Reduce time to treatment for MI patients

It's imperative for ED nurses to look closely at reducing delays to treatment for MI patients, emphasizes Estelle MacPhail, RN, MS, CNAA, CEN, nurse director for emergency and trauma services at Southern New Hampshire Medical Center. "When time is muscle, every minute counts. Immediacy of care encourages less damage and promotes better outcomes."

Many studies have documented that the sooner a person who is having a MI is given a thrombolytic agent and/or taken to a cardiac catheterization lab for angioplasty, the less damage occurs to the cardiac muscle. "Quick response time will improve patient survival and, potentially, quality of life by limiting or avoiding cardiac injury," says Kim Basham, ARNP, MSN, CS, CCRN, president of Healing Matters, a patient education group based in Louisville, KY.

If cardiac function can be salvaged or improved, less interventions will be necessary, such as vasopressors, inotropic agents, antidysrhythmia medications and/or intra-aortic balloon pumping, says Basham. "The patient's hospital length of stay may be shorter as well," she notes. "Obviously, if the patient's quality of life is preserved, there is no monetary value that can reflect this."

To reduce delays in treating MI patients, use these tips:

Get patients upstairs quickly. At Harborview Medical Center in Seattle, WA, a bed is prepared in advance when patients come in for an MI ruleout. "As soon as we know the patient is coming, we call the nursing supervisor and start working from that time to get them a bed, which is very helpful," says Mary Royce, RN, BSN, CEN, the ED's nursing educator. "That way, we know how many beds we have open, so a patient can generally be admitted within 20 minutes of their arrival."

Emphasize the ED component of chest pain pathway. "The pathway is activated just as we would with a trauma case, which makes care more expedient," says MacPhail. "Like a recipe, the pathway may vary a little bit, but it gives good guidelines and really expedites care."

Male or female patients 25 years or older that arrive by car or walk in with chief complaint of chest pain automatically fall into our chest pain pathway. "There are four phases, depending on the findings," notes MacPhail.

As soon as patients walk in and see the triage nurse, they are transferred to a room and an ECG is done. "The ECG interpretation is done by the ED physician. Then, if the patient moves to phase 2, the nurse starts the IV, a cardiac panel lab study is ordered, which includes CBC, Chem 25, CPK, Troponin I, Pt, and Ptt, a chest film is ordered immediately, and the cardiologist is called," MacPhail explains. "All these things are done in concert."

Both door-to-drug and decision-to-drug times are monitored. "Those times will differ if a patient is hypotensive, because in that case we have to treat the symptomology and then give them the thrombolytic therapy once we get that under control," notes MacPhail.

Starting MI pathways in the ED facilitates subsequent care. At Harborview Medical Center, pathways for Uncomplicated MI and Rule Out MI/Acute Chest Pain both begin in ED (see supplement, pages 2-4). "It's important for us to have the pathway start in the ED, because we know all the right labs, and studies have been ordered initially. We don't have to look through the ED notes to see if it's been done," says Patty Calver, RN, BSN, nurse manager for the hospital's cardiac evaluation unit.

The pathway also streamlines documentation. "It's documentation by exception, so nurses and physicians don't have to write a whole new set of orders and, possibly, forget things," says Calver. "If the physician signs the order, it's automatic that these things will be done, so it is a time saver." The only documentation needed is the physician's signature at the bottom of the form, unless there is a variation in the normal protocol, she explains.

Include aspirin in the protocol. Aspirin should always be given when acute ischemic syndrome is suspected, says Mary McDonald Hand, MSPH, RN, coordinator of the National Heart Attack Alert Program in Bethesda, MD. "Aspirin is a very simple therapy, but it is still not given 100% of the time," she stresses. "It should be given as soon as possible after the patient's arrival."

Reduce delays with ruleout MI patients. "There are two types of patients-those with clear-cut MIs and those we need more diagnostics for," says MacPhail. "With patients whose ECG is inconclusive, the decision to drug pathway is different."

