Are cardiac patients waiting too long in your ED? Cut dangerous delays now

You may have an AMI sitting in your waiting room

(Editor’s note: This is the first of a two-part series on improving care of ED patients with chest pain. This month, we give strategies to reduce door-to-needle time. Next month, we’ll report on improving assessment of women with heart attack symptoms.)

You already know overcrowding in your ED leads to lower patient satisfaction and higher stress levels. But crowded waiting rooms can be deadly to heart attack patients due to longer waits to receive lifesaving clot-busting medications, according to a new study.

Researchers found the median door-to-needle time for 3,452 acute myocardial infarction (AMI) patients treated at 25 EDs in Ontario, Canada, from 1998 to 2000 ranged from 40-47 minutes, depending on the size of the crowds in the ED.1

"We know that every minute counts for heart attack patients," says Michael J. Schull, MD, the study’s principle investigator. Schull is an ED physician at Sunnybrook and Women’s Hospital and scientist at the Toronto-based Institute for Clinical Evaluative Sciences. "Crowded conditions in the ED represent high-risk situations for cardiac patients."

To dramatically reduce treatment delays for chest pain patients, do the following:

  • Use standing orders at triage.

Obtain electrocardiograms (ECGs) at triage, and repeat these periodically if an at-risk patient is kept waiting, Schull suggests. "The more you make things routine, the more likely they are to happen," he says. "Nurses need to be aware that they may have an AMI sitting in their waiting room."

At University of Michigan’s ED in Ann Arbor, standing orders are used for any patient with a suspected AMI, with a 12-lead ECG given within five minutes and read by the attending physician within 10 minutes. "We also have a stat page that goes out to our interventional cardiology team 24 hours a day, so we can get the patient moving to the cath lab right away," says Lori Pelham, RN, ED clinical nursing supervisor.

In addition, nurses are able to access any previous ECGs done in the hospital, to provide a comparison ECG for attendings to view immediately.

Standing orders for chest pain include notifying the attending of the patient’s arrival; giving oxygen at 2 L/min; placing patients on a monitor; obtaining vital signs; starting an intravenous line; obtaining a complete blood count, electrolytes, partial thromboplastin time, plasma thromboplastin, and cardiac markers; giving aspirin; and administering nitroglycerin at the bedside.

To speed care, triage screeners assess patients the instant they walk in the door, adds Pelham. "This is in addition to our focused assessment area," she says. The triage screener is the first person that the patients see when they arrive, Pelham says. "Their job is to ask just enough questions to decide what priority the patient is," she adds.

  • Collect data electronically.

"Whenever you collect data of any kind manually in an ED, you’re not going to get valid data — it’s going to be all over the board," says Johnny Veal, RN, MSN, director of nursing for cardiac, emergency, AirCare, and trauma services at Wake Forest University Baptist Medical Center in Winston-Salem, NC.

When the ED set a goal of decreasing door-to-balloon times for AMI patients in May 2003, data were collected manually for time of arrival, triage, time the patient saw a physician, and the time he or she left the ED, but it was not very accurate, says Veal.

The ED invested in an electronic tracking system (manufactured by Burlington, VT-based IDX) to automatically capture this data.

"So we can pull that together and review each of those time segments; whereas before, we just didn’t have the ability. The more data that can be collected electronically in the ED, the better," says Veal, adding that data still are collected manually for door-to-notification, notification-to-arterial access, and arterial access to percutaneous coronary intervention.

After process changes were implemented, mean door-to-balloon time decreased from 120 minutes to 100 minutes, with 80% of patients getting to the lab within 90 minutes, he reports.

  • Give nurses extensive education.

At Wake Forest’s ED, nurses were given mandatory education on acute coronary syndrome and how it’s treated.

"We wanted our triage nurses to be able to read an ECG and identify different types of MIs," Veal points out. "They need to know if we are dealing with an ST-elevation MI patient with one look at the patient’s ECG."

This speeds identification of AMI so the patient gets treatment more quickly, he explains. "The sooner they get to the cath lab, the lower the mortality rate," Veal says.

A presentation and post-exam was made available via a nursing intranet site, so nurses can complete the inservice on-line. "This makes it less of a hassle for nurses," says Veal. They can do this anytime, if they have downtime at 2 a.m."

  • Streamline the process for reviewing ECGs.

Previously, if a patient’s ECG showed ST segment elevation and symptoms of a heart attack, the ED attending would consult with the cardiology fellow, who then would contact the cardiology attending, says Veal. "Now they bypass that completely and go directly from the ED attending to the cardiology attending," he says, adding that about 10-15 minutes are saved with the new process.

  • Review cases to pinpoint delays.

At Wake Forest, all cases that fall outside the ED’s criteria for door-to-balloon times are reviewed by the ED and cardiology chairs to identify areas that need improvement. Chart reviews revealed that after the decision was made to administer thrombolytics, transport to the cath lab was delayed.

"One issue was that there was too much time wasted trying to call in the actual crew, which was very time-consuming," says Veal.

The hospital’s dedicated physician access line, which is used to call in specialists, is now used to deploy the cath lab team. "Once it’s confirmed that the patient has to go, the ED can make one call, and the access line takes care of all the rest," he says.

  • Be able to do a quick ECG at triage.

To ensure a door-to-ECG time of 10 minutes or fewer, you should have a place next to triage to do the ECG so no transport is needed, recommends Schull. "Ideally, this should be right in the triage area, with adequate privacy for patients," he says.

When Wake Forest’s triage area was renovated, an ECG room was added. "We felt it was important to have a designated area to rapidly place patients where an ECG can be done immediately," says Veal.

  • Keep cath lab supplies in the ED.

At Wake Forest’s ED, a "cath lab box" contains consent and standard order forms, radiolucent defibrillator pads, instructions for patient preparation in the ED, and an elevator key for quick access to the cardiac catheterization lab. ED nurses now complete needed documentation and place pads on patients before they are transported.

"Before, all of that had to be done in the cath lab, which just slowed things down," Veal continues.

"Since we now have those special supply items in the ED, it is just one less thing that the cath lab does not have to do, so they can concentrate on setting up for the procedure," he adds.

  • Work as a team to give patients loading doses.

Previously, patients were given loading doses of abciximab and heparin with the infusion prepared in the ED. "That took some time, because those drugs require a loading dose and then a drip to follow," says Veal. "The drip had to be mixed by the pharmacy, which is a delay."

Now, ED nurses administer the bolus while the cath lab is preparing the infusion, which saves valuable time. "So we have a rapid transport out of the ED to the cath lab vs. waiting to get the infusion from our pharmacy," he adds.

Reference

1. Schull MJ, Vermeulen M, Slaughter G. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med 2004; 44:577-585.

Sources

For more information on reducing delays in caring for chest pain patients, contact:

  • Lori Pelham, RN, Clinical Nursing Supervisor, Emergency Department, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. Telephone: (734) 647-7565. E-mail: lpelham@med.umich.edu.
  • Michael J. Schull, MD, MSc, G-106, Institute for Clinical Evaluative Sciences, 2075 Bayview Ave., Toronto, Ontario, Canada, M4N 3M5. Telephone: (416) 480-6100, ext. 3793. Fax: (416) 480-6048. E-mail: mjs@ices.on.ca.
  • Johnny Veal, RN, MSN, Director of Nursing, Cardiac/Emergency/AirCare and Trauma Services, Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157. Telephone: (336) 716-3809. Fax: (336) 716-3427. E-Mail: jveal@wfubmc.edu.