EDs aren’t following heart attack guidelines: Revamp protocols now

Even smallest ED can meet recommendations for time frames

Minutes after a man dialed 911 and was rushed to an ED in rural Minnesota, the patient was on a helicopter being transported to a hospital 60 miles away to receive percutaneous coronary intervention (PCI) to open a blocked left anterior descending artery.

"The patient spent 17 minutes in the ED, 15 in the air, and in total took 61 minutes from arrival to the opening of a totally occluded artery," says Barbara Tate Unger, RN, FAACVPR, director of the Level 1 cardiac emergency program at the Minneapolis Heart Institute Foundation and Abbott Northwestern Hospital, also in Minneapolis. "He went home two days later."

This case is just one example of dramatic improvements in care received by heart attack patients in rural and community EDs as a result of the "Level 1 Heart Attack" program, a collaborative effort between the Minneapolis Heart Institute and 30 EDs.

Patients with heart attacks probably would expect that EDs are following current treatment guidelines, but this often is not the case. A new study reports that one-third of EDs are not complying with guidelines from the American College of Cardiology (ACC)/American Heart Association (AHA) for patients with ST-segment elevation myocardial infarction (STEMI).1

In 1994, the Bethesda, MD-based National Heart Attack Alert Program (NHAAP) gave specific recommendations to reduce delays in ED diagnosis and treatment for MI patients. The goal was — and is — 30 minutes from patient arrival to treatment. "In 2003, nearly 10 years later, 33% had neither written protocols nor guidelines in general for the process of managing the expeditious care required for the potential MI patient," says Mary Hand, MSPH, RN, coordinator for the NHAAP, who points to the study’s findings.

In addition, the updated 2004 ACC/AHA guidelines recommend that patients receive PCI within 90 minutes, and the surveyed EDs had an average time to PCI of 192 minutes. "The concern is that delays well beyond the 90 minutes will preclude patients from getting timely treatment," says Hand.

Hospitals put themselves at risk by not following the community standard of care for STEMI, which is spelled out in the ACC/AHA guidelines, says David Larson, MD, an ED physician at the 100-bed Ridgeview Medical Center in Waconia, MN, and the study’s author. "Having a written protocol is a tool that will help nurses and physicians follow the guidelines."

Delays and inconsistent care were identified at Larson’s own ED, which lacks a cardiac catheterization lab or 24-hour on-site cardiology. "We found that delays to reperfusion occurred while waiting to talk to the cardiologist," he says. "Also, the recommendations for a specific patient often depended on who the cardiologist was, and the time of day and day of the week."

The problems stemmed from the fact that the ED lacked a clear guideline for patients with STEMI. "I found that many EDs around the state had the same problems," says Larson. "This impression prompted me to do the survey."

The researchers discovered that even if EDs did have guidelines, they often did not address which patients get transferred and which receive thrombolytic therapy.

"I believe that we should be treating STEMI just like trauma: with clear hospital-specific guidelines that address triage and transport criteria," says Larson.

Smaller hospitals need help in doing this from their referral centers, he says. "This is exactly what is recommended in the most recent AHA/ACC guideline."

To address the problem, researchers developed the Level 1 program, with a goal of 90 minutes to treatment, even for EDs up to 240 miles away from receiving hospitals, reports Unger. Each of the 30 participating EDs now has a protocol that specifies exactly what treatment is given before a patient is transferred, including a rapid assessment, blood draws, chest X-rays, and medications, with the goal of transfer within 30 minutes.

As a result, medication compliance, lab testing, and patient preparation has improved dramatically at the participating EDs, reports Unger. (See steps of protocol, below.)

Criteria: ST-Elevation Myocardial Infarction or New Left Bundle Branch Block*

  • Activate team: Emergency physician and nurses, lab, and radiology
  • Dispatch transport team — helicopter or ground advanced life support. Consider fibrinolytic if anticipated delay in transfer
  • Contact Minneapolis Heart Institute (one phone call to activate)
  • Monitor, oxygen, intravenous (IV) line, and draw routine labs
  • Aspirin 325 mg by mouth
  • Clopidogrel 600 by mouth
  • Nitroglycerin 0.4 SL (repeat as needed or IV drip)
  • Heparin loading dose 60 u/kg (max 4,000 u), followed by continuous infusion 12u/kg/hr (max 1,000 u/hr)
  • Beta-blocker: Metoprolol 5 mg intravenously every five minutes x 3 (unless contraindications)
  • Morphine sulfate as needed for pain
  • Chest X-ray: Portable
  • Second IV (saline lock)
  • Attach hands-free defibrillation pads
  • Consider anxiolytic for transport
  • Transfer: In door — out door time goal fewer than 30 minutes

      * Onset of symptoms fewer than 12 hours.

