When it comes to obtaining an early ECG, there is a high degree of variability across EDs, according to the results of a recent study.1 “Our study reveals vulnerabilities in the systems designed to identify a patient with STEMI quickly,” says Christopher Baugh, MD, MBA, a co-author on the study and vice chair of clinical affairs in the department of emergency medicine at Brigham and Women’s Hospital in Boston.
Rapid identification of a STEMI is the first step in timely reperfusion, which is tied to better patient outcomes. “Patients who have delayed ECG and recognition of STEMI with poor outcomes represent an area of malpractice risk for emergency physicians,” Baugh notes.
Researchers studied STEMI screening at seven EDs and found a 29.2% difference in the missed case rate (the patients who did not undergo an ECG within 15 minutes of arrival but were diagnosed with STEMI) between the highest and lowest-performing EDs. The overall missed case rate for all seven EDs was 12.8%. The lowest and highest rates were 3.4% and 32.6%, respectively. The mean difference in door‐to‐ECG times for captured and missed patients was 31 minutes, with a range of 14-80 minutes of additional myocardial ischemia time for missed cases. “Our work identifies an important area for operations leadership in every emergency department to review their own workflows and performance,” Baugh offers. This ensures EDs are doing everything possible to meet the 10-minute “arrival to ECG interpretation” benchmark.
In another study, researchers asked 158 ED nurses about compliance with MI guidelines from the American College of Cardiology/American Heart Association.2 No goals were met “all of the time” by all the nurse participants. “All of the time” responses ranged from 52% (for giving analgesics) to 87% (for asking about chest pain). Eighty-one percent of participants had a goal of obtaining an ECG within 10 minutes of arrival, but only 27% of participants met all of the goals “all of the time.” The researchers recommend tailored educational interventions to improve compliance. To minimize delays in obtaining ECGs, Baugh advises that EDs consider all patient arrival methods, flex up staffing to accommodate surges in patient arrivals, establish a “clear and inclusive” 10-minute ECG policy, provide adequate staff and space to perform ECGs rapidly immediately adjacent to all ED entry points, and create a flexible mechanism to allow EPs to rapidly view and screen for STEMI. “If there are multiple physicians on duty, push tracings to the most available physician,” Baugh suggests. Also, EDs should provide continuing education on STEMI and STEMI-equivalent recognition on ECGs.
Baugh says the bottom line is that EDs must do “everything they can to implement a robust system aimed at meeting the 10-minute arrival to ECG interpretation benchmark for patients at risk.”
- Yiadom AB, Baugh CW, McWade CM, et al. Performance of emergency department screening criteria for an early ECG to identify ST-segment elevation myocardial infarction. J Am Heart Assoc 2017; Feb 23;6. pii: e003528. doi: 10.1161/JAHA.116.003528.
- Arslanian-Engoren C, Eagle KA, Hagerty B, Reits S. Emergency department triage nurses’ self-reported adherence with American College of Cardiology/American Heart Association myocardial infarction guidelines. J Cardiovasc Nurs 2011;26:408-413.