability
Require urgent cardiology follow-up and Exercise testing.
Refer to Rapid Access Chest pain Clinic and will aim to be seen within 2
weeks.
Start aspirin 75mg daily and Bisoprolol 10mg daily (if no contraindications)
Prescribe GTN spray for use PRN and advise to return if further pain
unrelieved by GTN.
Referrals to Rapid Access Chest Pain Clinic should be made using the attached form. This should be
faxed to the Cardiology department for the attention ******
FAX No: ****
Patient’s Name:
Medical Notes
History presenting complaint
Past Medical History
Drug History
Risk Factors
ALLERGIES
Examination findings
Impression/Diagnosis
Management:
1.
2.
3.
4.
Signature
Print Name
Date
Time
Investigation results
Hb
WCC
Platelets
Na
K
Urea
Creatinine
Glucose
ECG (A&E) shows:
ECG (4 Hours) shows:
Date and
Time
Comments / notes
TROPONIN RESULT
ECG (1 Hour) shows:
ECG (final) shows:
Signature
Date and
Time
Comments / notes
Signature
Date and
Time
Comments / notes
Signature
A&E Observation Ward Discharge Summary
POSSIBLE CARDIAC CHEST PAIN
PATIENT NAME/
ADDRESSOGRAPH
GP Details:
Name
Address
ADDRESS
DATE OF BIRTH
Dear Dr
Your patient attended the Accident and Emergency Department at Calderdale Royal
Hospital with POSSIBLE CARDIAC CHEST PAIN.
Your patient was admitted and treated on the unit and was discharged after fulfilling the
discharge criteria below.
□ Cardiac markers (Troponin-I) were normal.
□ Serial ECGs were normal.
□ There was no further chest pain prior to discharge.
(Tick as appropriate),
□ Your patient has been referred to the rapid access chest pain clinic and will be sent an
appointment shortly.
□ Your patient has been advised to contact yourself or the Accident & Emergency
department at Calderdale Royal Hospital should there be any further problems.
Additional Comments
Thank You
Signed
Date
Name
Designation
CALDERDALE ROYAL HOSPITAL – CARDIOLOGY DEPARTMENT
RAPID ACCESS CHEST PAIN CLINIC
A&E OBSERVATION WARD REFERRAL FORM
PATIENT NAME:
REFERRAL DATE:
DATE OF BIRTH:
CONFIRMED APPOINTMENT DATE:
TIME :
REFERRING GP:
ADDRESS:
TEL:
WHEN WAS PAIN 1st NOTICED BY PT?
< 1 week ___
< 3 month ___
SURGERY:
HOW OFTEN DOES PAIN OCCUR?
Only 1 episode ___
Once a day ___
Several times a day ___ Several times a week ___
Less than above ___
< 1 month
> 3 months ___
HOW LONG DOES PAIN LAST?
< 1 min ___
< 15 mins ___
DOES PAIN RADIATE?
< 5 mins ___
> 15 mins ___
Left Arm ___
Right Arm ___
IS PAIN BROUGHT ON BY EXERCISE?
Yes ___
Yes
Yes
Yes
Yes
Yes
___
___
___
___
___
No
No
No
No
No
No ___
Back ___
Throat / Neck ___
WHAT RELIEVES PAIN?
GTN Spray ___ Rest
___
Rubbing Chest ___ Nothing ___
No ___
HYPERTENSION ?
HIGH CHOLESTEROL?
FAMILY HISTORY IHD?
SMOKER?
DIABETIC?
Yes ___
___
___
___
___
___
CURRENT MEDICATION:
DOSE :
HAS PATIENT BEEN INVESTIGATED BY A
CARDIOLOGIST FOR THESE SYMPTOMS
BEFORE? Yes ___ No ___
(Please detail below)
Blood tests ordered?

Yes
No
Please order the following bloods - to be taken within 48 hrs so results available when patient attends
RACPC: FBC, Electrolytes, Creatinine, Thyroid Function, Fasting Glucose, Fasting Lipids.
Fax this form along with ECGs to the Cardiology Department on 01484 347182.
Ensure copies of this pathway and A&E Notes are sent to the Cardiology department ASAP.

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
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Please indicate the probability of ischaemic Heart Disease based on clinical assessment:
High
Moderate
PATIENT INFORMATION
You have been admitted to the Accident and Emergency
Observation Ward at Calderdale Royal Hospital with a diagnosis
of POSSIBLE CARDIAC CHEST PAIN.
Following a period of observation and specific investigations we
have ruled out a heart attack as the cause of your pain. (Please
note, we have not been able to clearly identify the cause of your
symptoms)
The doctor who discharged you from the unit may feel that
further investigation is necessary to completely exclude heart
disease. If this is the case you will have been informed about a
referral being made to the Cardiology Clinic. You should receive
an appointment regarding this in the next month.
If you have any further concerns please contact the Accident and
Emergency Department at Calderdale Royal Hospital 01422
222325.