Heart Attack Delays Still High-risk for ED

Delays for treatment for heart attack patients will continue to be a high-risk area for EDs legally, predicts Robert L. Norton, MD, a professor in the Department of Emergency Medicine at Oregon Health & Science University in Portland.

From 1997 to 2004, waits increased for heart attack victims from eight to 20 minutes, according to a study done by Harvard Medical School researchers that looked at 90,000 ED visits.1

"These findings surprised me," says Andrew Wilper, MD, the study's lead author and Assistant Professor of Medicine at University of Washington School of Medicine. "Given the emphasis on timeliness of care for patients suffering from an acute myocardial infarction, I did not suspect such dramatic increases in waits."

In some cases, an appropriately triaged patient's EKG doesn't meet criteria for an ST-wave elevation myocardial infarction (STEMI), but subsequent EKGs for the same patient later show a STEMI. This can lead to a malpractice lawsuit alleging delay in treatment, says Norton, even when care was appropriate.

The door-to-balloon time interval begins at the patient's arrival, he explains, but some time may have passed before the EKG shows diagnostic findings for STEMI.

"This leads to the door-to-balloon time interval exceeding the goal when, in fact, there was no delay in the diagnosis," says Norton. "The process of myocardial infarction is dynamic."

Non-English-speaking patients and cultural differences in expressing symptom complaints contribute to some delays in ED heart attack care, says Norton, as well as daily and hourly variations and surges in the number of patients presenting to the ED.

"Our efforts are directed toward improvements in processes so that we provide high-quality, evidence-based treatment for patients with heart attacks," says Norton. "We believe that this will also reduce our legal risk."

Crowding Adds to Legal Risks

John Tafuri, MD, FAAEM, regional director of TeamHealth Cleveland (OH) Clinic and chief of staff at Fairview Hospital in Cleveland, says that overcrowding and cost-cutting are "definitely playing a role in delaying treatment" in EDs, including care of heart attack patients.

"The attorneys are not focused on the reasons why. They are solely focused on the fact that the delay occurred," says Tafuri. "The trick for them is to demonstrate to the jury that the delay affected the outcome of their client's medical recovery."

Hospitals are not staffing EDs as generously as they have in the past because of decreased reimbursements and higher costs, he says, and more physician offices are referring patients to the ED.

Higher ED volumes are partly caused by private physicians booking their schedules more tightly, with less room to accommodate patients with emergent or semi-emergent problems, says Tafuri, and the fact that many patients are without primary care physicians.

"The more people you put through that system, the more likely it is that somebody who is critically ill will get delayed treatment," he says. Here are risk-reducing strategies to avoid delays in heart attack treatment:

• Perform EKGs at triage.

"Within 10 minutes of arrival, the ECG has to be done and shown to the ED attending, who has 60 seconds to decide STEMI or no STEMI," says Kevin Brown, MD, MPH, FACEP, FAAEM, principal with Brown Consulting Services in Armonk, NY, and former director of the department of emergency medicine at Greenwich (CT) Hospital.

Brown has reviewed lawsuits in which a markedly abnormal ECG was disregarded by the ED medical staff because it didn't fit the clinical picture, as in the case of what appears to be a back or shoulder strain but turns out to be a missed unstable angina or myocardial infarction, with the patient inadvertently discharged.

"The defense of 'I didn't order the ECG, the triage nurse did,' is not a sound argument," says Brown. "It will not engender empathy from a jury because it shows that the nurse was considering a cardiac issue but the physician wasn't, should an acute MI be delayed from being treated or, worse, be discharged."

If the EP is faced with an abnormal ECG and it doesn't fit the clinical picture, an explanation is needed for why it doesn't. "Don't just disregard the study," says Brown.

The EP should consider sending two troponins, at least four hours apart, he advises, to detect the case that presents before there is a bump in the cardiac marker, obtain an old ECG to compare it with, and look at the prehospital 12-lead.

"Above all, make sure to document your reasoning in the EMR for why you feel this isn't an acute coronary event," says Brown. "If absent, the opposing attorney will try to make it seem that you didn't appreciate the ECG's significance or failed to take it into your clinical decision making."

The ST elevations recorded on the prehospital 12-lead may have resolved with the oxygen, aspirin, and nitroglycerin given before the patient arrived, he explains.

