The biggest recent change in the emergency department (ED) management of acute coronary symdrome patients is the increased use of glycoprotein IIb/IIIa inhibitors, says Marli Bennewitz, RN, BSN, chest pain coordinator at St. Jude Medical Center in Fullerton, CA. "You should be familiar with the inclusion and exclusion criteria for this medication and appropriate dosing," Bennewitz emphasizes.
The changes made in March 2002 to the American College of Cardiology/American Heart Association guidelines for unstable angina and non-ST elevation MI (UA and NSTEMI) reflect evidence that shows some medications and interventions are more effective than others, says Sara Grant, RN, BSN, CEN, nurse clinician for the emergency and outpatient departments at West Allis (WI) Memorial Hospital. (For more information about the guidelines, see "New cardiac guidelines will impact your care: How will your practice change?" ED Nursing, August 2002, p. 129.)
For example, the use of antiplatelet therapy is now recommended along with aspirin for all of these patients, regardless of whether there is going to be percutaneous intervention, says Grant. The updated guidelines now recommend use of antithrombin drugs and/or glycoprotein IIb/IIIa inhibitors, says Grant. "So these have the potential to become complex and challenging therapies for nurses to manage," she adds. She notes that thrombolytics are not recommended in treating these patients.
Grant points to the guiding precept of "time is muscle" in emergency cardiac care. "A clear understanding of the drugs and their actions and being comfortable in their administration is key," she says. Here are ways to ensure that current recommendations for medications are followed in your ED:
• Make sure there is easy access to medications. There must be easy access to cardiac drugs to avoid delays in administration, says Grant. "For example, we did not stock clopidogrel in our medication dispensing cabinet because we considered it an inpatient drug," she says. "But we recently added it for ease and speed of retrieval when treating our patients with any of the acute coronary syndromes."
• Consult experts at your facility. Grant recommends partnerships with clinical pharmacy staff, ED physicians, and cardiology staff to create the documents and pathways to support best practices in your ED. "These individuals can also assist in inservicing ED nurses about the newer drugs and interventions," she says.
• Update protocols to include use of newer medications. At Gwinnett Hospital System, enoxaparin is included in the ED’s protocol for unstable angina. "We are one of the only hospitals in Georgia to be using enoxaparin for acute myocardial infarctions and unstable angina," reports Sandy Vecellio, RN, BSN, ED clinician at Gwinnett Medical Center in Lawrenceville, GA. "Most hospitals are still using heparin." (See the facility’s Acute Myocardial Infarction — Non-Thrombolytic/Unstable Angina Orders: click here.)
Vecellio says that short- and long-term outcomes were the same with the use of enoxaparin instead of heparin. "Our physicians and the cardiologists got on board with this protocol quickly, partly because we participated in the Assent III trial that showed these outcomes," she says.1 "The nurses gave this drug combination in the trial; so then when we implemented it, it was a smooth transition," adds Vecellio.
The use of enoxaparin makes the nurse’s job easier for drug administration, says Vecellio. "There is less room for error because you do not have to figure drip rates, and the nurse is freed up to attend to the patient’s needs," she says.
• Use a chest pain coordinator. As chest pain coordinator, Bennewitz is responsible for the quality of care patients receive and also acts as a resource at the bedside in the ED. "I develop all the standing-order sheets, protocols, policies and procedures, and track our outcomes," she says. "Since 1995, we have added to our repertoire in the ED continuous ST monitoring, 15-lead electrocardiograms, and troponin testing."
• Ask drug reps to provide inservices for nurses. A drug representative gave numerous inservices to the staff on enoxaparin and the safety and efficacy of the drug, says Vecellio. The staff were supplied with green armbands that state that the patient has been given enoxaparin. "If we transfer a patient to another facility, they will see at a glance that enoxaparin was given," says Vecellio. "It is another patient safety feature, since there is no drip hanging."
Vicki Cadwell, RN, MS, CEN, CCRN, the ED clinical educator at Saint Jude, says that ED nurses have benefited from the support of the drug reps who always are willing to provide inservices. "I use my drug reps a lot. Most of them are very willing to come in to provide inservices to nursing staff, and I have good relationships with them," she says.
However, Cadwell notes the ED has a very stringent vendor policy, and reps are not allowed to just "drop in" to visit the physicians. "We find that that really can disrupt a unit," she says. "They must have an appointment with either myself or our director in order to come into the ED."
Cadwell says that the reps come to the ED with the understanding that they will be educating the nursing department. "If a physician happens to be free to discuss the product, that is an added bonus," she says. "The ones that I work most closely with do not use nursing to gain access to the physicians. They truly believe in the importance of nurses knowing about the product."
1. The Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 Investigators. Efficacy and safety of tenecteplase in combination with enoxaparin, abciximab, or unfractionated heparin: The ASSENT-3 randomized trial in acute myocardial infarction. Lancet 2001; 358:605-613.
For more information about medications for acute coronary syndromes, contact:
• Marli Bennewitz, RN, BSN, Chest Pain Center Coordinator, St. Jude Medical Center, 101 E. Valencia Mesa Drive, Fullerton, CA 92832. Telephone: (714) 992-3000, ext. 3463. Fax: (714) 992-3109. E-mail: MBENNEWI@sjf.stjoe.org.
• Vicki Cadwell, RN, MS, CEN, CCRN, Clinical Educator, Emergency Department, Saint Jude Medical Center, 101 E. Valencia Mesa, Fullerton, CA 92835. Telephone: (714) 992-3979. Fax: (714) 447-6415. E-mail: firstname.lastname@example.org.
• Sara Grant, RN, BSN, CEN, Nurse Clinician for the Emergency and Outpatient Departments, West Allis Memorial Hospital, 8901 W. Lincoln Ave., West Allis, WI 53227. Telephone: (414) 328-6154. Fax: (414) 328-8584. E-mail: email@example.com.
• Sandy Vecellio, RN, BSN, Gwinnett Medical Center, 1000 Medical Center Blvd., Lawrenceville, GA 30046. Telephone: (678) 442-3243. Fax: (678) 442-4531. E-mail: SVecellio@promina.org.