Door-to-balloon times can reach record lows

At Singing River Hospital in Pascagoula, MS, an "ST-elevation Myocardial Infarction (STEMI) Alert Protocol" helps ED nurses to meet a door-to-balloon time of 60 minutes or less.

First, an EKG is obtained and presented to the ED physician for confirmation within five minutes, says Bobby Kiser, BSN, an ED nurse on the hospital's STEMI Protocol Committee. Locating the ED physician for EKG review has been a problem at times, however.

"Paging the physician for location has helped," says Kiser. "Encouraging the ED techs to have the physician sign and time the EKG review has allowed management a tracking tool for problems. This tends to make the physicians more accountable."

If a STEMI is suspected, an ED nurse initiates these steps:

  • The patient is placed on a monitor and defibrillator pads.
  • IV access is obtained with a 18 or 20 gauge IV, using two sites if possible, with concurrent lab draw. Intravenous fluid therapy is initiated, as directed by the ED physician. Extensions are added to IV tubing for additional points of access.
  • A point-of-care cardiac profile is performed, and lab draws are labeled to include a complete blood count with platelets, international normalized ratio, basic metabolic panel, and lipid profile.
  • Beta blockers, anti-coagulants, anti-platelet(s), nitrates, narcotics, and other appropriate medications are administered per physician's orders.
  • An ED tech or STEMI nurse preps the patients' groins.
  • The patient and family are updated, and the ED physician explains cardiac catheterization and percutaneous intervention procedure.
  • The patient is prepared for transfer to the cardiac catheterization lab.

Once the STEMI Alert page has been initiated, an "all call" page system notifies the on-call cardiologist, cath lab personnel, house supervisor, lab personnel, and respiratory therapist assigned to the ED.

From January 2008 to August 2010, the ED's door-to-balloon time for patients presenting with signs and symptoms of a MI decreased from 91.22 minutes to 53.70 minutes. "Call back times are recorded by ED clerk as part of the ongoing monitoring tool used to improve door-to-balloon times," says Kiser.

"Well below" standards

All ED patients with chest pain receive an EKG within 10 minutes at Fletcher Allen Health Care in Burlington, VT.

"We have adopted a 'pit crew' attitude when an acute cardiac patient comes into the ED," says Donna Chicoine, RN, BSN, ED nurse educator.

Physician, nurses, and EMTs all respond as a team to start peripheral lines, draw the cardiac panel, start medications, and disrobe the patient. "We are well below the recommended [American Heart Association] door-to-balloon standards of 90 minutes," says Chicoine. "We have one patient with a door-to-open artery time of 17 minutes, and he came through triage and not EMS."

EMS is now doing 12-leads in the field and transmitting these so they can be shown to an ED physician, adds Chicoine. If a STEMI is called from the field EKG, the catheterization lab, charge nurse, and cardiology are all paged simultaneously.

"If the catheterization lab is ready and the patient does not require any immediate life-saving intervention, the patient is quickly assessed on the EMS stretcher in the hall by one of the ED physicians or cardiology and bypasses the ED," says Chicoine.

At one point, the ED managers believed that the 10-minute EKG window was being met, but they found after reviewing two months of charts that the average timeframe was actually twice as long. Here is how the ED got back to the 10-minute mark:

  1. The responsibility was assigned to the triage EMT for the patients who arrive through triage, and to the receiving nurse for EMS patients.
  2. Nurses and EMTs were educated on the subtleties of cardiac symptoms.
  3. EKGs are performed on all cardiac complaints and on patients who have a cardiac history. "ED nurses do not hesitate to call for a physician immediately if EKG changes are evident," adds Chicoine. (Also see stories on one ED's 'STEMI Kit,' below, and using ED cases as learning tools.)

Clinical Tip

'STEMI kit' gives easy access to meds

ED nurses at Singing River Hospital in Pascagoula, MS, use a "STEMI Kit" containing radiopaque lead wires, IV extensions, clippers with blades, timer, and a checklist for preparation of patients going to the cardiac catheterization lab. The kit also includes a pharmacy bag with these medications:

  • Lovenox 100 mg injection;
  • heparin bolus 1000 units/ml times 10 ml;
  • heparin drip;
  • nitroglycerin 0.4 mg SL tablets;
  • nitroglycerin drip 100 mcg/ml;
  • aspirin 325 mg tablet;
  • Lopressor (metoprolol) 5 mg injection times three;
  • Plavix 300 mg tablets times two equals 600 mg;
  • normal saline prefilled syringes times five;
  • normal saline 1000 ml bag.

"The drugs used are easily available for the nurse if orders are given, thus decreasing time in locating and retrieving meds," says Bobby Kiser, BSN, an ED nurse on the hospital's STEMI Protocol Committee. "This helps to decrease time in the ED, allowing the patient to reach the cath lab sooner."

Clinical Tip

Use post-ED info as learning tool

What happens after a cardiac patient leaves the ED? Often, ED nurses never find out. At Fletcher Allen Health Care in Burlington, VT, the catheterization lab gives the ED regular feedback on patient outcomes.

"The feedback on the STEMI patients is important to the ED nurses," says Donna Chicoine, RN, BSN, ED nurse educator. "It is a way to follow up with education and training if something was missed."

However, it is also positive reinforcement for care well done. "This is often missing for many patients we care for emergently. It is nice to know our care helped to save someone's life," says Chicoine.

Feedback usually is given with a call-back to the specific ED nurse who cared for the patient. "The ED is included in a roundtable discussion with the catheterization lab and the transferring hospitals that send STEMI patients to our hospital," says Chicoine. "Door-to-open artery time continues to improve for the ED and sending facilities."

Recently, a patient presented with gastrointestinal symptoms, and complaints of chest discomfort. "The nurse felt something was not quite right and did an EKG that showed the patient was having a STEMI," says Chicoine. Another nurse at triage decided to do an EKG on a patient in the hallway because the ED and waiting room were full. She discovered that despite chest discomfort that was vague, he was indeed having a STEMI.

"Either of these patients could easily have been missed or had worse outcomes if the ED nurses had not trusted their critical thinking or had less awareness of cardiac issues," says Chicoine.