A MI Ruled Out Protocol was developed (see supplement, pages 2,3) to decrease delays for ruleout MI patients. "We found out that ruleout MI patients were just as significant a number for us than actual MIs," explains MacPhail.

The pathway begins in the ED, where a creatine kinase (CK) and CK isoenzyme-cardiac muscle subunit (CK-MB) essay panel is done and repeated in three, six, and nine hours. "The patient gets a repeat ECG in nine hours after being admitted to the observation bed upstairs, is monitored, and has a treadmill stress test," says MacPhail.

Expedite stress test for admitted patients. Southern New Hampshire's Rapid Track Chest Pain Protocol Orders (see supplement, page 1) ensure that ED patients receive a stress test without delay. "Before, if the patient was admitted on the weekend, the test was delayed. Their average length of stay was over 22 hours," says MacPhail. "Now, no matter what day they are admitted, they get their stress test right away, which decreases the cost of care." Average costs are approximately $1000 when the patient stays 23 hours, compared with more than $4000 when the patient stayed two or three days, she notes.

Patients also get quicker results. "Right after the stress test and the ongoing ECG, patients can find out if they are ruled out," says MacPhail. "They like the idea of getting instant results from the stress test, instead of waiting several days and missing work."

Start necessary tests immediately. "Nurses can reduce time to treatment by being involved in the pathway and not waiting for a doctor's order," says MacPhail. "There are certain things you should do in concert with the physician."

The ED's pathway directs nurses on all shifts to start EKGs. "We had no problem on nights because the nurses did the ECGs, but the staff on days and evenings would wait for the ECG tech to be called," says MacPhail. "Now, all our nurses do ECGs if by chance the ECG tech is unable to respond immediately, which speeds up the process." Nurses will also automatically draw blood and start the IV lines if the patient is going to receive thrombolytic therapy, she notes.

Store medication in the ED. "Storing the thrombolytic in the ED is a time saver. That way, you don't have to wait for it to be transported from the pharmacy," MacPhail explains. "The nurses have the drug in the crash carts, located in the cardiac rooms.They are able to prepare the thrombolytic at the patient's bedside as ordered by the physician and/or cardiologist immediately-without having to go to the pharmacy."

Pathways should include instructions for nurses to begin procedures, says Royce. "Our nurses have standing orders to put the patient on a monitor, start them on oxygen, draw the labs, do their ECG, everything except give them medications," she notes.

Benchmark your ED's times. University of Cincinnati Medical Center's ED uses Genentech benchmarking data to track delays. "Data are compiled retrospectively, with all patients who end up with some kind of acute myocardial event looking at time points," says Cathy Hamilton, RN, the ED's clinical coordinator. "We track when symptoms began, how they got there, when first ECG was done, whether it was diagnostic, when decision was made for thrombolytics, and door to drug times."

Data collection forms are sent in to learn how the ED's times measure up nationally. "This way, we know where our delays are, so if we wanted to get our time to treatment down further, we would know what to target first," says Hamilton. "National recommendations are good goals to strive for, but it also helps to know how you stack up against the national average, state average, and like institutions."

Where Delays Occur

It should be noted that the greatest proportion (roughly 65%) of overall delay occurs outside the hospital when the patient and those in whom they confide react in various ways to heartattack symptoms," stresses Julie Bracken, RN, MS, CEN, director of nursing education for Cook County Hospital in Chicago and representative of the Emergency Nurses Association for the National Heart Attack Alert Program in Bethesda, MD.

Still, ED nurses can do a lot once patients arrive to reduce overall delay if they focus on four critical timepoints: Door, Data, Decision, and Drug, notes Hand.

Door. "It's important that patients don't ignore signs and symptoms and come to the ED as quickly as possible," urges MacPhail. "EDs should be proactive in publicizing signs and symptoms, and encourage patients to come in immediately." The medical center's ED physicians frequently participate in a local TV program to review symptoms of MI, she notes.

