Will a STEMI patient survive? New evidence says your actions are key
Will a STEMI patient survive? New evidence says your actions are key
Emergency department delays linked to risk of death
Do all of your ST-elevation myocardial infarction (STEMI) patients receive treatment within recommended timeframes every time? If there are delays in primary percutaneous coronary intervention (PPCI) or fibrinolysis, these delays can significantly increase the patient's risk of death within 30 days, according to a study of 1,832 patients treated in 2006 and 2007 at 80 Quebec, Canada, hospitals.1
The study confirms the link between reduced mortality with faster treatment times, both with fibrinolysis and with primary angioplasty, according to Peter Bogaty, MD, one of the study's authors and a cardiologist at Laval Hospital's Quebec Heart Institute in Sainte-Foy, Quebec.
If primary angioplasty cannot be done in a timely fashion as recommended by guidelines, then generally, fibrinolysis should be favored, adds Bogaty. "The study suggests that the faster treatment, whichever it is, is associated with better survival," he says.
The study's findings indicate that regions and hospitals with shorter times to reperfusion, whether with angioplasty or fibrinolysis, increase the chance of survival for their patients. "Faster reaction time and reduction of time to reperfusion are lifesaving. This is more important than just believing that one treatment is better than another," says Bogaty. "Unfortunately, too often, as our study shows, treatment times are less good than they could and should be."
From the moment the patient with STEMI seeks help, whether by calling an ambulance or coming to the ED by her or his own means, "the clock starts ticking," says Bogaty. "Key issues are the rapidity of obtaining the first EKG, getting that EKG into the doc's face, and streamlining the subsequent therapeutic approach."
Eileen Negri, RN, CEN, an ED nurse and director of education services at Bronson Methodist Hospital in Kalamazoo, MI, warns that "When assessing patients for myocardial infarctions, misdiagnosis can have serious consequences." Here are ways Bronson's ED has reduced delays in STEMI treatment:
ED nurses are trained in 12-lead interpretations to be able to quickly recognize and re-triage cardiac patients.
"All nurses working at triage are required to attend a class to assist with the acuity and placement of these patients," says Negri.
12-lead EKGs are completed immediately at triage on patients not arriving by EMS.
"This has cut our door-to-EKG time down to four minutes," says Negri.
An acute myocardial infarction page is used for early notification of all essential team members.
The cardiac interventionalist, the catherization lab, the equipment management for infusion pumps, the ED pharmacist and the rapid response team are paged. Alison Hofheinz, MSN, CNS, the hospital's STEMI coordinator, says, "Notification is triggered immediately after the 12-lead EKG is reviewed by the provider and specific risk factors are assessed for the individual patient."
Rapid response advanced practice nurses gather data from the history and physical assessment, prior to the cardiologist's arrival in the ED.
These nurses stay with the patient in the ED, and during transport, until the handoff is made. "This eliminates the waste of valuable time usually spent non-productively," says Hofheinz. "It allows us to actively use this time to gather data and smooth the transition from ED to the lab for the patient."
Two-way hands-free communication devices are used between the cardiac catheterization lab and ED staff.
The catheterization lab technician can communicate with ED nurses as the patient is being transported. "This allows them to use their hands to continue to set up equipment needed for the procedure," says Hofheinz.
The cath lab nurse parks immediately outside of the ED with security assistance, rather than in the usual employee ramp a block from the ED.
"This eliminates wasting time walking this distance during an emergency situation," says Hofheinz. (See related stories below on getting patients to the cardiac catheterization lab and using standing orders to reduce delays.)
Reference
- Lambert L, Brown K, Segal E, et al. Association between timeliness of reperfusion therapy and clinical outcomes in ST-elevation myocardial infarction. JAMA 2010;303:2148-2155.
Source
For more information on care of myocardial infarction patients in the ED, contact:
- Peter Bogaty, MD, Quebec Heart Institute, Laval Hospital, Sainte-Foy, Quebec, Canada. Phone: (228) 809-5154. E-mail: [email protected].
