Don't let ED overcrowding put AMI, pneumonia patients at risk

Emergency nurses 'can provide better care'

(Editor's note: This is a special issue covering delays in clinical care as a result of ED overcrowding. This month, we cover pneumonia and acute myocardial infarction patients that aren't receiving timely interventions, a rapid triage system that ensures patients aren't harmed due to crowded waiting rooms, and ways to ensure that patients in severe pain don't wait for relief.)

Would you be shocked to learn that a large number of patients with acute myocardial infarction (AMI) and pneumonia are dying because certain interventions aren't done in the ED? That's what a new study suggests, with researchers estimating that poor care in EDs causes 22,000 needless deaths each year.1

Of 1,492 heart attack patients at 544 EDs from 1998 to 2004, only 40% received aspirin therapy and 17% received beta-blockers. Of 3,955 pneumonia patients, 69% received antibiotics as recommended, and 46% had blood oxygen levels assessed. All of these interventions are required by The Joint Commission and the Centers for Medicare & Medicaid Services.

"The system, which ED nurses and physicians are working within, can provide better care for our heart attack and pneumonia patients," says Julius Pham, MD, the study's principal investigator and assistant professor of medicine in the Johns Hopkins Department of Emergency Medicine in Baltimore.

ED nurses should act as a "check and balance" to physicians to be sure patients receive the most appropriate treatment, says Pham. "Nurses can take the lead in developing protocols where every patient with a heart attack will receive aspirin and beta blockers, unless contraindicated," he says. Likewise, protocols should be used to ensure that pneumonia patients receive oxygen assessment and antibiotics, adds Pham.

At the University of California — Los Angeles (UCLA) Medical Center, ED nurses use protocols for AMI and pneumonia patients that require specific medications and interventions, says Johanna Bruner, MS, RN, FNP, director of the Emergency Medicine Center. "We constantly review the protocols for compliance with core measures guidelines and post results for all to review."

Another study found that prolonged ED stays for patients with non-ST segment elevation MI are linked to increased adverse events and worse adherence to American College of Cardiology/American Heart Association guidelines.2 Researchers looked at 42,780 patients and found that patients with long stays received recommended therapies less often.

The key issue for ED nurses is to facilitate the transition to inpatient orders as soon as possible, says Deborah B. Diercks, MD, the study's lead author and assistant professor in the Department of Emergency Medicine at University of California — Davis Medical Center in Sacramento. "Since the ED has little control over when admitted patients receive an inpatient bed, we need to be sure to initiate appropriate therapy in the emergency department," she says.

Fewer antibiotics given

When ED waiting rooms are crowded, pneumonia patients wait longer for antibiotics, sometimes to the point where they do not receive them at all, according to two new studies.3,4

Christopher Fee, MD, lead author of one of the studies and assistant clinical professor in the Division of Emergency Medicine at University of California, San Francisco, says, "I think the time to antibiotics is a good surrogate marker for quality of care, since other processes of care are likely to be affected in a similar manner when the ED becomes crowded."

The researchers expected to find that time-to-antibiotics was delayed at a certain threshold, which would indicate that staff had become overwhelmed, says Fee. "What surprised us was that we were unable to find convincing evidence that any such threshold existed," he says. "It actually looks just as plausible that even at low ED patient volumes, the addition of one more patient led to a delay in antibiotic administration."

The take-home message for ED nurses: Don't be complacent even if the ED is relatively empty, says Fee. "It is apparent that even during those times, each additional patient leads to delays in antibiotic administration for pneumonia patients and is likely to cause similar delays for other interventions in other patients," he says.

The study shows that EDs have very little "buffer zone" to accommodate additional patients, says Fee. "Nurses can help by anticipating the need for [intravenous] access, labs, chest X-rays, and blood cultures," he says. "Protocols should be used to expedite these steps."

Don't hesitate to ask ED physicians if a patient is going to need antibiotics, says Fee. "This may serve as a reminder to a busy physician to check on lab results and X-rays, and stimulate them to write the order that they haven't yet done," he says.

