Are you giving poor care for acute coronary syndrome?
Are you giving poor care for acute coronary syndrome?
Is your ED complying with current guidelines for patients with acute coronary syndrome (ACS)? Evidence-based interventions are not being done for some non-ST segment elevation ACS patients with elevated troponin levels, according to a new study.1 Researchers found that 10%-20% of these patients do not receive established medical therapies such as aspirin or heparin within 24 hours, and 30% don’t undergo cardiac catheterization during their hospital stay.
To improve care of ACS patients, do the following:
• Once a patient is found to have an elevated troponin level, implement appropriate therapies without delay.
These include aspirin, heparin, beta-blockers, and GP IIb/IIIa inhibitors, if catheterization is planned, says Matthew T. Roe, MD, MHS, assistant professor of medicine at Duke University Medical Center in Durham, NC, and the study’s principal investigator.
• Have systems in place to quickly recognize elevated troponins.
In addition, ACS treatment algorithms should be established so that patients with elevated troponins are consistently treated with evidence-based therapies regardless of the time of day, time of troponin elevation after hospital arrival, treating physician, cardiologist on call, location of the patient when troponin elevation is first recognized, or volume of patients in the ED, says Roe.
ED nurses should be proactive at following up on troponin results, alerting ED physicians of patients with elevated troponins, and prompting appropriate medical therapies based upon ACS treatment algorithms, he says.
"Furthermore, ED nurses who work in triage should carefully evaluate patients without classic chest pain symptoms but with symptoms such as shortness of breath, weakness, back pain, epigastric pain, and fatigue, so that timely ECG [electrocardiograms] can be obtained and patients with ACS with atypical symptoms can be recognized earlier," Roe says.
• Don’t miss signs at triage.
The patient’s family history and appearance are important to consider, says Cindy Westhafer, RN, CEN, assistant unit director of the ED at Santa Monica-University of California, Los Angeles (UCLA) Medical Center. Be aware of how they look in terms of skin color, moisture, and general respiratory effort, she says. "Having nausea, dizziness, syncope, or near syncope should increase your level of concern," she says. "Vital signs are not terribly helpful unless they are abnormal."
• Look for atypical presentations.
Atypical presentations include pain in jaw or other nonchest areas, or an overwhelming sense of tiredness. "If coupled with nausea, diaphoresis, dizziness, syncope or near-syncope, they are more concerning," says Westhafer. She gives the following examples of patients treated in her ED whose ECGs revealed they were having a myocardial infarction:
— A man in his 30s complaining of mild left shoulder pain who was slightly diaphoretic and had a grayish look. "The nurse who saw this patient thought he didn’t look right before she had even spoken to him," she says.
— A woman in her early 50s who felt that something was wrong but had no specific complaints. "She felt embarrassed to have come to the ED, but wanted reassurance that she was OK," says Westhafer.
— A man in his mid-60s with no chest pain complaining of vomiting.
— An 86-year-old woman who had broken her left shoulder two weeks earlier and who complained of increasing pain.
• Avoid delays in care.
When a patient presents with chest pain at Santa Monica-UCLA’s ED, these steps occur:
— A 12-lead ECG is done and shown to the ED physician for interpretation within 15 minutes.
— If the patient has acute changes indicating an acute myocardial infarction (AMI), the patient’s cardiologist or on-call cardiologist is contacted.
— The cardiac catheterization team is activated. "We have an average ED door-to-cath room time of about 40 minutes," says Westhafer.
For patients whose chest discomfort is now gone, with no changes or nonspecific changes on their ECG, the same steps are done as for the AMI patient "except now we have the luxury of time," says Westhafer. These patients are placed on a cardiac monitor, pulse oximetry, and given oxygen at 2 L/m, given aspirin 325 mg, unless they have allergies to aspirin or other contraindications, with intravenous access obtained, ECG performed, and lab work done including a complete blood count, basic metabolic panel, Troponin I, and coagulation panel.
"If the chest discomfort or previous symptoms returned or became worse, we would repeat the ECG," says Westhafer. "About 90% of the decision on admitting a patient for ACS is based on their presentation and history, which is then proved or disproved over the next 24 hours by diagnostic testing."
Reference
- Roe MT, Peterson ED, Pollack CV, et al. Influence of timing of troponin elevation on clinical outcomes and use of evidence-based therapies for patients with non-ST-segment elevation acute coronary syndromes. Ann Emerg Med 2005; 45:355-362.
Sources
For more information on improving care of ACS patients, contact:
- Matthew T. Roe, MD, MHS, Division of Cardiology, Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27705. Telephone: (919) 668-7059. E-mail: [email protected].
- Cindy Westhafer, RN, CEN, Assistant Unit Director, Emergency Department, Santa Monica-University of California Medical Center, Los Angeles, 1250 16th St., Santa Monica, CA 90404. E-mail: [email protected].
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