It is commonplace for the initial ECG to be normal or nonspecific with mild ST-T wave abnormalities when first done, notes Brown. In patients at risk for an acute coronary syndrome with ongoing chest pain and an ECG that is normal or has nonspecific findings, he recommends doing serial ECGs at least every 30 minutes for the first hour and a half if the patient remains symptomatic so that labile T waves or transient ST segment changes can be detected.

Be sure that triage personnel, ED nurses, and physicians are aware that patients, particularly older women, may present with atypical symptoms.

Brown says that in any ED, patients with vague, atypical symptoms, such as a patient with vomiting and epigastric pain that appears to be just another gastroenteritis case, will "slip through the net" and remain in the waiting room or get sent to the ED's fast track.

"The worst combination is a patient who has an atypical presentation and a nonspecific ECG," says Brown. "Waiting for a positive troponin usually tacks on an additional 60 minutes, unless your ED does in-house stat troponins."

Tafuri says that most cases he's reviewed involving ED delays in heart attack care had plaintiffs who presented with atypical symptoms, such as an elderly woman with nausea experiencing a STEMI.

"Most frequently, it isn't a classic chest pain type of thing, and symptoms are relatively nonspecific," Tafuri says. "In those populations, you have to maintain an extra level of vigilance. Treat those patients very aggressively in terms of how you triage and reevaluate them."

The fact that a patient came in with very vague symptoms and didn't get immediate care "could mitigate it somewhat in the eyes of the jury," he says. "It all depends on how the attorneys present the case. Certainly, you are much worse off if someone comes in with classic heart attack symptoms and has a delay in treatment."

However, just because a patient has atypical symptoms doesn't mean a jury won't find against you, he warns, particularly if there were other indications that suggested the patient was seriously ill, such as abnormal vital signs.

"The public is more aware of atypical presentations, particularly in women," says Tafuri. "In general, the public expectation of medical care has been raised substantially. The expectation is much higher than it was 20 years ago."

Jurors aren't likely to be sympathetic to delays in care for a heart attack patient, he adds, regardless of the reason. "The perception is such delays should not occur," says Tafuri. "In certain cases, there may be a very sympathetic physician who could convince a jury that it was beyond his or her control. But such cases are rare."

• Implement standing orders at triage.

ED triage nurses at Oregon Health & Science University utilize nurse-initiated orders to obtain EKGs for patients with specific chief complaints more quickly. EKGs are completed within five minutes of the patient presenting to triage, and are immediately reviewed by an EP to determine whether criteria for a STEMI are met. "This has greatly reduced our time from triage to activation of the STEMI team," reports Norton.

• Have a well-coordinated STEMI team in place, with specific roles and responsibilities.

Once Oregon Health & Science University's STEMI team is activated, a rapid response team nurse presents to the ED to assist with emergency care of the patient, adding nursing resources to the ED nursing team.

"The catheterization laboratory team is activated. The interventional cardiologist is notified and begins preparation for receiving the patient in the cath lab," says Norton.

• Ensure that EMS performs 12-lead EKGs in the prehospital setting.

"Our EMS has this capability," reports Norton. "With this system in place, we have significantly reduced our door-to-balloon time."

If the paramedic recognizes or suspects a STEMI, the EKG is transmitted to the receiving ED and the STEMI team is activated, all before the patient's arrival.

• Review all STEMI activations with the emergency medicine team, the cardiology team, and the EMS team.

The goal is to review what went well and what needs improvement. "If system obstacles are identified that may have led to delays, then action plans are initiated to address those system issues," says Norton. "Our STEMI team meets bimonthly to review all STEMI cases."


1. Wilper AP, Woolhandler S, Lasser KE, et al. Waits to see an emergency department physician: U.S. trends and predictors, 1997-2004. Health affairs 2008;27(2):w84-w95.


For more information, contact:

• Kevin Brown, MD, MPH, FACEP, FAAEM, Brown Consulting Services, Armonk, NY. Phone: (914) 760-8632. E-mail: krbrownmd@verizon.net.

• Robert L. Norton, MD, Professor, Department of Emergency Medicine, Oregon Health & Science University, Portland. E-mail: nortonr@ohsu.edu.

• John Tafuri, MD, FAAEM, Regional Director TeamHealth Cleveland Clinic. Phone: (216) 476-7312. Fax: (440) 835-3412. E-mail: jotafu@ccf.org.

• Andrew Wilper, MD, School of Medicine, University of Washington. E-mail: andrew.wilper@va.gov.