STEMI guidelines put you front and center
ED nursing actions are key
You're probably the first person to see the 12-lead EKG of a patient with a possible ST-elevation myocardial infarction (STEMI). In addition, you're probably the one who initiates your ED's STEMI protocol, says Jean McSweeney, PhD, RN, FAHA, FAAN, a member of the Mission: Lifeline Advisory Working Group, the American Heart Association (AHA)'s STEMI initiative.
Newly updated guidelines from the American College of Cardiology/AHA put a spotlight on ED nurses, as they focus on quick timing of assessment, quick diagnosis of STEMI, and activation of protocols.1
"Use of specific order sets, checklists, tool kits, and clinical pathways ensure adequate documentation that is easily retrievable for review and audit purposes," adds McSweeney. (For some examples, go to www.americanheart.org/missionlifeline. Click on "Mission: Lifeline Summary Table." Scroll down and click on "POE protocols" and also click on "Reperfusion Checklist.")
Because STEMI protocols are time-driven, to ensure the patient receives transfer to the cardiac catheterization lab and restoration of blood flow in less than 90 minutes, "nurses must be familiar with the protocol and how to activate it rapidly according to their hospital policy," says McSweeney.
At Kaweah Delta Medical Center in Visalia, CA, all ED nurses are trained to perform 12-lead EKGs. "We do not depend on other ancillary departments to perform this function," says Dave Sanbongi, RN, prehospital EMS coordinator in the ED. "Our standard is a maximum of 10 minutes from patient arrival time to the 12-lead EKG being handed to a physician for review." Here is how ED nurses meet this goal:
Staff are trained on the importance of rapidly obtaining a 12-lead EKG with immediate physician review.
"Our clinical education department offers 12-lead EKG interpretation classes," says Sanbongi. "ED nurses can attend this course free of charge."
Any patient who presents with suspected cardiac chest pain is brought immediately to a room.
The registration and triage process is performed at the bedside. "If a room is not immediately available, we can perform a quick 12-lead EKG in a dedicated room in the triage area. The ED team leader will work on making a bed available," says Sanbongi.
Nurses can repeat a 12-lead EKG if the patient continues to have chest pain 30 minutes after completion of the first EKG.
"An EKG with ischemic changes but no STEMI is a time bomb waiting to explode," says Sanbongi. "These patients need to be aggressively treated and monitored."
- Kushner FG, Hand M, Smith SC, et al. 2009 Focused Updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction. Circulation2009; 120:2,271-2,306.
For more information on improving care of ST-elevation myocardial infarction patients, contact:
- Rosemary Arviso-Green, RN, BSN, Emergency Department, Mission Hospital, Asheville, NC. E-mail: Rosemary.ArvisoGreen@msj.org.
- Dave Sanbongi, RN, Emergency Department, Kaweah Delta Medical Center, Visalia, CA. Phone (559) 624-6048. E-mail: DSanbong@kdhcd.org.
Can't decide? Then look at risk factors
If you can't decide whether to initiate a cardiac chest pain standardized procedure, find out if the patient has any cardiac risk factors.
"The patient may be presenting with symptoms that make a weak case for suspected cardiac ischemia," says Dave Sanbongi, RN, prehospital EMS coordinator in the ED at Kaweah Delta Medical Center in Visalia, CA. "But if they have any risk factors, then err on the side of caution and proceed down the cardiac pathway."
Cardiac risk factors include family history of cardiac disease, history of coronary artery disease, previous cardiac events, cardiac interventions, hypertension, diabetes, smoking, obesity, hyperlipidemia, and sympathomimetic drug abuse. "Also, if a patient has a surgical scar on their chest, then it would not be unreasonable to assume they've had some type of cardiac surgery," says Sanbongi.
If a patient is not a good historian, obtain any prior medical records that might shed light on the patient's current complaint, or obtain information from caregivers, Sanbongi says.
"The worst thing you can do is to rule out an acute myocardial infarction or cardiac pain by seeing if you can reproduce the pain and seeing if the pain gets worse upon inspiration or better with the infamous 'GI cocktail,'" says Sanbongi. "If the patient has risk factors, then they need a proper cardiac workup."
ED nurses do EKG within 3 minutes
If a patient complains of chest pain, he or she ideally is brought right back to a treatment room for an immediate EKG. But if that isn't possible, don't let that stop you from giving the EKG within minutes.
"If a bed is not immediately available, an EKG is done in triage within five minutes," says Rosemary Arviso-Green, RN, BSN, an ED nurse clinician at Mission Hospital in Asheville, NC.
The EKG is immediately reviewed by the ED physician. If he or she calls a "code STEMI," the team is immediately paged. "In March 2010, our door-to-EKG time was three minutes, the ED phase was 26.5 minutes, and our ED-to-cath lab was 55 minutes," reports Arviso-Green. Here are three ways the ED cut delays:
1. If the patient arrives via ambulance, paramedics perform 12-lead EKGs, and the STEMI might be called from the field.
"This is vitally important, because care can be initiated and all systems are in place when the patient arrives," says Arviso-Green. "In many cases, the patient can go straight to the cath lab upon arrival at the ED door."
2. "Code STEMI" packets are prepared in advance so they can be pulled immediately by ED nurses.
These contain an Acute Myocardial Infarction Response Sheet, an Acute MI /ED Emergency Cath Lab Order Set, ED/Cath Lab Code STEMI Flow Sheet, and consent forms. (ED nurses who wish to see documentation in use at Mission Hospital may contact email@example.com.)
3. When the STEMI is called, two or three ED nurses assist the primary nurse.
"This allows one to scribe and the others to provide direct patient care," says Arviso-Green.