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Facilitating treatment in patients with stroke or chest pain through a dedicated ED chest pain/stroke unit

2002; Elsevier BV; Volume: 28; Issue: 4 Linguagem: Inglês

10.1067/men.2002.125654

1527-2966

Laura Bazarnick, Patricia Napolitano, Joanne Capodanno, Debra Graf,

Venous Thromboembolism Diagnosis and Management

Current management of acute myocardial infarction and stroke contrasts dramatically with the supportive care provided a decade ago. Early identification of myocardial infarction and stroke, and restoration when possible of coronary or cerebral perfusion, have been shown to improve outcomes in these patients.1Timm TC Ross R McKendall GR Braunwald E Williams DO the TIMI Investigators Left ventricular function and early cardiac events as a function of time to treatment with t-PA: a report from TIMI II (abstract).Circulation. 1991; 84: II-230Google Scholar, 2National Institute of Neurological Disorders and Stroke t-PA Stroke Study Group Tissue plasminogen activator for acute ischemic stroke.N Engl J Med. 1995; 333: 1581-1588Crossref PubMed Scopus (9747) Google Scholar The American Heart Association has joined the American College of Cardiology, the National Heart Lung and Blood Institute, and the National Heart Attack Alert Program to produce a series of recommendations and timed goals for the rapid identification and management of patients with acute myocardial infarction.3Ryan TJ Antman EM Brooks NH Califf RM Hillis LD Hiratzka LF et al.ACC/AHA Guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 1999; 34: 890-907Abstract Full Text Full Text PDF PubMed Scopus (717) Google Scholar, 4National Heart Attack Alert Program Emergency department: rapid identification of patients with acute myocardial infarction (DHHA publication No. NIH 93-3278). : Public Health Service, National Institutes of Health, Bethesda (MD)1993Google Scholar Likewise, the National Institute of Neurological Disorders and Stroke has recommended timed goals for the evaluation of stroke patients who are candidates for thrombolytic therapy5Advanced cardiac life support. : American Heart Association, Dallas (TX)1997: 9-1,Google Scholar(Table 1).Table 1Recommended timed goalsSuspected ischemic chest painArrival to 12-lead EKG10 minutesArrival to thrombolytic administration30 minutesStrokeArrival to physician examination10 minutesArrival to CT scan completion25 minutesArrival to CT scan reading45 minutesArrival to thrombolytic administration60 minutes Open table in a new tab The emergency department at Community Medical Center in Toms River, NJ, has developed a dedicated chest pain/stroke unit to provide such rapid assessment and early intervention. In this article we share our experiences in developing this unit. Community Medical Center is a 596-bed facility with 84,500 annual ED visits. Our treatment options for patients with myocardial infarction or stroke are limited to intravenous thrombolytic therapy; we do not currently have the ability to perform coronary angioplasty or cerebral intra-arterial treatment. The emergency department at Community Medical Center, which was originally built to treat 28 patients, has been subdivided to hold 46 patients. At any given time, up to half of the treatment bays are occupied by admitted patients waiting for inpatient beds. Although lack of physical space, holding of admitted patients, and an ever-increasing volume of incoming patients are problems common to many emergency departments, the emergency department at Community Medical Center is unique in that 28% of its primary service area is older than 65 years of age, compared with 13% in the general population.6Community medical center emergency department facilities planning, final report. : Health Strategies & Solutions, Inc, Philadelphia2000Google Scholar Until the chest pain/stroke unit was established, patients with chest pain or stroke symptoms were triaged on the basis of acuity, relative to all other patients in the emergency department. In 1999, 513 patients were admitted via the emergency department for stroke, and only 3 were identified and treated with a thrombolytic agent. This number dropped to 2 stroke patients identified and treated with a thrombolytic agent between January and August of 2000, even though the total number of stroke patients admitted via the emergency department during 2000 increased to 558. A retrospective analysis of patients with chest pain during May 2000 showed the following: These patients received an EKG, on average, 21 minutes after arrival (median, 17 minutes), regardless of an emergent triage level. Of the patients diagnosed with myocardial infarction and determined to be eligible for a thrombolytic, less than 30% received it within the recommended goal of 30 minutes from arrival. Through ED process improvement activities, we became aware of the need to provide more efficient and effective interventions for these 2 groups of patients. The process improvement team identified obstacles to meeting timed goals:•Large volume of patients presenting to the emergency department simultaneously•Overcrowding in the emergency department with no immediately available treatment bays•A large volume of “stat” tests, including computerized tomography (CT) scans, without a process to prioritize them, results in tests being done in timed order rather than by acuity•Inherent delays in the triage and registration process, which include completion of the nursing record and chart prior to being brought to a treatment area•Knowledge deficit of ED staff and prehospital personnel, including dispatchers, concerning the assortment of stroke symptoms and the impact of early intervention•Lack of public awareness of the importance of recognizing symptoms and seeking treatment early We decided that a dedicated rapid assessment area in the emergency department with treatment protocols for patients with chest pain or stroke symptoms had the potential to eliminate delays in the administration of definitive care, which could in turn decrease morbidity, mortality, and length of stay in these 2 groups of patients. Our team initially identified a consolidated 5-bed area, located in close proximity to the ambulance entrance, the triage room, and the critical care area of the emergency department, to rapidly move these patients to the treatment area. The administrative director of the emergency department assembled a team, including ED nurses, physicians, registrars, neurology nurses, a neurologist, the chairman of cardiology, a radiologist, the director of prehospital care, an information systems analyst, a pharmacist, and ED educators. Our team initially identified a consolidated 5-bed area, located in close proximity to the ambulance entrance, the triage room, and the critical care area of the emergency department, to rapidly move these patients to the treatment area. All staff associated with this program, including triage personnel, registered nurses (RNs), and licensed practical nurses (LPNs) attended a mandatory education session. This area was staffed 24 hours with an RN and an IV-certified LPN. We installed cardiac monitors and established criteria for patient entry to the chest pain/stroke unit (Table 2).Table 2Criteria for entry to chest pain/stroke unitChest pain• Chest pressure, fullness, pain, or squeezing• Pain radiating to the shoulders, neck, arms, jaw, or back between scapula• Chest discomfort or shortness of breath associated with lightheadedness, syncope, diaphoresis, or nausea• Feeling of impending doom• Epigastric pain• Chest discomfort with palpitations• Jaw pain• Unexplained syncopeStroke• Unilateral paralysis or weakness• Numbness• Language disturbance• Visual disturbance• Monocular blindness• Ataxia• Vertigo in association with any of the above• Altered level of consciousness• Any combination of the above Open table in a new tab We opened the unit on November 15, 2000. Any unstable patient is triaged directly to the critical care area of the department. Hemodynamically stable patients arriving via ambulance who meet the criteria are brought directly to the chest pain/stroke unit. Patients who meet the criteria and arrive via the ED lobby are identified by the triage nurse, who escorts the patient to the chest pain/stroke unit without delay at triage. While the chest pain/stroke unit nurse interviews and assesses the patient, the triage nurse notifies registration and assigns the ED physician. Registration is performed at the bedside after the initial assessment is completed. The chest pain/stroke unit nurse initiates nursing standing orders specific to the presenting complaint (Table 3).Table 3Nursing standing ordersAll patients• Vital signs with pulse oximetry• Document patient weight• Document time onset of symptoms• Insert saline solution lock 20 gauge or larger• Nasal oxygen 2 L per minute after pulse oximetry• Cardiac monitor• Draw labs from saline solution lock (rainbow)• 12-lead EKG• Obtain old EKG for comparison• Begin thrombolytic exclusion checklistNeurologic patients• Perform Accucheck blood sugar• No heparin, warfarin, or aspirin until ordered• Note obvious magnetic resonance imaging exclusion criteriaChest pain patients• Aspirin, 325 mg by mouth unless allergic or taken within 24 hours Open table in a new tab Then, after obtaining the 12-lead EKG, the nurse notifies the assigned ED physician, who examines the patient immediately. The physician initiates orders by using an ED order set in the computerized order entry system, specific to the patient's presenting complaint, to expedite care (Table 4).Table 4ED order setsSuspected stroke or transient ischemic attack• Noncontrast CT of brain (thrombolytic candidate vs noncandidate)• Transfer patient to critical care room or regular care area• Continue monitor• Complete blood cell count with differential, BMP-7, prothombin time, partial thromboplastin time, type and screen• Chest radiograph, portable or regular• Start additional saline solution lock• Labetalol, 10 mg IV over 2 minutes for manual blood pressure >180 systolic or >105 diastolic for 2 consecutive readings 15 minutes apart; may repeat every 10 minutes up to 150 mg or until blood pressure is <180 systolic and <105 diastolicSuspected coronary syndrome• Transfer patient to critical care room or regular care area• Continue monitor• Complete blood cell count with differential, BMP-7, prothombin time, partial thromboplastin time, type and screen, troponin I• Chest radiograph, portable or regular• Nitroglycerine, 25 mg in 250 mL D5W at 