Cut door-to-cath time dramatically in your ED

The steps you take can save a patient’s life

Twenty minutes after a man having a heart attack came through the door of Mercy General Hospital’s ED in Sacramento, CA, a balloon was inflated in the hospital’s cardiac catheterization lab. The man did well and was discharged home two days later, reports Becky Roberge, RN, the ED’s clinical nurse educator.

If ED nurses hadn’t acted quickly, the outcome could have been very different, including complications such as arrhythmias, heart failure, permanent heart damage, and possibly death, she says.

The key to success in this case was the ED nurse’s immediate response to the emergency medical services notification that they suspected an acute myocardial infarction (AMI), says Roberge. "The longer it takes to get reperfusion to the cardiac muscle, the more chance there is for cardiac muscle damage," she says.

ED nurses took the following steps immediately:

— The ED charge nurse notified the cardiac catheterization lab and paged the cardiologist.

— Nurses prepared a critical care treatment area.

— When the patient arrived, nurses immediately did an electrocardiogram (ECG), started an intravenous (IV) line, and drew the necessary labs. At the exact same time, the cardiologist met the patient in the ED. "The patient was transported to the cath lab five minutes after arriving," says Roberge.

All chest pain patients need to be treated as an AMI until proven otherwise, stresses Roberge. "Having a standard process in place for rapid assessment of these patients is key," she says. "This is a team effort, which requires collaboration from all involved."

The sooner a patient receives percutaneous coronary intervention (PCI) and blood flow is restored to the heart muscle, the less chance of permanent damage, says Marli Bennewitz, RN, chest pain center/cardiac wellness coordinator. "Time is muscle," she says. "Patients who do not have timely interventions are at a greater risk of developing heart failure in the future."

Here are steps taken by EDs to reduce door-to-cath lab time:

• EKGs are done at triage or before.

As an ED nurse, you must expedite the initial assessment of all chest pain patients to determine if they are having an AMI, says Roberge. "This means that the ECG is acquired and presented to the physician within 10 minutes," she says.

Through monthly audits of charts, nurses discovered that a lot of door-to-ECG delays were due to not actually having a physical space to do the ECGs, especially during high census times, says Page West, RN, CCRN, MHA, director of Mercy General’s ED.

The ED purchased a dedicated ECG machine for triage and a reclining chair. "The month before we implemented ECGs in triage, our average door-to-ECG times for our chest pain patients was 11 minutes," she says. "Six months later, it had decreased to 2.8 minutes."

At St. Jude Medical Center in Fullerton, CA, high-quality ECGs are faxed to the ED before the patient even arrives, resulting in door-to-balloon times of under 60 minutes for all AMI patients, reports Bennewitz. "We have been able to reduce the time to PCI from the recommended time of 90-120 minutes to 60 minutes or below," she says.

When the ED nurse receives a report from the field that the paramedics have a diagnostic ECG of an AMI, two things are done: The cath lab is immediately notified, and the ED physician calls in the cardiologist, says Bennewitz. "All this occurs before the patient has arrived in the ED," she says. "At night when the cath lab is closed, the nurse calls in the cath lab staff as soon as they are notified of a diagnostic ECG."

At Mercy General, ED nurses have "developed trust with the EMS personnel," says Roberge. "They know that when they bring a suspected AMI patient to our ED, we immediately act on their field assessment."

• Cardiologists and cath lab are notified simultaneously.

Once you know the patient is having an AMI, valuable minutes can be saved by paging the on-call cardiologist and cath lab at the same time, says Roberge. Also, initial treatment is begun immediately, such as starting the IV, drawing labs, and giving aspirin, she says. Then, the nurse prepares the patient for transport to the cath lab.

By alerting the cath lab in advance, nonemergent cases can be held, Roberge explains. "This way, we have a cath lab suite available as soon as the cardiologist has made the decision to take the patient," she says.

• Clinical nurse educators share statistics with ED nurses.

A bulletin board posts monthly statistics so ED nurses can see the difference their actions make, says Roberge.

"We also created an AMI Newsletter that is distributed to both the cath lab and ED staff," she says. The newsletter lists current statistics, upcoming events, patient success stories, and a column with staff questions answered by Roberge and the hospital’s manager of cardiovascular research.

• An "ECG award" is given.

The award recognizes Mercy General’s ED nurses on a monthly basis for the fastest door-to-ECG times, says West. "We recently invited all the recipients to a luncheon to thank them for their dedication and great work. We have also had cake celebrations for the entire ED for reduction in door-to-ECG times and recognized EMS personnel when their actions have enabled us to produce rapid door-to-cath lab times," she says.

Sources

For more information on reducing door-to-cath lab times in the ED, contact:

  • Marli Bennewitz, RN, Chest Pain Center/Cardiac Wellness Coordinator, St. Jude Medical Center, 101 E. Valencia Mesa Drive, Fullerton, CA 92835. Telephone: (714) 992-3000, ext. 3463. E-mail: mbennewi@sjf.stjoe.org.
  • Becky Roberge, RN, Emergency Department, Mercy General Hospital, 4001 J St., Sacramento, CA 95819. Telephone: (916) 733-6250. E-mail: Becky.Roberge@chw.edu.
  • Page West, RN, CCRN, MHA, Director, Emergency Department, Mercy General Hospital, 4001 J St., Sacramento, CA 95819. Telephone: (916) 453-4930. Fax: (916) 453-4636. E-mail: page.west@chw.edu.