Improve AMI therapy by working with ICU, ED
Hospital cuts waiting time 16 minutes
An Arkansas hospital has developed a case map to improve the administration of thrombolytic therapy to patients with acute myocardial infarction (AMI) that has reduced time to treatment from an average of 47 minutes to 29 minutes. Including the emergency department (ED) staff in the process was integral, says the intensive care unit (ICU) administrator who helped spearhead the effort, because they are the clinicians who initially evaluate patients.
Shirley Granderson, RN, director of the ICU at Crawford Memorial Hospital in Van Buren, AR, says that for the last two years, the intensive care unit (ICU) staff have worked with ED staff to study the time it takes a patient experiencing AMI to receive thrombolytic therapy on presentation to the ED. The study is part of the National Register of Acute Myocardial Infarction study, which is sponsored by Genentech in South San Francisco, CA, makers of the thrombolytic agent tissue plasminogen activator (t-PA). The study is ongoing at many U.S. hospitals.
"On original data collection and analysis, we discovered there was a delay in the treatment of the patient receiving thrombolytic therapy," explains Granderson. "Unnecessary delays included excessive time spent in the ED once the patient was diagnosed with AMI."
She says the hospital’s procedure required the ED physician to contact the attending physician regarding whether to administer thrombolysis, and a consulting physician was contacted to give the therapy. Additional time also was spent transporting the patient to the ICU to administer the thrombolytic agent.
"Clearly, our process didn’t facilitate efficiency, coordination, or timeliness, even though patient outcomes were satisfactory," Granderson notes. "The goal of this study is to ensure that all patients who present with a diagnosis of AMI and who receive thrombolytic therapy be treated within 30 minutes of presentation to the ED."
The following are some of the indicators being used in the study to measure outcomes:
• When the patient enters the ED complaining of chest pain, a 12-lead electrocardiogram (EKG) is obtained when there is a diagnosis of impending AMI.
• Lab work is completed, such as a complete blood count.
• The decision is made by the ED physician to deliver thrombolytic therapy.
• The thrombolytic agent is given.
Granderson says additional goals of the study included critiquing the process and monitoring and observing the thrombolytic patient.
Based on initial findings, a thrombolytic case map was developed as a collaborative effort, including the ED, ICU, and case manager.
"The decision was made to initiate thrombolytic therapy by the ED staff," Granderson says. "Inservices to ED nurses and physicians regarding procedures, complications, and the use of the thrombolytic agent were completed. Through the use of the case map and collection and analysis of data, we discovered that to ensure patients’ safety and optimal outcome, the thrombolytic therapy will be completed by the unit initiating it."
Granderson adds that having the therapy completed by ED staff allows for better continuity of care, and it saves time because patients aren’t being transferred elsewhere to receive thrombolysis.
Since the study began, she says the time from presentation to administration of the thrombolytic agent has decreased from an average of 47 minutes to 29 minutes. Granderson says she also has garnered the cooperation of the ED and attending physicians in devising the process and creating the case map. (See sample case map, pp. 173-174.)
"The ED physicians and staff are now competent to administer thrombolysis," Granderson says. "We anticipate better patient outcomes with fewer complications over time by expediting administration time. We have achieved improved interdepartmental communication within the facility by using a multidisciplinary performance improvement approach. The community and patients we serve have benefitted from our increased efficiency and coordination of care along the continuum."
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