ED nurses at University of California Irvine Medical Center follow a protocol for community-acquired pneumonia based on guidelines from the Infectious Diseases Society of America and the American Thoracic Society. (See ED protocol. To access the guidelines, see resource information at the end of this article.)

The algorithm addresses care and antibiotic selection for patients treated and discharged from the ED, as well as patients admitted from the ED to the medical floor or intensive care unit, says Tania V. Bridgeman, PhD, RN, director of clinical path development for the Department of Emergency Medicine.

"The algorithm is accessible on the ED computer greaseboard and is printed off and placed on the patient's chart," she says. Here are steps taken by ED nurses:

— At triage, nurses initiate orders including chest X-ray, gram stain of sputum, blood cultures for temperature greater than 38° C, and a complete blood count.

— Antibiotics are administered prior to discharge from the ED.

— If the patient meets inpatient criteria, antibiotics are to be administered within six hours of presentation, with the first dose given in the ED.

— A risk score is determined, with abnormal lab findings given a numeric value, such as a score of 10 for pleural effusion. "This helps nurses to decide the level of care necessary," says Bridgeman.

Because the ED nurse can order labs and diagnostic tests at triage, a faster diagnosis is possible, she says. The algorithm reduces the chance of inappropriate administration of an antibiotic and reduces the time to drug administration, Bridgeman says. "The ED nurse basically drives the utilization of the algorithm, which serves as an evidence-based guideline to all staff and residents," she says.

The protocol reminds nurses to give antibiotics within a six-hour time frame, which is difficult with a full ED and a pending diagnosis, says Bridgeman. "ED nurses are continuously reminded of the time constraints and do their best to meet the six-hour-or-less timeframe," she says. "To date, there has not been inappropriate administration of an antibiotic."

At UCLA Medical Center, antibiotics are given based on the patient's presentation and symptoms if pneumonia is diagnosed on a chest X-ray, says Bruner. "We will do blood tests as well, but we want to get those medications in under a four-hour time period, and we will expedite care to do this for the sake of the patient," she says.

The ED's performance improvement committee, comprised of nurses and a physician, reviews results of audited charts for core measure compliance and identifies areas in need of improvement, adds Bruner. "Then we educate to ensure compliance and good patient care," she says.


1. Pham JC, Kelen GD, Pronovost PJ. National study on the quality of emergency department care in the treatment of acute myocardial infarction and pneumonia. Acad Emerg Med 2007; 14:856-863.

2. DB Diercks, MT Roe, AY Chen, et al. Prolonged emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association Guidelines for Management and increased adverse events. Ann Emerg Med 2007; 50:489-496.

3. Fee C, Weber EJ, Maak CA, et al. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med 2007; 50:501-509.

4. Pines JM, Localio AR, Hollander JE, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med 2007; 50:510-516.


For more information about improving care of acute myocardial infarction and pneumonia patients, contact:

  • Tania V. Bridgeman, PhD, RN, Director of Clinical Path Development, Department of Emergency Medicine, University of California Irvine Medical Center, Orange, CA. Phone: (714) 456-3697. E-mail:
  • Johanna Bruner, MS, RN, FNP, Director, Emergency Medicine Center, University of California — Los Angeles Medical Center, Los Angeles. Phone: (310) 206-2447. E-mail:
  • Deborah B. Diercks, MD, Assistant Professor, Department of Emergency Medicine, University of California — Davis Medical Center, Sacramento, CA. Phone: (916) 734-4052. Fax: (916) 762-8851. E-mail:
  • Christopher Fee, MD, Assistant Clinical Professor of Medicine, Division of Emergency Medicine, University of California — San Francisco, San Francisco. Phone: (415) 353-1634. Fax: (415) 353-1799. E-mail:
  • Julius Cuong Pham, MD, Assistant Professor of Medicine, Johns Hopkins Department of Emergency Medicine, Baltimore. E-mail:

A PDF file of the 2007 Infection Disease Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults can be accessed at no charge at the American Thoracic Society's web site ( Under "Education," click on "ATS Documents: Statements, Guidelines & Reports," and then "IDSA/ATS Community Acquired Pneumonia Guidelines."