If patients are brought by ambulance, it has been shown to lead to earlier treatment with thrombolytics than when patients delay seeking care and arrive by private vehicle, says MacPhail. "Currently, only about half of patients call 911 when they have heart attack symptoms," she notes.

Holding focus groups with patients can help to identify reasons why they do not call 911, Hand says. "From focus groups with patients, one thing that has interestingly been reported is that sometimes, patients expect the heart attack symptoms to be different than what they actually experience," she reports. "For example, patients may think a heart attack is very dramatic, like a cardiac arrest when the patient falls over as shown on TV. So they may not call when experiencing chest discomfort."

There is also a tendency to want to ascribe their symptoms to something else, such as indigestion, says Hand. "Patients also have a fear of embarrassment when from calling an ambulance with lights and sirens, coupled with a fear of loss of control over their life," she explains. Even if patients have had a prior heart attack, they don't necessarily get to the ED any earlier with the next attack, says Hand. "The presentation may be different, so they don't recognize it as a heart attack," she suggests.

Nurses should provide positive reinforcement to patients for coming in and getting checked, even if it turns out to be a false alarm, advises Hand. "If nurses encounter patients who end up ruling out for a heart attack, they can nevertheless provide education about the importance of coming in early should they experience symptoms in the future, and of following up with their personal physician to evaluate their risk of coronary heart disease," she says. "This will help promote achievement of the Golden Hour."

Data. Triage nurses need to have a high index of suspicion, Hand emphasizes. "They need to really try to identify all the patients who have a potential cardiac problem," she says. Once a cardiac problem is suspected, triage nurses should investigate if a prehospital ECG was done, says Hand. "If so, it needs to be hand delivered to the physician immediately," she emphasizes. "Otherwise, the nurse needs to ensure that a 12-lead is obtained right away. The 12-lead ECG is still the gold standard and really must be done before anything else." ED nurses should be provided with a standing order to obtain ECGs, stresses Bracken. "An ECG must be considered part of the vital signs," she says. "The patient should be simultaneously placed on cardiac monitoring."

According to National Heart Attack Alert Program guidelines, hospital EDs should also have standing orders that include the following interventions for patients with suspected myocardial ischemia or acute MI, says Hand:

Cardiac monitor; oxygen therapy; IV access; nitrates (In some EDs, standing orders for nitrates, sublingual or spray, may be desirable and feasible for selected groups, such as patients already using sublingual or transdermal nitroglycerin); administration of aspirin for unstable angina or suspected acute MI in patients who have no allergy to aspirin products; and blood studies (e.g., CK and CK-MB)

ED nurses should also ensure all equipment, including the ECG machine and cardiac monitors, is in good working order and supplies such as paper, electrodes, and conductive gel are available to avoid delays, says Bracken.

Decision. Nurses should hand carry the ECG results to the physician if possible, says Bracken. "Getting the ECG to the physician is often a key source of delay," she says. "The nurse is instrumental in identifying any contraindications to thrombolytics, such as a recent surgery, a known bleeding disorder, or head trauma."

Other ways to help in decision-making in the diagnosis of acute MI when patients have questionable symptoms or ECG findings include echocardiography, biochemical markers, continuous ST-segment monitoring, serial 12-lead ECGs, and computer-based decision aids, says Hand.

Drug. The National Heart Attack Alert Program has recommended that thrombolytic therapy for eligible acute MI patients occur within 30 minutes of arrival, notes Basham. "Thirty minutes sounds like a long time, but in a busy ED, this time can pass quickly, especially if the system of care delivery is not coordinated and organized," she says. Organized pathways can help streamline care so that the 30 minute goal is achievable and realistic, she says.

Patients should be informed of the benefits and risks of thrombolytics in a few minutes. When the patient's questions or concerns require input from the physician, the nurse should facilitate the dialogue to prevent treatment delays caused by patient indecision, recommends Hand.