Some EPs unfamiliar with MI guidelines
Some EPs unfamiliar with MI guidelines
Liability risk is "significant" if staff don't follow current recommendations
by Staci Kusterbeck, Contributing Editor
A recent study has revealed that 28% of 509 emergency physicians (EPs) surveyed were not at all familiar, or only somewhat familiar, with the 2004 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (STEMI).1
"We found a lack of physician awareness of national treatment guidelines in the U.S., which means many patients may not be receiving the lifesaving treatments they need in a timely manner," says W. Frank Peacock, MD, the study's lead author and vice chief of emergency medicine research at The Cleveland (OH) Clinic Foundation.
Since the goal of treatment is to minimize damage to the heart muscle caused by a lack of blood flow stemming from a clogged artery, each minute that ticks by without treatment translates to more damage, disability and potential death, says Peacock.
The STEMI guidelines recommend mechanical reperfusion via percutaneous coronary intervention (PCI) if a patient can undergo the procedure within 90 minutes, known as the door-to-balloon time. If a patient cannot undergo PCI within this 90-minute timeframe, the guidelines recommend pharmacologic reperfusion via fibrinolytic therapy within 30 minutes, known as the door-to-needle time.
However, 51% of the EPs surveyed said that fibrinolysis-eligible patients would only sometimes, rarely, or never receive a fibrinolytic agent when the time to PCI exceeds 90 minutes. Nearly 70% of the physicians surveyed reported that it is not realistic that STEMI patients can undergo PCI within 90 minutes of medical contact for cases when patients need to be transferred to a PCI-capable hospital.
It was surprising that so many physicians admitted to being unfamiliar with the guidelines, says Peacock. "These are the best-referenced guidelines for the care of heart attack in the nation. They are the most evidence-based recommendations that exist," he says. In fact, the actual number of physicians unfamiliar with the guidelines is much higher than 28%, according to Peacock. "What was really surprising was that only 8% were able to identify the correct recommendation regarding treatment within the first 3 hours," says Peacock. "So although 72% thought they knew the guidelines, the overwhelming majority did not." Of those who said they knew the preferred strategy, 88% selected PCI and 4% selected fibrinolytic administration.
In actuality, neither strategy is preferred, which is an important distinction because it means that any delay in one procedure should prompt the immediate performance of the other, says Peacock. "Right now we have this bias toward intervention with the OR as opposed to opening of the arteries," he says. "It's all geared toward getting coronary intervention done, and that is only beneficial if it's done quickly. If it's done late, it's less than optimal."
Litigation regarding the diagnosis and treatment of myocardial infarction results in some of the largest monetary awards that emergency physicians encounter, says Peacock. "Liabilities are significant," says Peacock. "Patients with a bad outcome whose care does not adhere to guidelines represent the greatest risk for the hospital." Missed heart attack is not the most common award involving ED malpractice lawsuits, but it is the largest award, he notes. "It's even worse to get the diagnosis and not follow the guidelines," says Peacock. "Not knowing the recommended diagnostic and treatment strategies for this very common and very high-risk condition is just plain stupid."
There are indeed significant liability implications for EDs if the STEMI guidelines are not followed, says Bryan A. Liang, MD, PhD, JD, executive director of the Institute of Health Law Studies at California Western School of Law in San Diego, CA and co-director and adjunct associate professor of anesthesiology at University of California—San Diego School of Medicine.
Physicians are presumed to know the appropriate treatment for any condition, so lack of knowledge of the standard of care will put physicians in a "very risky position" if patient injury occurs, says Liang.
This is particularly true for heart attack patients coming to the ED, says Liang. "First, there is a significant risk of patient injury in these circumstances, and thus significant damages at stake. Second, these are national, highly respected guidelines that are published and available to ED physicians," he says. Since ED patients with cardiac symptoms are at risk for significant disability and death if not treated appropriately, there is an urgent need for ED personnel to be well-versed in the recommendations, says Liang.
"Appropriately structured quality improvement activities may be effective because they create a reason to pay attention to education," says Peacock. For example, objectively measure several process-dependent outcomes, such as time to treatment, time to diagnosis, and examine why specific treatments were selected. "With this method, where improvement is needed will become apparent," Peacock says. "Have an educational initiative for the staff. Then re-measure the outcomes to determine if the system is meeting the objectives, or if further work and education is needed."
ED directors and managers should survey staff, then create in-service training to address any knowledge gaps that exist, says Lang. "EDs must ensure that staff are well aware of important guidelines for this and other treatments," says Liang. "This is a systemic issue that needs to be addressed systemically."
Reference
1. Peacock W, Bhatt D, Diercks D, et al. American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the management of patients with ST-elevation myocardial infarction: Cardiologist and emergency physician opinions and knowledge. Ann Emerg Med 2006:48(4):S29.
A recent study has revealed that 28% of 509 emergency physicians (EPs) surveyed were not at all familiar, or only somewhat familiar, with the 2004 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (STEMI).Subscribe Now for Access
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