Are you giving older MI patients poor care? Change your practice now
Are you giving older MI patients poor care? Change your practice now
Elderly patients aren’t being considered for life-saving interventions
If a 70-year-old man had a syncopal episode but reported he was undergoing radiation therapy, would you still suspect an acute myocardial infarction (AMI)? If a 90-year-old woman had several comorbidities, would you still consider all treatment options regardless of her age?
For the man with syncope, a 12-lead electrocardiogram (ECG) was done within minutes, and it was discovered that the man was having an AMI. "The key for this case was the screening net — assuming the cause could be cardiac," says Jennifer Williams, RN, BC, CEN, CCRN, clinical nurse specialist for emergency services at Barnes-Jewish Hospital in St. Louis.
A study has found that older patients presenting to the ED with AMI receive lower-quality medical care than younger patients. For example, these patients are less likely to receive effective therapies in the ED such as aspirin, beta-blockers, and reperfusion therapy.1
These patients could have poor outcomes that are avoidable, due to not getting appropriate interventions in the ED, says David Magid, MD, MPH, the study’s lead author and ED physician at the clinical research unit at Kaiser Permanente Colorado in Denver.
The patients in the study who did not receive treatment were clear-cut candidates, he adds. "There shouldn’t have been a lot of confusion," Magid says. "The people we identified as needing reperfusion therapy all had classic ECG findings. The patients who needed beta-blockers all had cardiac positive enzymes and were clearly having an MI."
Older patients have more comorbidities and illnesses, which makes them more likely to have adverse events or complications from medication therapy, says Magid. This may make ED staff reluctant to administer these medications, because they fear an adverse outcome, he adds.
"It may be that when staff see an 85-year-old patient, they assume they’re probably not a candidate without carefully evaluating it," says Magid. "But a lot of older patients are candidates for therapies. We should not automatically assume they are not, just because they are older."
Older patients also have a higher risk of death after a heart attack, notes Magid. "While there may be a higher risk of complications associated with these therapies in older patients, the benefits outweigh the risk," he says. "So by not giving these therapies to older patients, we may be depriving the patients who would benefit the most."
To improve care of older MI patients, try these:
• Perform a thorough assessment.
Kim Henson, RN, ED nurse at Spartanburg (SC) Regional Medical Center, says, "Sometimes a complete medical history and medication list may be missed, due to nurses being busy." This miss can result in medication interactions, unanticipated side effects, and overdoses, she adds.
• Use protocols to ensure consistent care.
At Spartanburg’s ED, whether the patients come in via ambulance or by car, they are placed on an acute coronary syndrome pathway, which means that a 12-lead electrocardiogram (ECG) is obtained within 10 minutes of arrival, and an intravenous (IV) line is immediately established with labs drawn, Henson explains.
Standing orders also include starting a heparin lock, lab tests, and administering aspirin therapy, nitroglycerin, morphine sulfate and possibly metoprolol tartrate, she adds.
When a patient with signs and symptoms of AMI presents to the ED at Barnes-Jewish, the nurse obtains a brief cardiac history and immediately obtains a 12-lead ECG, reports Williams.
"The nurse asks the patients if they are diabetic, if they have a history of hypertension, cardiac disease, or intervention, and the time of onset of symptoms," she says.
If the ECG results reveal an AMI, the patient is immediately moved to a treatment room for further examination. At that point, the decision is made to administer thrombolytics, take the patient to the cardiac catheterization lab, or medically manage the patient, says Williams. "Our protocols allow for all patients to have the same screen, regardless of their age," she says. "This prevents a subjective bias based on age."
• Don’t overlook vague complaints.
Older patients may complain of generalized aches and pains or weakness, which can be dismissed as arthritis, neuropathy, fibromyalgia, or confusion, says Henson. "Sometimes older patients have difficulty describing specific complaints," she says.
Even if older patients report only vague symptoms, you always should consider the possibility of an AMI, says Williams.
"Older patients may not describe their symptoms in the typical manner," she emphasizes. "Be very suspicious of vague abdominal pain, nausea, back pain, and general weakness. Assume all syncopal episodes and falls are of cardiac origin until proven otherwise."
• Involve family members as needed.
Older patients may be reluctant to undergo emergent procedures, Williams explains. "Taking the time for explanations and family involvement can assist with addressing the emergent need for intervention," she says.
After the decision was made for an elderly man to go to the cardiac catheterization lab for treatment, he insisted on his wife being notified first. "She was not in the facility at that point, but needed to be contacted at the patient’s request," says Williams.
Having contact information available enabled the staff to contact the man’s wife quickly, and the patient was reassured and agreed to the intervention, she recalls. "Make sure that you get emergency contact information before you let the family leave so that you can contact them immediately," says Williams.
Reference
- Magid DJ, Masoudi FA, Vinson DR. Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients. Ann Emerg Med 2005; 46:14-21.
Sources
For more information on care of older myocardial infarction patients in the ED, contact:
- Kim Henson, RN, Emergency Department, Spartanburg Regional Medical Center, 101 E. Wood St., Spartanburg, SC 29303. Telephone: (864) 560-6000. E-mail: [email protected].
- David Magid, MD, MPH, Clinical Research Unit, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 90237-8066. Telephone: (303) 636-3131. Fax: (303) 636-3109. E-mail: [email protected].
- Jennifer Williams, RN, BC, CEN, CCRN, Clinical Nurse Specialist, Emergency Services, Barnes-Jewish Hospital, Mail Stop 90-21-330, St. Louis, MO 63110. Telephone: (314) 747-8764. E-mail: [email protected].
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