Do you always obtain an EKG under 10 minutes?

Obtaining an EKG in a timely manner is critical, says Brian W. Selig, MHA, BSN, RN, CEN, NE-BC, nurse manager of the ED at the University of Kansas Hospital in Kansas City, MO, "especially with the recent emphasis on time-critical diagnosis by the Joint Commission and [the Centers for Medicare & Medicaid Services.]"

At University of Kansas Hospital, ED nurses strive for a door-to-balloon time on ST-elevation myocardial infarction patients of less than 60 minutes, says Selig. "One of the initiatives that we have put into place to help achieve this is the need to have a door-to-EKG time on all patients of under 10 minutes," he says.

Any patient with a complaint or presenting symptoms that qualify as acute coronary syndrome (ACS) gets an EKG completed and read by a physician within 10 minutes of their arrival to the ED, says Selig. These patients are included:

  • Atraumatic chest pain less than 24 hours old;
  • Any patient with any chest pain and two or more associated symptoms, including nausea, vomiting, shortness of breath, or diaphoresis;
  • Any patient with chest pain with risk factors of smoking, age over 65, family history, high cholesterol, diabetes, hypertension, known drug abuse, or known cardiac history;
  • Any patient with known heart disease, diabetes, or age over 70 with atypical symptoms of abdominal pain, dizziness, fainting, shortness of breath, weakness, nausea, vomiting, diaphoresis, palpitations, altered mental status, upper extremity pain, jaw pain, or upper back pain.

"While some of these may seem typical, many times the symptoms are overlooked because the patient doesn’t seem to be in distress," says Selig.

Patients may present with atypical symptoms, says Selig, such as women older than 40 years with shortness of breath, nausea, dizziness, or syncope, any patient with syncopal episodes, overdose, or seizures. Here are two ways that the University of Kansas Hospital’s ED nurses get quick EKGs:

A technician can complete an EKG even before the patient is triaged, in a room next to the entrance.

"The physician can be reading it while the patient is getting the rest of their triage completed," says Selig. "Even during times where the ED is full, we are still able to make our 10-minute door-to-EKG time."

ED technicians and nurses are both trained to complete EKGs.

"Oftentimes, it takes a long time to get the house EKG tech to come to the ER to do a stat EKG," says Selig. "There is virtually no way to meet the door-to-EKG time if you are calling someone from outside of the unit to come to your ED to get it done." (See related story, below, on inclusion criteria for an ED’s chest pain pathway.)

Sources

For more information on reducing delays in obtaining EKGs, contact:

  • Ann Heywood, RN, MSN, CEN, SANE, Trauma Nurse Coordinator, CVPH Medical Center, Plattsburgh, NY. Phone: (518) 562-7378. Fax: (518) 562-7950. E-mail: AHeywood@cvph.org.
  • Brian W. Selig, MHA, BSN, RN, CEN, NE-BC, Nurse Manager, Emergency Department, The University of Kansas Hospital, Kansas City. Phone: (913) 588-6506. E-mail: bselig@kumc.edu.

Possible MI? ED nurses use this inclusion criteria

Triage nurses at CVPH Medical Center’s Emergency Care Center in Plattsburgh, NY, use an acute coronary syndrome screening tool for patients presenting with chest pain, according to Ann Heywood, RN, MSN, CEN, SANE, trauma nurse coordinator.

If the patient meets the inclusion criteria listed below, says Heywood, nurses follow the chest pain pathway, which includes an EKG within 10 minutes of arrival.

  1. If the answer to any of the below questions is yes, and the patient is 30 years old or older or has a history of known heart disease, ED nurses proceed immediately with the Chest Pain Program:
    • Is there any unexplained discomfort between the nose and the navel that has lasted continuously for more than 10 minutes?
    • Is there indigestion, heartburn, nausea, and/or vomiting associated with chest discomfort?
    • Is there fainting or unexplained severe weakness or dizziness?
    • Does the patient have shortness of breath?
    • Is the heart racing, skipping, or pounding?
  2. If the patient is younger than 30 years, has any of the above symptoms, and also gives any of the history listed below, ED nurses proceed immediately with the Chest Pain Program:
    • Coronary heart disease, including history of heart attack, coronary bypass surgery, angioplasty, angina, abnormal stress test, abnormal heart catheterization, or chest pain relieved by nitroglycerin;
    • Smoking within the past 10 years, elevated cholesterol, high blood pressure, diabetes mellitus, obesity, family history of premature heart disease, recent cocaine use, or use of birth control pills;
    • Other blood vessel disease, including stroke or threatened stroke, carotid artery disease or bruit, poor circulation of the legs, or loss of vision or amputation due to poor circulation or hardening of the arteries.

"Exclusion criteria are recent history of trauma, visible lesions, palpable lesions of the skin or chest wall, and isolated breast disease," says Heywood.