EKG at triage slashes door-to-aspirin time

Chest pain process not without snags

The ED staff at Contra Costa Regional Medical Center (CCRMC) in Martinez, CA, has slashed its time to aspirin for chest pain patients from 67 minutes to about eight minutes by completely revamping its triage process.

In the past, the patient would be seen by a nurse, says Steven Tremain, MD, CCRMC's director of system redesign and senior medical director. "They would describe their pain, the nurse would look at our set of criteria, and if they looked like a cardiac case, they would be admitted to a high-profile bed in the ED where the whole rule-out MI [myocardial infarction] process would be started," Tremain says. "We redid the process so that every patient gets an EKG [electrocardiogram] right in triage, and if not contraindicated, they all get aspirin."

The change started in late 2005, when CCRMC began participating in the Boston-based Institute for Healthcare Improvement's (IHI) "100,000 Lives" campaign, a nationwide quality improvement initiative. (See resource at bottom of article). "Even before IHI, we had been concerned with our triage delays in getting patients with chest pain evaluated, and specifically, we had always fought a battle about prioritizing seemingly low-acuity chest pain vs. high-acuity chest pain," says David Goldstein, chief of staff for the ED." They had a lot of difficulty creating reasonable expectations for the nurses who were doing triage, so they ended up with very unpredictable and nurse-dependent information, Goldstein says.

Tremain adds, "What we learned is that it's very hard to predict which chest pain is [myocardial infarction] and which is not."

When the hospital joined the IHI campaign, administrators decided to take another look at this issue, says Goldstein.

Dissecting the process

The ED staff began by "taking apart" the triage process, Goldstein recalls.

"We realized we had unrealistic expectations of nurses at triage to differentiate chest pain patients that we [the physicians] ourselves had trouble differentiating when we saw them," he says. "We realized we were putting the cart before the horse, and that a uniform practice would be better than attempting to get nurses to do something that probably was not even possible: differentiating very sick people vs. those who were not so sick."

Goldstein had a gurney placed in the triage area, and every patient who presented with chest pain received an EKG and an aspirin at time of triage, unless they were allergic to aspirin. "All EKGs were then reviewed immediately by an ED physician," adds Goldstein. The rest, as they say, is history.

Goldstein concedes there are some downsides to the new protocol. "It has actually lengthened the triage process when you include all these chest pain patients, because we do a lot of EKGs on patients who previously might not have gotten one or been made a high priority," he notes. Getting an EKG probably takes only three to four minutes, says Goldstein, but it also requires more personnel. "You've got to pull a nurse or a medical assistant from the ED to do it; but since we would have done those an hour later anyway, our only real limitation is space," he says.

"In addition, we don't know yet whether we are making a difference in terms of thrombolytic [clot-buster] timing," says Goldstein. "Our assumption is that it will, but we have not seen enough cases yet to do a study." He believes, however, that the new process is making a difference there as well, "and we know that should improve outcomes."

As with any such process change, Goldstein says, the biggest barrier is to change physician practice. "In fact, the biggest challenge that still remains for us are the physicians," he says. "They are resistant to the idea that patients they perceive as having low acuity chest pain get a higher-acuity evaluation and are maintained as such."

CCRMC uses a five-level triage system. Chest pain patients are classified as Triage I until the EKG is studied and the ED physician is certain they do not need thrombolytics. "But we still maintain them at a Level 2 until they are seen by a physician," says Goldstein, although he asserts they still are brought back for treatment much more quickly on a consistent basis than they otherwise might have been.

How does he handle the negative feedback from physicians? "You re-explain to them every time you do an EKG why it is you are doing it," he says. "When we can show our time to thrombolytics has significantly improved, that will be the proof of the pudding — that we have brought about a big quality change."


For more information on using EKG in triage for chest pain patients, contact:

  • David Goldstein, MD, Chief, Emergency Department, Contra Costa Regional Medical Center, Martinez, CA. Phone: (925) 370-5973.
  • Steven Tremain, MD, Director of System Redesign and Senior Medical Director, Contra Costa Regional Medical Center, Martinez, CA. Phone: (925) 370-5100.

For more information about the "100,000 Lives" campaign, go to the web site, www.ihi.org/ihi and click on the "100,000 Lives" logo.