Treatment under 30 minutes boosts odds for MI patients
Treatment under 30 minutes boosts odds for MI patients
If door-to-needle time is under 30 minutes in your ED, your heart attack patient has a better chance of surviving, says a new study.1
Researchers looked at 62,470 patients with ST-segment elevation myocardial infarction (STEMI) treated using fibrinolytic therapy at 973 hospitals that participated in the National Registry of Myocardial Infarction from 1999 to 2002. They found that mortality rates were lower with shorter door-to-needle times (2.9% for 30 minutes or less, 4.1% for 31-45 minutes, and 6.2% for more than 45 minutes).
To reduce door-to-needle times in your ED, do the following:
• Obtain electrocardiogram (EKG) results before the patient arrives.
At University of Colorado Hospital in Denver, ED nurses can take action more quickly because patients who arrive by ambulance have an EKG done before arriving at the ED.
"If there is ST-segment elevation, we are alerted, putting patients in a better position for rapid ED response," says Lorna K. Prutzman, RN, MSN, director of emergency/stroke services. Immediately after a "cardiac alert" is received, the ED charge nurse notifies the interventional cardiac team, and the STEMI is confirmed with a stat EKG upon the patient's arrival.
If the patients are candidates for the cardiac catheterization lab, they are immediately transported. "By this time, the interventional team has responded to the ED, and they accompany the patient to the cath lab," she says. "Our departments' best performance is 10 minutes from door to cath lab."
Instead of door-to-needle time, the ED tracks door-to-balloon time, because this marks the time oxygenation is restored to the cardiac muscle, says Prutzman. "If the patient arrives at the cath lab in 10 minutes, a noncomplicated case can have a door-to-balloon time of 40 minutes," she says. "The same alert process is put into play for ambulatory patient arrivals with chest pain. However, the response is slightly slower without the pre-hospital warning."
At Emory University Hospital in Atlanta, ED nurses use the same process to decrease door to balloon times and activate the cath lab team based on the pre-hospital EKG. "When we identify a patient with a STEMI, we use a one-call process to activate the team," says Samuel Shartar, RN, CEN, ED nurse manager. "During business hours, the ED charge nurse directly contacts the cath lab charge nurse to expedite patient transfer."
• Identify patients without delay.
ED nurses must rapidly identify patients with possible symptoms of acute coronary syndrome, both typical and atypical, says Jenny C. Underwood, RN, BSN, CCRN, acute myocardial infarction coordinator at Duke Health System in Durham, NC. "This is key to decreasing door-to-balloon times for patients with STEMI."
At Duke University Medical Center, ED nurses rapidly obtain a 12-lead ECG and work with the ED physician on identifying ST elevation and activating the "AMI Hotline" team of cardiac cath lab personnel. "Patients do not receive lytics, as we have primary PCI [percutaneous coronary intervention] capabilities," she says.
If you don't have a pre-hospital diagnostic EKG, your first and most important step is to obtain a rapid EKG within the first 10 minutes of the patient's arrival, says Shartar. "This is the decision point to diagnose STEMI and activate the cath lab team," he says.
• Perform timesaving steps.
While your patient is being stabilized, do the following, says Shartar: Perform clipper preparation of the groins. Apply defibrillation pads and a portable cardiac monitor/defibrillator to the patient. Ensure there is a full oxygen tank on the stretcher.
"All of these steps help to reduce transportation delays, which contributes to reducing time from the ED to the cath lab. This translates into reduced door-to-balloon or needle times," says Shartar.
Reference
- McNamara RL, Herrin J, Wang Y, et al. Impact of delay in door-to-needle time on mortality in patients with ST-segment elevation myocardial infarction. Am J Cardiol 2007; 100:1,227-1,232.
Resource
An operations manual developed by the Reperfusion in Acute MI in Carolina Emergency Departments (RACE) project is available at no charge on the North Carolina Chapter of the American College of Cardiology's web site (www.nccacc.org). Click on "Click here for more information about RACE and to read the new press releases." Scroll down to "Optimal System Specification by Point of Care Operations Manual" and click on "Download PDF."
If door-to-needle time is under 30 minutes in your ED, your heart attack patient has a better chance of surviving, says a new study.Subscribe Now for Access
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