Minnesota Hospital Process Changes to Improve Use and Timing of Thrombolytics

These interventions were used by Minnesota hospitals as a part of the Cooperative Cardiovascular Project. This list was compiled by Stratis Health of Bloomington, MN, which is the peer review organization for Minnesota and worked with the hospitals to improve performance.

Hospital Process

• Administering thrombolytics

Move mixing of thrombolytics from pharmacy to critical care unit.
Administer thrombolytics in ED
Initiate thrombolytics without waiting for laboratory results (using ECG results instead).
Keep everything needed to administer thrombolytic in one place.
Streamline procedures for drug restocking and availability.
Drug kit should be user-friendly.

• Standing orders, protocols, pathways

Create standing orders that activate a flow sheet to help nurses document timing of thrombolytics — the flow sheet remains a permanent part of medical record.
Develop critical measure checklist.

• Laboratory

Prioritize lab work for chest pain patients.
Revise laboratory procedures.

• Nursing procedures

Admit distressed chest pain patients directly to ICU from ED without formal physician’s order.
Start IVs, ECG, X-rays and lab work without initial formal physician orders.

• ECG

Streamline procedure, preferably perform ECG in ED by RN.
Change ECG machine locations to make them more available in ED.
Dedicated machine situated directly in ED.

Resources

• Training

Cross-train nurses to work in different hospital areas.
Education of nurses is an automatic component of competency for working in the ED and ICU.
Train all physicians, internists and nurses working in the critical care unit.

• Staffing

ED and Urgent Care clinics are manned by physicians 24 hours a day, seven days a week.
Create a thrombolytic team: for example, at one hospital an emergency response team consisting of 4-5 extra people was created. They record, start a checklist, involve the ED nurse to move the process more quickly and are available at each shift to bring together the lab, ICU nurse, recording nurse, and 1-2 additional nurses to carry out the protocol. Each team member is cross-trained.
Revise on-call and staffing procedures for ED coverage.

Ambulance Process

Place ECG machine in ambulance to speed up process using the FAX via phone directly to the physician; print-out is available when patient arrives at ED (bought with community donations).

Physician Process

Involve physicians in quality improvement monitoring having them provide feedback to other physicians and act as "mentor" to ED staff.
Allow ED physicians more latitude in making decisions in the treatment of AMI patients.

Hospital Communication

Maintain close working relationship between ED and ICU.
Post and distribute ACC/AHA Guidelines for the Management of Patients with Acute Myocardial Infarction.

External Communication

Educate community about signs and symptoms of a heart attack and calling 911.
Conduct seminars for women sensitizing them to symptoms of heart disease and making them aware of lack of gender equity in areas of prompt treatment.