3 mL/h; increase by 3 mL/h until pain is relieved or systolic blood pressure is <100• Morphine, 2 mg IV every 10 minutes as needed for pain (not relieved by nitroglycerine); may repeat up to 10 mg, then notify physician• Metoprolol, 5 mg intravenous push over 5 minutes, repeat every 10 minutes × 2 Open table in a new tab Depending on the order selected, “thrombolytic candidate” or “noncandidate,” radiology is alerted to the urgency of the CT scan and or chest radiograph and are in agreement to take the patient first. We move thrombolytic candidates (either stroke or myocardial infarction), regardless of stability, to the critical care area of the emergency department to await the decision to treat. Noncandidates are moved into the main department to await results and disposition. Although the patients move out of the unit to another nurse, neither the patients nor the nurses mind because we have had good communication and continuity of care. Data are collected, concurrently, on every patient in the chest pain/stroke unit by the RN and LPN assigned to the chest pain/stroke unit area. The following data are collected: patient demographics, mode and time of arrival, time of 12-lead EKG, time of nurse assessment, time of physician assessment, time of CT scan if appropriate, patient eligibility for thrombolysis and time drug administered, diagnosis, and disposition. Data were compiled daily for the first 4 months of the program, then 3 random days per week for the subsequent 8 months. These data were aggregated monthly by an ED educator and reported at staff meetings, ED physician meetings, and the chest pain/stroke unit team meetings. No external funding was obtained for this process. We analyzed data on 3591 patients evaluated in the chest pain/stroke unit. The ages of the patients ranged from 12 to 102 years, with an average of 65 years. Fifty-five percent were female and 45% were male. Presenting complaints were 21% neurologic, 75% cardiac, and 4% syncopal. Sixty-nine percent of the patients in the chest pain/stroke unit were admitted to the hospital. Median door to physician examination times in all patients was 6 minutes (mean, 9 minutes). With cardiac patients, the median door-to-EKG time was 7 minutes (mean, 12 minutes). Seventy-five, or 3%, were diagnosed with acute myocardial infarction. Twenty-one of the 75, or 28%, received a thrombolytic, with an overall average door-to-drug time of 45 minutes. When the ED physician made the decision to give the drug, the average door-to-drug time was 29 minutes (N = 7), whereas when an attending physician or cardiologist made the decision, the average time was 52 minutes (N = 14). Of the 54 patients who were not thrombolytic candidates, reasons for ineligibility included non-Q wave infarction (31), time (12), advanced age (6), recent stroke or surgery (2), new lung mass (1), active gastrointestinal bleed (1), and cardiac arrest (1). Of the patients with neurologic complaints, 214, or 28%, were admitted with a diagnosis of stroke. During the course of the year, 10 stroke patients received a thrombolytic. The average door-to-CT scan time in the patients eligible for thrombolytics was 22 minutes. The neurologist was consulted in all cases. The average door-to-drug time in these patients was 83 minutes. The average door-to-CT scan time in the nonthrombolytic candidates was 62 minutes. It was not possible to accurately track the time of the CT scan reading in these patients. Of the 204 noncandidates, the reasons for ineligibility included outside time frame or onset unknown (144), mild or rapidly improving symptoms (24), confirmed or suspected intracranial bleed (18), advanced age/dementia (6), recent stroke (4), seizures (3), recent head injury or surgery (2), elevated partial thromboplastin time (1), severe deficit (1), and vaginal bleeding (1). Early problems with the program included reluctance on the part of triage nurses to send patients directly to the chest pain/stroke unit, and large volumes of admitted patients in the emergency department, causing a backlog in the chest pain/stroke unit and inability to move patients through. Triage nurses were surveyed to find out why they were reluctant to send patients directly to the chest pain/stroke unit. We found that they were uneasy about making a decision based on such a brief primary assessment, instead of the focused assessment to which they are accustomed. They thought that such a quick decision would mean that some patients might be inappropriate for the unit. To address the problem of backlogged patients, the chest pain/stroke unit team recommended that 2 beds be available in the unit at all times to accept patients with chest pain or stroke symptoms, even at the expense of having other patients wait in the lobby. During high-volume periods, this is not always possible, however, so we flag the triage note with a bright green sticker labeled “CPSU.” This sticker notifies the primary nurse to institute the standing orders and begin the appropriate process, regardless of where the patient is in the emergency department. In addition, we purchased a 12-lead EKG machine for the triage room and use it when the department is filled to capacity. Also, we shared follow-up information about patients' outcomes with staff, and this seemed to encourage the use of the unit more. Since the inception of the program, there have been no instances of a patient with a myocardial infarction being inadvertently detained in the waiting room, as had happened in the past during extremely high-volume periods. Triage nurses were surveyed to find out why they were reluctant to send patients directly to the chest pain/stroke unit. We found that they were uneasy about making a decision based on such a brief primary assessment. After 1 year, the process has become finalized. The literature reveals estimates that 20% of patients with acute stroke get to the hospital in less than 3 hours7Furlan AJ Acute ischemic stroke: new strategies for management and prevention (interview by Wayne Kuznan).Geriatrics. 