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EKGs in triage?

Emergency   (7,783 Views 22 Comments)
by etceducator etceducator (New Member) New Member

etceducator has 9 years experience and specializes in emergency/ peds ER.

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We are looking for a way to decrease our door to EKG time (particularly for possible STEMI patients). Do any of you do EKGs in triage to screen patients for possible MI? If so, how do you do this? I vaguely remember learning that EKGs need to be done supine (not sitting), but I am trouble finding written evidence. Any suggestions? I am trying to write a protocol, and get the necessary equipment in the triage room (stretcher vs. reclining chair). I need to justify what I recommend. Any help would be greatly appreciated. Thanks!

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BULLYDAWGRN has 10 years experience as a RN and specializes in ICU/ER/TRANSPORT.

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This is and idea that has been passed around at many of the part time/prn hospitals I work at as well as the full time place where I work. It was even done at one on a trial basis, the problem was lack of space and staff and triage being slowed down. The triage rooms where I work arent very big at all, and really could'nt support a stretcher or bed.. I do believe ekgs should be done suspine or modified fowlers position. What we do is probably in line with everyone else, chest pain pt get first dibs to the triage room, rapid triage assessment done, b/p,temp,hr,spo2 and we may get a quick 3 lead strip depending on your pulse rate or if you feel fluttering in chest. Placed on 02, call report to er team leader, pt is then taken straight back to er room in w/chair. I think ekgs in triage could do ok in larger facilities that have larger triage rooms, not the triage closets that I work in and that have more than one triage nurse to help clear the waiting room when the other triage nurse is taking some extra time doing an ekg.

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neneRN has 8 years experience as a BSN, RN and specializes in Emergency, Trauma.

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We currently have a Chest Pain Screening Area back in the treatment area staffed with an RN and a tech to do an EKG, IV, bedside labs/troponins, screen for risk factors, and give ASA. Now that we're an accredited chest pain center, we are really trying to get that door to EKG time down to under 10 minutes...so we are now redesigning triage to have the CPSA out in triage instead. Then, the triage nurse can triage at the same time the screening is being done.

We've also started doing just an abbreviated triage on all chest pain pts...instead of doing the whole triage form with entire med/surg Hx and med rec form, they now ask only allergies, cardiac Hx and brief assessment of chest pain. Then the rest of the triage form, including the med reconciliation sheet is completed later on by the nurse who ends up with the pt. This way, the initial triage takes just a couple of minutes.

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casi has 3 years experience as a ASN, RN and specializes in LTC.

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Not a nurse yet, but my mom recently had herself a heart attack and went to one of the smaller hospitals in the area. They do EKGs at traige in a nice little closet behind the traige desk that they converted into a nice little closet with a gurney and a privacy curtain. Then they have a PA/NP that can come in right away and get necissary orders started.

The biggest problem I saw with this is it takes the one and only traige nurse out of traige action and slows things down quite a bit. Because the only triage nurse is held up starting IVs and administering medications when the EKG comes back wonky until the patient can get an actual bed in the ER.

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teeituptom is a BSN, RN and specializes in ER, ICU, L&D, OR.

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we either do them immediately at triage on presentation or they are walked immediately back to a room. either or works

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nuangel1 has 30 years experience as a BSN, RN and specializes in CT ,ICU,CCU,Tele,ED,Hospice.

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as soon as pt comes in with c/o cp the register calls on the phone ofr the tech to came do ekg .pt is brought to fast track bed if avail or ed bed ekg done and shown to md .if changes stays in main ed gets triaged by rn seen by md and orders done.ekg ok and depending on age and sx pt returnes to fast track and is triaged by np or pa labs orders etc done by rn.works for us .has improved our door to ekg times .

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teeituptom is a BSN, RN and specializes in ER, ICU, L&D, OR.

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Door to EKG time should be

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phiposurde has 9 years experience and specializes in critical care,flight nursing.

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At my hospital, we have a STEMI protocol. When EMS believe they have apossible STEMI, they send there 12 lead to our institution by fax. One of our doctor look at it. Plus we make admiting, the cath lab aware that we have activated the protocol. After the mD have a look at the cg he can either: decide to desactivate the process( so that they can go to the nearest center), bring them in but repeat the 12 lead at triage and wait to call the cath lab or call cath lab and repeat the 12 lead at triage. I believe our best time right now was 20 min from home to baloon. They also mention a walking pt on the protocol but since we don't usually do a 12 lead attriage I don't see how we would have that possibility. But we do have now what we call a subwaiting room. It's a place where people can go sit after treatment is initiated and they have one bed block for assesment. I have not been at triage since we start that new waiting room. But if i would have a very suspicious patient with no bed available. I would use that bed and do a 12 lead!

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EMSnut45 is a BSN, RN, EMT-P and specializes in ICU and EMS.

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Chest pain patients come straight back to a bed (bypassing triage). A "team" usually develops (atleast an RN and one or two techs) and goes at the patient full-force to get the EKG, IV, labs, monitor, etc (we have protocols that we can act on). While we are working the patient up, the doc/PA comes in to do a brief exam/patient interview and writes initial orders. After the "work-up" is complete, the nurse who is assigned to the patient completes the triage form. We have found that this "team" approach gets everything done within 10 minutes (versus the 20-30 minutes if the nurse/tech is working by themselves). Half of the time, the nurse assigned to the patient doesn't realize that they have a new patient until they are told that "Mr. Jones is in room 4 with chest pains... work-up is done." It really helps with morale-- we all help eachother!!

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etceducator has 9 years experience and specializes in emergency/ peds ER.

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Thank you for all the responses. We already have a STEMI protocol and do great on EMS patient presentations and classic chest pain presentations to triage. I guess where I am struggling are with the not so classic AMI symptoms. Do you do rapid triage/assess/ EKGs on everyone that says chest pain? Or do you go by certain risk factors? I just don't want to miss the subtle ones that come in through the front door. We have usually a RN and tech at triage. Sometimes 2 RNs 11-11. We have 3 small triage rooms, so we could set up a protocol/ rapid assessement room. I just need to set up some guidelines for which CP patients go through this process. Does anyone remember seeing anything about sitting vs. supine EKGs? I found one study showing ST changes with body position changes, but not really a standard position for the most accurate EKG reading. Thanks!

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neneRN has 8 years experience as a BSN, RN and specializes in Emergency, Trauma.

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We do the abbreviated triage/chest pain screening on ALL chest pain pts (except those 25 and under with no CAD Hx or street drug use).

However, the whole chest pain process has been so pounded into our triage nurses' heads that they send anyone who mentions the words "chest pain" through it...i.e., even the "I have N/V, diarrhea, and fever, and oh by the way, I had chest pain 3 days ago," so its really overused, and a lot of crap goes through the screening area, potentially backing up our true chest pains...so I do think some criteria identifying your truly at risk pts would help.

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teeituptom is a BSN, RN and specializes in ER, ICU, L&D, OR.

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We do the abbreviated triage/chest pain screening on ALL chest pain pts (except those 25 and under with no CAD Hx or street drug use).

However, the whole chest pain process has been so pounded into our triage nurses' heads that they send anyone who mentions the words "chest pain" through it...i.e., even the "I have N/V, diarrhea, and fever, and oh by the way, I had chest pain 3 days ago," so its really overused, and a lot of crap goes through the screening area, potentially backing up our true chest pains...so I do think some criteria identifying your truly at risk pts would help.

The crap exists, rule them out at triage with a fast ekg, downgrade them to their appropiate level.

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