Source: Minneapolis Heart Institute Foundation.

"They have prepared patients for an angio in as little as 14 minutes," she says. Average time to PCI decreased from 192 minutes to 98 minutes.2

This proves that even the smallest ED can comply with national guidelines and best practices for MI patients, says Unger. "Some EDs have a census of fewer than four patients a day and a staff of two," she says. "They may get one of these cases every two months."

Since ED nurses may rarely see MI patients, pocket cards were developed listing the steps of the protocol for quick reference.

Unger emphasizes that this is not a one-size-fits-all program. "Some EDs do not have a helipad, so ground transport to an airport is needed, but other EDs have an in-house lab, secretaries for faxing, and a helipad out the back door," she says.

However, every participating ED sets the same goal: A patient should be transferred within 30 minutes.

Only half of the EDs surveyed had quality assessment processes in place for STEMI. EDs need to monitor the time of the patient’s arrival and the time it takes to obtain an ECG, make a treatment decision, administer lytics, or time to PCI or transfer, says Hand. "Only by monitoring these times and regularly assessing and improving them can EDs feel confident they are continuously improving the care of the patient with an MI."

Nurses at the participating EDs now receive reports on compliance, such as whether patients received beta-blockers and aspirin, and they look for novel ways to cut delays, says Unger. "Before, nurses would know they had an MI in the ED, but there would be no follow up whatsoever," she says. "Now nurses can hear positive feedback on their work and feel more empowered."

Based on input from nurses, EDs have made practice changes such as having nurses perform blood draws while starting intravenous lines for angiograms and creating a tool box with prepackaged medications for quick access, says Unger.

Grand Itasca Clinic & Hospital’s ED in Grand Rapids, MN, is staffed with two nurses and a single physician. When a heart attack patient arrives, a group pager is sent to the intensive care unit, ED clinicians, laboratory, X-ray, registration, and respiratory.

"It was essential to make teamwork happen spontaneously with one call-out," says Kathy Helmbrecht, RN, ED clinician. "We need our two ED nurses to initiate care for our heart attack patient, instead of making phone calls."

Patients now are in a cath lab and under a cardiologist’s care at Abbott within 120 minutes from the time they walk in the door of the ED, she reports. "Our goal is to have the patient in and out of our ED doors in 30 minutes."

The page sets everything in motion simultaneously. For example, X-ray technicians bring the portable X-ray machine to the ED, process the chest X-ray, show it to the physician, then package it up to go with the patient to the receiving ED.

"A rural ED is not staffed like the metro EDs; our nurses need to wear multiple hats," says Helmbrecht. "But patients who come to our rural ED are within two hours away from a cardiologist’s care and the cath lab opening up a plugged artery to save their life."


  1. Larson DM, Sharkey SW, Unger BT. Implementation of acute myocardial infarction guidelines in community hospitals. Acad Emerg Med 2005; 12:522-528.
  2. Henry TD, Unger BT, Sharkey SW, et al. Design of a standardized system for transfer of patients with ST-elevation myocardial infarction for percutaneous coronary intervention. Am Heart J: In press.


For more information, contact:

  • Mary Hand, MSPH, RN, Coordinator, National Heart Attack Alert Program, National Heart, Lung, and Blood Institute, Bethesda, MD. Telephone: (301) 594-2726. E-mail: handm@nhlbi.nih.gov.
  • Kathy Helmbrecht, RN, Emergency Department, Grand Itasca Clinic & Hospital, Grand Rapids, MN. Telephone: (218) 326-7720. E-mail: Kathy.Helmbrecht@granditasca.org.
  • David Larson, MD, Emergency Department, Ridgeview Medical Center, Waconia, MN. Telephone: (612) 327-7885. E-mail: dlarsonmd@visi.com.
  • Barbara Tate Unger, RN, FAACVPR, Director, Level One Cardiac Emergency, Minneapolis Heart Institute Foundation/Abbott Northwestern Hospital, Minneapolis. Telephone: (612) 863-1213. E-mail: bjunger@charter.net.