ED nurses get ECGs done in 10 minutes or less

Catch all potential myocardial infarctions at triage

A patient drove herself to your ED with pain in her jaw, but it seems to have subsided. Would this patient sit in your waiting room for minutes or hours — or would she get an electrocardiogram (ECG) immediately?

"With our patient census growing every day, we often have people waiting for hours," says Kerry Short, BSN, RN, CEN, education coordinator for the ED at Froedtert Hospital in Milwaukee.

Any patient who presents with chest pain and has associated risk factors such as smoking, high cholesterol, or family history is an "automatic ECG," she says. Nurses also obtain immediate ECGs for patients with atypical symptoms, such as jaw pain, arm pain, shortness of breath, dizziness, or upper abdominal pain with associated risk factors, says Short.

Because of an astute triage assessment and immediate ECGs, ED nurses at Osceola Regional Medical Center in Kissimmee, FL, caught two myocardial infarctions with atypical symptoms that could have gone undetected. "The patients were in the cath lab within 20 minutes and treated successfully," says Michelle Tracy, RN, MA, CEN, CPN, clinical educator for emergency services. "Had the patients sat in the waiting room for an extended period of time, they could have suffered irreparable heart muscle damage or even cardiac death."

At Aurora Medical Center in Oshkosh, WI, all ED nurses were re-educated on triage of cardiac patients, says Jane Hottinger, RN, MSN, the ED's clinical educator. "We included the typical presentation of a patient with chest pain, but also stressed the atypical symptoms of chest pain, specifically with patients who are elderly, diabetic, women, and those who may be cocaine users," she says.

For patients with atypical symptoms, ECGs previously took 20-30 minutes and now take fewer than 10 minutes, says Hottinger. "After we have our ECG and interpretation, we are able to start a saline lock and draw blood to send for rapid cardiac enzymes within 10 minutes or less," she says. "All our nurses and techs are taught how to perform an ECG at orientation and, as of this year, will be checked annually for competency."

ECG times cut in half

At Osceola's ED, a goal of 10 minutes was set for door-to-ECG, says Tracy. "However, we continued to miss this target, with an average time of 18 minutes," says Tracy. Whenever a patient needed an ECG, the technician usually was away from the triage area, she explains.

To address this problem, a technician now is stationed at triage to give ECGs and also helps the ED triage nurse with reassessment of vital signs.

ED nurses now make the ECG the first priority and have an "ask questions later" policy, says Tracy. "If the patient states that they are here for chest pain, we stop everything and do the ECG," she says. "We now have an average time of 6.7 minutes. We have cut our times in half, and the patient receives expedient care."

Since several potential MI patients may present at the same time, a second ECG machine was added at triage, says Tracy. "We have had to change the mindset that it is essential to have someone up front to do ECGs even if that means leaving the back short," she says. "Charge nurses have been educated not to pull the tech from triage."

At Kanabec Hospital in Mora, MN, a small critical access hospital with about 7,500 ED visits annually, nurses are trained to call for an ECG immediately on any cardiac patient, and those patients bypass triage and go directly to a room, says Dorothy Kohl, RN, CEN, ED manager. "We're a small hospital, but our goal is five minutes for stat ECGs, and that is our average time," Kohn says. "Obviously there are occasional outliers, but those are rare."

At Legacy Health System in Portland, OR, ED technicians are paged as "stat ECG" for an immediate response, and ED nurses do ECGs if the techs are not available, says Judy Nordblom, RN, clinical nurse specialist for emergency services.

They have a goal of nine minutes and have been meeting this goal for more than two years, says Nordblom. "Basically, the patient is immediately roomed, undressed, and an ECG is done," she says.

They have made the ECG a priority over all other things, Nordblom adds. "It is the only way we have been able to maintain the times," she says.

ED nurses were all trained by cardiopulmonary services, and now an ED technician trains all new nurses at orientation on a monthly basis, says Nordblom. The training consists of lead placement, information input, and techniques for tracing errors, movement, and wave lines. "If a nurse is having a difficult time, we send them with cardiopulmonary to do morning rounds for two to four hours to learn techniques," she explains.

At Osceola's ED, nurses are completing a nine-hour computer-based class to improve triage skills, reports Tracy. "We had an incident where someone came in with complaints of epigastric abdominal pain, and they did not do an ECG," she says. The patient was having an acute MI and was sent to the cath lab after evaluation by the ED physician. "The patient had a positive outcome, but our motto is 'time is muscle,' and we strive to save what we can," Tracy says.

Sources

For more information on triage assessment and electrocardiograms, contact:

  • Jane Hottinger, RN, MSN, Clinical Educator, Emergency Department, Aurora Medical Center, 855 N. Westhaven Drive, Oshkosh, WI 54904. Telephone: (920) 456-7420. Fax: (920) 456-7421. E-mail: dhottinger@new.rr.com.
  • Dorothy Kohl, RN, CEN, Manager, Emergency Department, Kanabec Hospital, 301 S. Highway 65, Mora, MN 55051. E-mail: dorothykohl25@msn.com.
  • Judy Nordblom, RN, Clinical Nurse Specialist, Emergency Services, Legacy Health System, 1015 N.W. 22nd Ave., Emergency Administration Room 290, Portland, OR 97210. Telephone: (503) 413-6364. Fax: (503) 413-8010. E-mail: JNordblo@LHS.org.
  • Kerry Short, BSN, RN, CEN, Education Coordinator, Emergency Department, Froedtert Hospital, 9200 W. Wisconsin Ave., Milwaukee, WI 53226. Telephone: (414) 805-6720. E-mail: kshort@fmlh.edu.
  • Michelle Tracy, RN, MA, CEN, CPN, Clinical Educator, Emergency Services, Osceola Regional Medical Center, 701 W. Oak St., Kissimmee, FL 34741. Telephone: (407) 518-3208. E-mail: michelle.tracy@hcahealthcare.com.