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Door-to-EKG delays? Get them close to zero
At Tufts Medical Center in Boston, the ED's protocol encourages any member of the ED staff a technician, nurse, or physician to perform an EKG whenever they find a patient presenting with angina or anginal equivalents.
This step is one of the interventions that has reduced the ED's door-to-EKG times, which can have a significant impact on the outcome of patients with possible ST-elevation myocardial infarction (STEMI), according to Alexandra Penzias, RN, MEd, MSN, CEN, clinical nurse educator for the Department of Emergency Medicine and co-author of the protocol. [The protocol used by ED nurses is included. For assistance, contact customer service at (800) 688-2421 or firstname.lastname@example.org.]
"All nursing and ED tech staff have been trained and maintain annual competency in performing 12-lead EKGs. Nursing staff have advanced training in dysrhythmia interpretation," adds Penzias.
The protocol states that the practitioner performing the EKG must hand carry it to an attending physician, who does a rapid evaluation/interpretation of the EKG. He or she initials the printout with an order to activate the STEMI pager and initiate protocolized care for acute coronary syndromes, STEMI, non-STEMI, or dysrhythmia.
"Our protocol encourages a 'closed loop' of communication between practitioners until a diagnosis of, or clearance for, STEMI, non-STEMI, or threatening dysrhythmia," says Penzias.
Triage delays cut
To reduce delays at triage, an ED tech acts as a "pre-triage greeter" during the highest volume hours, typically 11 a.m. to 7 p.m. The greeter gets the patient's name, date of birth, presenting complaint, and a set of vital signs.
"ED techs who act as greeters are also educated regarding our protocol and obtain EKGs on patients presenting to the ED with chest pain or a constellation of symptoms referred to as 'anginal equivalents,'" says Penzias. "We typically hire baccalaureate nursing students and EMTs into these positions. Their role is critical to the success of the protocol."
To further cut delays, a reclining phlebotomy chair and an EKG machine was placed in triage. "However, because the ED environment is so complex and fast-paced, a protocol and education alone will not guarantee ongoing success," says Penzias. To be sure the ED is providing rapid evaluation and treatment for this population, the ED physician and nursing leadership teams review all STEMI cases every month.
"We evaluate each case for lessons learned and for potential systems issues that are attributed to expeditious or delayed care," says Penzias.
Perform EKG at triage
Even if a treatment room isn't available right away, Tracy Simmons, RN, clinical educator for the ED at OSF St Francis Medical Center, says to "get the EKG done at triage and take a look."
"The more time that the patient waits to have their vessel opened equals potentially more irreversible damage to their heart," says Simmons.
Cathy C. Fox, RN, CEN, CPEN, clinical nurse educator for the ED at Sentara Virginia Beach General Hospital, says there is an EKG machine available 24 hours a day in triage, staffed by a nurse. "This is to ensure an EKG is completed within 10 minutes on all chest pain patients upon arrival," she says. "In the event we have two or more patients presenting with chest pain at the same time, another nurse or an ED technician will complete an EKG in one of our three triage rooms."
If a second patient does present to triage with chest pain, the registration attendant calls the charge nurse on a portable phone, and initiates the EKG in any available room.
"We do not delay the EKG by doing vital signs or initiating IV access," says Fox.