- Alison Hofheinz, RN, MSN, CPNP, Trauma and Emergency Center, Bronson Methodist Hospital, Kalamazoo, MI. Phone: (269) 341-8964. Fax: (269) 341-8244. E-mail: [email protected].
- James Noland, CRNP, BC-PNP, MSN, CEN, CCRN, Emergency Department, Huntsville (AL) Hospital. E-mail: [email protected].
Speed cath lab arrival: Define clinical tasks "Getting a patient to the cath lab promptly requires the completion of multiple tasks," says James Noland, CRNP, BC-PNP, MSN, CEN, CCRN, an ED nurse practitioner at Huntsville (AL) Hospital. These tasks include starting intravenous lines, administering medication, collecting lab samples, shaving the patient, speaking with the family, and ensuring that all documentation is complete. Defining clinical duties gets the patient to the cath lab more quickly, Noland says. "For example, the ED tech always shaves the patient if needed, one nurse always inserts the IV, one nurse begins the documentation process, and the pharmacist prepares medications," he says. "This leads to increased efficiency and expedites the patient to the cath lab." |
Obtain important data on MI patient at triage 'Jump-start' the evaluation By using standing orders, ED nurses can gather data for the ED physician about acute myocardial infarction (AMI) patients, according to Jason M. Varsch, RN, CCRN, CCEMTP, an ED nurse at St. Joseph's Hospital and Medical Center in Phoenix. "This ultimately reduces delay in care," says Varsch. "Simply put, if the physician has all the data he or she requires, then the diagnosis can be made. The patient can be set to the cath lab or receive fibrinolysis sooner, thus decreasing further damage to the myocardium." St. Joseph's ED nurses obtain a chest X-ray, 12-lead EKG, and labs. "Nurse can initiate standard treatments which have been clinically proven to decrease mortality in patients suffering from myocardial infarction. These include aspirin, oxygen, peripheral intravenous access, and nitroglycerine," says Varsch. After a 12-lead EKG is done within five minutes and immediately given to the ED physician, blood is drawn for lab tests if the phlebotomist has not yet arrived. "Once the ED physician confirms a diagnosis of MI requiring cath lab intervention, the cardiologist, house manager, and cath lab are notified," says Varsch. "If it is at night, then the cath lab nurses are paged at home. A verbal report is given to them as they drive from home to the cath lab." Perform EKG at triage At Bronson Methodist Hospital in Kalamazoo, MI, a nurse-driven triage protocol allows for clinical decision making for any patient with acute coronary syndrome (ACS) symptoms. "This allows for a jump-start in the evaluation of ACS symptoms. It is often initiated prior to the medical screening exam," says Alison Hofheinz, MSN, CNS, STEMI coordinator and clinical nurse specialist for the Trauma & Emergency Center. The protocol includes orders for a 12-lead EKG, labs, administration of aspirin, and IV access. Bronson's ED nurses are all skilled in 12-lead interpretations. "The ability to recognize the significance of the ECG findings allows them to quickly re-triage the patient to the best treatment area currently available, based on their anticipated needs," says Hofheinz. Recently, a 30-year-old man without any cardiac history told a triage nurse that his upper body hurt. The nurse learned he was having pain in his chest, neck, and upper arms. After reviewing the EKG within three minutes of the patient's arrival, she placed the patient in a large trauma room instead of a regular treatment room. "This change was made in anticipation that an increased number of caregivers would be needed to simultaneously provide all of the care required if the patient went to the cath lab," says Hofheinz. The ED physician initiated the AMI page, 10 minutes after the patient's arrival. Upon arrival to the cath lab, his left anterior descending artery was found to be completely occluded. "Intervention to this artery was performed. The blood flow was restored 72 minutes after arrival," says Hofheinz. |
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