New myocardial infarction guidelines will dramatically change your practice

Recommendations are for patients sitting right at the very edge’ of an MI

Are all your myocardial infarction (MI) patients with ST-segment elevation (STEMI) treated with door-to-needle time within 30 minutes and door-to-balloon time within 90 minutes? And are you giving serial electrocardiograms (ECGs) to symptomatic patients with nondiagnostic ECGs every five to 10 minutes?

If not, you aren’t practicing according to new guidelines from the Bethesda, MD-based American College of Cardiology (ACC) and the Dallas-based American Heart Association.

"The guidelines are posted on the ACC web site and should be practiced now," urges Elliott M. Antman, MD, FACC, chair of the committee that developed the guidelines and professor of medicine at Harvard Medical School in Boston. (To access the complete guidelines, go to www.acc.org. Click on "Clinical Statements/Guidelines." Under "July 1, 2004," click on "ST-Elevation Myocardial Infarction: ACC/AHA Guidelines for the Management of Patients With."

If you don’t change your practice to reflect the new recommendations, you could be facing increased liability risks, he adds. "Liability is a tricky issue since individual patient decision making supercedes guidelines," Antman notes. "But as a whole, we would consider sites that do not practice according to the guidelines as providing inferior care to STEMI patients."

The guidelines are for patients who clinically have symptoms that look like a STEMI but have not yet had a diagnostic ECG change, says Julie Bracken, RN, MS, CEN, associate director of nursing staff development at University of Illinois Medical Center in Chicago and former ED clinical nurse specialist at Cook County Hospital. "This is the population that is sitting right at the very edge," she says.

Most of these patients wind up in the ED with symptoms, but definitive diagnosis is difficult as their MI usually is evolving, says Bracken.

"There are quite a few important changes all ED nurses should be aware of in the new guidelines," according to Marli Bennewitz, RN, BSN, chest pain center coordinator at St. Jude Medical Center in Fullerton, CA. The new guidelines will be reviewed at the ED’s clinical services meeting and the cardiology quality review council, where all necessary changes to the existing protocol and computerized order sets for STEMI will be made to comply with the latest recommendations, she reports.

"The entire ED staff then will be inserviced on the changes," says Bennewitz. "The publishing of these guidelines provides an excellent opportunity for every ED to revisit their existing protocols and again focus on the No. 1 killer of Americans."

To dramatically improve care of MI patients, make the following practice changes based on the new guidelines:

  • Keep door-to-needle time within 30 minutes, and keep door-to-balloon time within 90 minutes.

"The time to reperfusion is key, no matter whether it is by pharmacologic- or catheter-based means," says Antman.

Many EDs are not meeting these time frames, he adds. "There are definitely delays, more so for the door-to-balloon issues," says Antman, pointing to recent data from the National Registry of Myocardial Infarction, an observational study sponsored by San Francisco-based Genentech, showing that time from door to balloon in one hospital was more than 185 minutes.

The new guidelines leave no wiggle room for failure to meet these time frames, says Bracken. "While previous recommendations have been giving organizations time to get there, these new guidelines actually take us to where we should be," she underscores.

Obstacles to meeting the time frames include lack of cardiac catheterization lab capabilities and lack of quick access to cardiologists, says Bracken. "For small EDs, the challenge isn’t going to be new," she says. "They are just going to do it more quickly than they have in the past."

Door-to-balloon times often are delayed because you have to get the patient into the catheterization lab, notes Bracken. "Depending on what your cardiology facilities are like, you may have to wait until the previous patient is done. Or during an off-shift, staff may have to be mobilized from home, which increases the time," she explains.

Facilities with in-house resources are able to meet the balloon time much more quickly, but this will be a challenge for EDs without 24-hour resources, predicts Bracken. To address this, the guidelines recommend that EDs have agreements with centers that have catheterization labs and cardiac surgery capabilities. "Most facilities probably have these agreements in place, but this is the impetus to encourage those who do not, to develop them," she says.

The guidelines now recommend that patients with cardiogenic shock, severe congestive heart failure, and/or a high risk of dying should be transferred to a facility with cardiac catheterization laboratory capabilities, reports Bennewitz. "They specify that the patient should be transferred within 30 minutes," she says. "If you work at a hospital that does not have cath lab capabilities, your guidelines should include a mechanism to transfer a patient to a tertiary facility, if necessary, within 30 minutes."

  • Have a multidisciplinary team develop new protocols based on the guidelines.

You need guideline-based, institution-specific written protocols for triaging and managing patients with symptoms suggestive of STEMI, says Bennewitz.

Step forward and volunteer to be a resource to the committee or volunteer to participate, to make a direct impact on the protocol and make sure that the patients are getting the best possible care, urges Bracken.

"ED nurses need to get themselves involved in teams developing the protocols," she says. "And once the protocol has been developed, they need to drive implementation of the ED piece of it."

By being involved in the committee, you can look at outcomes to see the impact on the patient, says Bracken. "It would give you a more global view of the care of the patient from admission through discharge," she says.

  • Ensure all patients who present with chest discomfort or anginal equivalent receive a 12-lead ECG and it is shown to an ED physician within 10 minutes of arrival.

If the patient remains symptomatic, serial ECGs every five to 10 minutes or continuous ST-segment monitoring should be performed, says Bennewitz. "They also recommend performing right-sided ECGs on all patients with inferior STEMI," she says.

If the initial ECG is not diagnostic for STEMI, but the patient remains symptomatic and there is a high clinical suspicion, the guidelines state that serial ECGs must be performed at five- to 10-minute intervals, or you must perform continuous 12-lead ST-segment monitoring to check for potential ST segment elevation.

"That will have major impact in the ED, because the majority of them are not doing this at five- to 10-minute intervals," says Bracken. In fact, most EDs have protocols with serial ECGs performed at four- to six-hour intervals, she explains.

Either the ECG has to be done every five to 10 minutes, ST segment monitoring has to be performed (which has not been general practice in the ED), or the patient will have to be moved to a chest pain center or observation bed where this monitoring can occur, says Bracken.

"Whether it will be a nurse or technician that will have to do the serials, it’s definitely going to be a reallocation of resources to that specific patient population," says Bracken. "This will have a major impact on ED nurses, because if they are not doing the 12-lead themselves, they will need an ED tech dedicated to that patient pretty quickly and to remain with that patient to continue to do the serial ECGs as recommended."

The goal of the frequent monitoring is to catch MIs as soon as possible for patient who are having symptoms and have not yet had a diagnostic ECG, she explains. "The earlier you implement care, the better the outcome for the patient," says Bracken.

Sources

For more information on the care of patients with ST-segment elevation myocardial infarction, contact:

  • Elliott Antman, MD, Cardiovascular Medicine Division, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115. Telephone: (617) 732-7139. Fax: (617) 975-0990. E-mail: eantman@rics.bwh.harvard.edu.
  • Marli Bennewitz, RN, BSN, Chest Pain Center Coordinator, St. Jude Medical Center, 101 E. Valencia Mesa Drive, Fullerton, CA 92832. Telephone: (714) 992-3000, ext. 3463. Fax: (714) 992-3109. E-mail: mbennewi@sjf.stjoe.org.
  • Julie Bracken, RN, MS, CEN, Associate Director, Nursing Staff Development, University of Illinois Medical Center, 1740 W. Taylor St., Chicago, IL 60612. Telephone: (312) 996-9267. Fax: (312) 996-0630. E-mail: jbracken@uic.edu.