1999; 54: 47-52PubMed Google Scholar and that only 2% are treated with a thrombolytic.2National Institute of Neurological Disorders and Stroke t-PA Stroke Study Group Tissue plasminogen activator for acute ischemic stroke.N Engl J Med. 1995; 333: 1581-1588Crossref PubMed Scopus (9747) Google Scholar, 8Bonnono C Criddle L Lutsep H Stevens P Kearns K Norton R Emergi-paths and stroke teams: an emergency department approach to acute ischemic stroke.J Neurosci Nurs. 2000; 32: 298-305Crossref PubMed Scopus (10) Google Scholar Our experience confirms these data. Seventy-one percent of our stroke patients are excluded because of the 3-hour window, and thus our chest pain/stroke unit team has begun to teach stroke awareness programs in the local community to address this issue. The recommended goal [with myocardial infarction] is to have appropriate patients receive thrombolytics within 30 minutes of arrival to the hospital. Our overall door-to-drug time is 45 minutes. Times of 60 to 90 minutes are reported elsewhere. Thanks to our overall program, we are able to meet the goal of 10 minutes to physician examination and 25 minutes to CT performance in stroke patients who are thrombolytic candidates. The average door-to-needle time in 2 large published studies of thrombolytics in the treatment of ischemic stroke (CASES and STARS) ranged from 90 to 96 minutes.11Albers GW Bates VE Clark WM Bell R Verro P Hamilton SA Intravenous plasminogen activator for treatment of acute stroke: the standard treatment with alteplase to reverse stroke (STARS) study.JAMA. 2000; 283: 1145-1150Crossref PubMed Scopus (622) Google Scholar, 12Hill MD Buchan AM the CASES Study Group The Canadian Activase for Stroke Effectiveness Study (CASES) (abstract S63.005).Neurology. 2000; 54: A390Google Scholar Some persons suggest that, in view of these 2 large studies, the 60-minute door-to-drug time is unrealistic and should be viewed as an ideal target rather than a criterion of successful practice.13Saver J, Kasner S, Levine S. Stroke research clarifies many questions. Available at: URL: http://www.medscape.com/viewprogram/448Google Scholar The CASES group data suggest that greater experience with t-PA administration in stroke leads to greater practice efficiency. The door-toneedle times at centers that treat 1 t-PA stroke patient per month was 98 minutes, versus 84 minutes at centers treating more than 1 patient per month.12Hill MD Buchan AM the CASES Study Group The Canadian Activase for Stroke Effectiveness Study (CASES) (abstract S63.005).Neurology. 2000; 54: A390Google Scholar, 13Saver J, Kasner S, Levine S. Stroke research clarifies many questions. Available at: URL: http://www.medscape.com/viewprogram/448Google Scholar Our experience is 83 minutes. Among the challenges in the care of patients with myocardial infarction are the significant delays that can occur in the emergency department before definitive care such as thrombolysis is implemented. The recommended goal is to have appropriate patients receive thrombolytics within 30 minutes of arrival to the hospital. Our overall door-to-drug time is 45 minutes. Times of 60 to 90 minutes are reported elsewhere.9Sharkey SW Brunette DD Ruiz E Hession WT Wysham DG Goldenberg IF et al.An analysis of time delays preceding thrombolysis for acute MI.JAMA. 1989; 262: 3171-3174Crossref PubMed Scopus (145) Google Scholar, 10Kline EM Smith DD Martin JS In-hospital treatment delays in patients treated with thrombolytic therapy: a report of the GUSTO time to treatment sub-study (abstract).Circulation. 1992; 86: 2793Google Scholar The chest pain/stroke unit program has successfully eliminated unnecessary delays in the door-to-data and data-to-decision phases in these patients and has achieved a door-to-EKG time of 10 minutes. The program has also heightened awareness of definitively treating stroke patients instead of just giving supportive care. An increased number of patients received a thrombolytic after compared with before institution of the program. The program has laid the groundwork to qualify for federal and state funding as a primary stroke center. In addition, standing orders such as automatic retrieval of old EKGs helps the physician make a decision. Prior to these standing orders, the physician had to request that an old EKG be obtained for comparison. Our chest pain/stroke unit is here to stay. In fact, a 7-bed chest pain/stroke unit will be incorporated into our new 74-bed emergency department, which is now being built.