ED catches atypical MI patients with rapid EKGs

Nurses report 'extraordinary saves'

At Virginia Commonwealth University Medical Center in Richmond, ED nurses implemented a new electrocardiogram (EKG) process for chest pain patients in April 2008. The goal is to catch myocardial infarction patients with atypical signs and symptoms by bypassing most of triage and getting the EKG within three to four minutes of the patient's arrival.

"We aggressively triage chest pain patients by foregoing much of the triage process to obtain a rapid EKG," says Steve Rasmussen, RN, CEN, clinical coordinator for the ED.

Any patient age 30 years or older with a complaint of chest pain, pressure, or discomfort receives an EKG. Serial cardiac enzymes and a nuclear scan study are obtained. If the cardiac enzymes or nuclear scan study have any question of being positive, the patient is admitted to the ED's 23-hour observation unit for a follow-up stress test prior to discharge.

"This type of aggressive response to chest pain can be burdensome to ancillary and nursing staff that are already overtaxed," acknowledges Rasmussen. "This can be a challenge when the ED is overcrowded with long admission waits and few resources."

To activate the cardiac catheterization team more quickly, ST-segment elevation myocardial infarction (STEMI) alerts are called from the field. The goal is to get the patient to reperfusion in the cath lab within 90 minutes from the time of STEMI recognition in the field. "Not only have we been able to hit our target times, but we have had some extraordinary saves," says Rasmussen.

Patients bypass triage

Previously, ED nurses used information obtained at triage to decide which patients would go back immediately and which would have to wait for beds to become available. "If patients presented with classic signs of cardiac problems, the decision was no problem, but it was those atypical presentations that would slip through the cracks," says Rasmussen.

When there is a bed available, patients go back immediately to be seen. "But with the increase in patient numbers and the ED at 140% capacity in the treatment area, triage becomes increasingly important, and only the sickest patients come back," says Rasmussen.

For this reason, lives potentially can be saved by quickly obtaining an EKG for patients presenting with certain complaints before completing the normal triage process. "EKGs are literally obtained within three or four minutes," says Rasmussen. "The EKG is then reviewed by an attending physician, with a decision made to bring the patient into the treatment area or return to complete the normal triage process."

Sources

For more information on care of chest pain patients in the ED, contact:

  • Steve R. Rasmussen, RN, CEN, Clinical Coordinator, Emergency Department, Virginia Commonwealth University Medical Center, Richmond. Phone (804) 828-7330. Fax: (804) 628-0488. E-mail: srasmussen@mcvh-vcu.edu.
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