View source for Harbor:Stress Testing

* '''OOP''' - refer back to in-network PCP for cardio workup

* '''DHS empaneled''' - if low risk, message PCP for further cardio workup or schedule for stress test (typically doing CCTA)
** The 2021 ACC Chest Pain Guidelines [https://www.ahajournals.org/doi/10.1161/CIR.0000000000001030 2021 ACC Chest Pain Testing Guidelines (section 4)]
*** [https://www.ahajournals.org/cms/asset/5a965b34-e797-45ed-87a8-f4b71f4dbd6f/cir.0000000000001030.fig08.jpg 2021 AHA ED Chest Pain Testing Algorithm]

* DHS Eligible
** '''Low risk (HEART score <3, consider<4)''' - ensure patient goes to Registration Window 6 to finish the Medical application/empanelment process
** Intermediate to high risk, admit to CORE for further eval (typically CCTA, sometimes nuc test)
** On the rare occasion you sill feel the need to order the '''CV Treadmill Stress Test''', the order goes to the Heart station and they will schedule the patient.  It is not done by the ED clerk or ED PAC.  
*** Remember, patients should be able to ambulate independently without a cane or walker for about 2 blocks, and make sure the EKG does not have resting ST abnormalities, LBBB, pacing or WPW


**** If they do not meet these criteria, consult cardiology to determine the best option
*** If the stress test is abnormal, Cardiology will arrange f/up for the patient

** 3 - Place order for '''"CV Treadmill Stress Test"'''
*** Reason for procedure "Chest Pain"
*** '''Special Instructions "Schedule in 3-4 business days"''' 
*** Outpatient P-MIBI Nuclear stress has to be arranged by CORE
** 4 - In DEPART section, click '''"Schedule Follow-up Appointment"''' so clerk makes appointment prior to patient DC
*** If the COVID test is positive, the Cardiology fellow/attending at the Heart Station will call the patient to discuss 
**** 1 - COVID symptoms
***** If asymptomatic for >10 days (or >20 days if severe COVID disease or immunocompromised), the appointment will stand
***** If symptomatic, the appointment will be canceled and the Cardiology fellow/attending at the Heart Station will message the empaneled PCP to ensure close follow-up
**** 2 - Cardiac Symptoms
***** The Cardiology fellow/attending at the Heart Station will call the patient to further risk stratify
****** If deemed high risk, Cardiology will schedule an alternate non-AGP stress test
****** If deemed low-risk, stress testing will be deferred to the PCP for follow up
**'''If test is abnormal, cardiology follow up automatically generated by HEART station.''' 
**If test is normal, no notification occurs, other than typical follow up. If you want someone to follow up on the result, consider messaging empaneled PCP or refer to CCC.


* '''DHS Eligible without assigned PCP'''
** 1 - '''Ensure patient is ambulatory'''(walk 2 blocks); if not able to complete a treadmill stress test, consult cardiology to determine best option
** 2 - Send COVID test  via "'''AMB Pre-surgical/Procedure Coronavirus COVID-19 Screening'''" order
*** Select "nasopharyngeal" then modify order
**** Change order for '''future visit to "no"'''
**** Change '''collection priority to "STAT"'''
** 3 - Place order for "CV Treadmill Stress Test"
*** Reason for procedure "Chest Pain"
*** '''Special Instructions "Schedule in 3-4 business days"''' 
*** Outpatient P-MIBI Nuclear stress has to be arranged by CORE
** 4 - In DEPART section
*** '''***CCC for NERF***''' (get a PCP assigned)
*** Click '''"Schedule Follow-up Appointment"''' so clerk makes appointment prior to patient DC
** If the COVID test is positive, the Cardiology fellow/attending at the Heart Station will call the patient to discuss 
*** 1 - COVID symptoms
**** If asymptomatic for >10 days (or >20 days if severe COVID disease or immunocompromised), the appointment will stand
**** If symptomatic, the appointment will be canceled and the Cardiology fellow/attending at the Heart Station will message the empaneled PCP to ensure close follow-up
*** 2 - Cardiac Symptoms
**** The Cardiology fellow/attending at the Heart Station will call the patient to further risk stratify
***** If deemed high risk, Cardiology will schedule an alternate non-AGP stress test
***** If deemed low-risk, stress testing will be deferred to CCC for follow up
**'''If test is abnormal, cardiology follow up automatically generated by HEART station.''' 
**If test is normal, no notification occurs, other than typical follow up. If you want someone to follow up on the result, consider messaging empaneled PCP or refer to CCC.


Drs. Chappell, Shah, & Pillutla 8/19/2020

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