Revamp your AMI protocol with new guidelines

It’s essential to revise your protocol to stay current with new guidelines for acute myocardial infarction (AMI) patients, urges Sandra Sieck, RN, cardiovascular community coordinator at Providence Hospital in Mobile, AL. New guidelines that recommend rapid diagnostic testing in the ED and new treatment modalities represent a paradigm shift in treatment.

The guidelines, published jointly by the Dallas-based American Heart Association (AHA) and the Bethesda, MD-based American College of Cardiology (ACC), stress early interventions in the ED, which lower overall costs, according to Sieck. "Who would ever guess the ED would be keeping up with the ACC/AHA guidelines? It is a change that will impact the hospitals economically and with great patient outcomes."

Sieck says if a patient presents to the ED with atypical symptoms of chest pain, and after a few minutes the symptoms are gone, the ED physician has two choices: "Either admit the patient and drive up health care costs, or discharge the patient and worry about a missed acute MI, which could lead to litigation."

Ultimately, in that scenario, the patient most often was admitted, says Sieck, adding that the guidelines gave new options for ED management of those patients.

No more hit or miss

Previously, ED interventions with cardiac patients was a hit-or-miss situation, she says. "Maybe a hospital had a systematic approach with an acute MI protocol, or maybe they just went by the way they always did things: judgment." ED managers have never really been concerned with the ACC/AHA guidelines because they would only have the patient for a short time, Sieck adds.

That’s no longer the case, she emphasizes. "The rapid testing, as in serial enzymes, has decreased our diagnostic times significantly," Sieck says. "There are even bedside assays available now."

At Providence, ED protocols were developed based on the guidelines. "This will produce an increase in quality of care, increase in revenue, decrease in cost, and decrease in length of stay," says Sieck.

Here are key points of the ED AMI protocol, which categorizes patients in one of four tracks:

Track I — AMI (inadequate distal collateralization) ST elevation enzymes on admission (0/hrs):

continuous cardiac monitoring;

— nitroglycerin, beta blockers, ace inhibitors (less than 5% of this population receive this drug), aspirin;

— primary treatment: reperfusion;

— thrombolytics, primary angioplasty or percutaneous coronary intervention.

Track II — Non-Q Wave/ Unstable Angina (with distal collateralization)Non-ST Elevation:

— enzymes 0, 3, 6, 9 hours;

— continuous cardiac monitoring;

— nitroglycerin, aspirin;

— primary treatment: prevention of total occlusion;

— anti-ischemic drugs;

— glycoprotein IIb/IIIa inhibitors (anti-platelets);

— low molecular weight heparins;

— if the patient is refractory to medical treatment, then the patient is sent to the cath lab.

Track III — Chest Pain of Probable Cardiac Origin:

— enzymes 0, 3, 6 hours;

— continuous cardiac monitoring;

— medications (nitroglycerin, aspirin given as needed).

Track IV — Chest Pain of NON-Probable Cardiac Origin:

— electrocardiogram, cardiac monitoring, labs;

— quickly identified after clinical judgment often found to be gastrointestinal, pneumonia, or musculoskeletal.

The first two tracks are geared around the concept of "acute coronary syndrome," which is discussed in the guidelines, Sieck stresses.

"Treatment should begin immediately in the ED. The patient should not be moved around the hospital for several hours, just because they did not have ST elevation," she says. "The goal is to begin treatment and carry out the disposition. Time is muscle!"

At Providence Hospital, 33% of all acute MIs diagnosed within the ED came from Track III, notes Sieck. "Where would they be if there was not a systematic approach to these patients?"

Track IV is for patients who are atypical presenters, with normal electrocardiogram, normal enzymes, and chest pain that comes and goes. "The question is, do you send them home or admit them?" asks Sieck. "This patient is held in the chest pain center until definitive tests are completed without the traditional 2.66-day stay." This clinical judgment is completed within nine hours or less, she adds.

Use the guidelines as a guide to change your protocols, Sieck urges. Consider these areas:

• Are your Track I patients getting ace inhibitors or beta blockers?

• Are you sending all Track II patients to the cath, or are you administrating anti-ischemic drugs, monitoring the patient for 12-23 hours and then sending a stable patient the cath lab the next day?

• Where are the track III patients within your institution?

"These are the questions you should be asking."

For more information about incorporating the guidelines into your ED protocol, contact:

Sandra Sieck, RN, BBA, Cardiology, Providence Hospital, 6801 Airport Blvd., Mobile, AL 36608. Telephone: (334) 633-1646. Fax: (334) 607-9145. E-mail: