STEMI Protocols

[Medic2RN, BSN, RN, EMT-P]

I need to ask the vast, smart ED nurses here...do any of you have a dedicated STEMI protocol sheet?

I had a STEMI arrive via ambulance. I notified the Doc prior to arrival, grabbed out STEMI med box and got to work. The time frame from door to cath lab was within time limits, but the process itself for the primary nurse (me) was less than smooth. I had the ER doc and cardiologist giving verbal commands continuously, while I gave the meds and scribbled cryptic notes to document later. The problem is, we don't have time later. I got another nurse to help give medications and help me while I began to furiously scribble the orders onto my documentation and the physician's order form since none of the doctors did.

At some point, the cardiologist flung the consent form somewhere in my pile of mess on the counter. About 20 minutes later the cath lab Rns showed up to take the patient. In that time, the other nurse and I had started another IV, gave ASA, nitro, benadryl, metoprolol, heparin, tridil, morphine, placed a foley, multiple ECGs, V/S, called a family member for the patient, and did most of the documentation.

I gave the ER doc the physician's order sheet to sign which he asked, "You want me to blindly sign off on this?" At which point I said, "Yes, you will. They were all verbal orders that you and the cardiologist asked for. Sign it."

I was copying the documentation while the patient was whisked away. I had to go to the cath lab in order to give them everything, plus they didn't take (or get the patient's signature yet) on the consent.

The cardiologist asked why I had not gotten the consent yet. So, I had to go to the patient to have the person sign it. Then a cath lab nurse was rather rude when she asked why I had not copied all of the lab results. Well, they are all on the computer now. Look them up. She was sitting in front of the computer berating me for not having time to check the labs and copy them for her.

Later, they called and reported me to my charge nurse for the labs. I'm thinking this is going to become an issue.

I spoke to the ER Doc after this was all said and done and we agreed that we should have a standard protocol that ER nurses could follow based on what the ER and cardiologists want pre-cath. Reduce the redundant and voluminous paperwork that the ER nurse does not have time to do in this time sensitive situation.

My response to this whole situation is to start to research the development of this type of sheet since my ER doesn't have it and we really should.

So a long story to ask, how does your ED deal with STEMIs?

[RNCEN]

Isn't the cardiologist responsible for getting the consent? That's not your job, it's his/hers. Your job is to make sure it's included in the chart when the patient goes for the procedure, right?

We have a whole PCI packet that includes all the necessary paperwork. I'm a tech, so I'm not sure exactly what it includes.

[Dixielee, BSN, RN]

We have really streamlined the STEMI protocols over the last few years. We used to be responsible for all the things you mentioned as well as a pubic shave! We do always have 2 RN's and a tech with a STEMI. Most come in by EMS but not all. Our EMS does a great job of calling it in as a STEMI so we are ready, and they start the line, initiate meds, etc. We also have 24/7 EKG techs in the ED.

We don't place foleys as a general rule, in fact we rarely do. Cath lab gets the consents signed now. We used to have 3 separate pages, one for the cath, another for possible stent placement and yet another for possible bypass surgery. There are now all in one and "pre filled out", so all they require is a signature from the doc and the witness.

We do have a packet of meds already put together in the Pyxis, so we just hit the button for STEMI pack and have it all in a large zip loc bag ready to go. Any meds not used, stay in the bag and sent to the pharmacy for credit and restock. We also have standard orders, so unless there are extenuating circumstances, there is no need to change any orders. We do start the meds, and do all we can, but as soon as the cath lab arrives, the patient goes no matter what is left on the list. The cath lab has access to the same computer info we do, but many times they take the patient before anything is back anyway. (We do bedside troponins though).

We have had great success with the streamlining of the process, great door to cath lab times, and very good outcomes. There is really no friction between ED and cath lab staff as we all have the same goal and are on the same page.

Streamlining also takes the us versus them out of it, regardless of who the "them" is, i.e. physician, cath lab staff. Patients do not return to the ED after cath, the cath lab staff gets them to the floor, ICU, surgery, etc. so once they are gone from us, they are gone.

Good luck with improving your processes!

[Anna Flaxis, BSN, RN]

We have a Cath Alert packet that contains all the paperwork you'll need for a STEMI. There is a standard order sheet that includes blank spaces for information such as time of onset of symptoms, time of arrival in the ED, time of arrival of the ED physician, time of EKG done in the ED, time of arrival of the cardiologist, time of arrival in the cath lab, etc. All you do is write down the time in the appropriate blank and initial it. The standard meds are on the sheet, with check boxes the doc can either check, or the nurse can check when they get the v.o. The consent form is also in the packet. Also, we have STEMI kits in the Pyxis, so all you have to do is make one selection to get all the potential drugs you might need. When the radio call comes in, you just grab the packet, grab a STEMI kit from the Pyxis, and take it to the room and get the room ready. It's really a great streamlined process. I think my record from ED door to cath lab is 12 minutes. Really, the only thing that slows the process down is the time it takes to assemble the cath lab team and get the cath lab ready.

Oh, and you still have to write a narrative note (we do paper charting), but I usually wait until after I've accompanied the patient to the cath lab, and finish up my charting while the cath team gets started. Sometimes, if things aren't really crazy in the ED, I can stick around long enough to see the intervention.

[DayDreamin ER CRNP]

We have a "heart alert" box. Once the doc calls the Heart Alert and it is paged to the "team" the primary RN gets the heart alert box out of the pyxis. Our box is basically a small tackle box with a plastic tab that serves as a "lock" for the box. The ER pharmacist is part of the heart alert team and he/she draws up all the meds based on the pt's weight. In the even the pharmD isn't available the doc or primary RN can draw up the meds.

In the box we have everything needed for any type of cardiac event and there are flow sheets in the box. We also have a weight/dose table for all the meds we typically give, ie: angiomax, etc.

We also have the morphine, zofran, etc in the box. There is also the "official" med and documentation sheet in there. Basically, the only thing not in this box is any fluids or any razors for shaving the pt.

Our cath lab typically shaves the pt unless we have a small wait to get upstairs. Our cath lab and ER staff work very closely to keep our "door-to-cath-lab" times to a minimum and to get pts stable very quickly. We don't even worry about getting labs printed off and all that. The cath lab nurse can access all the info she needs. We do give bedside report but with the flow sheets and official documentation sheets make that task super easy and quick.

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[NO50FRANNY]

Hi there,

In our ED, the STEMI gets phoned through by ambulance crew who have specific criteria that the pt. must meet to announce a STEMI. Triage nurse hits emergency bell and advises resus team and Consultant ED physician with ETA and report from pre-hospital crew. Resus consultant physician (attending?) or most senior ED doctor (outside hours) calls Interventional Cardiologist (prior to pt. arrival) who assembles cath lab team or calls them in via paging system. The idea of this system is that it is better to send staff home or stand down than waste time (and cardiac tissue) waiting for verification. Cath lab staff do not collect pt. we take them up. They don't get unloaded off the ambulance stretcher when they arrive, we exchange defib machines, get one ECG, and maybe take some blood if cath lab isn't ready. Resus consultant confirms STEMI from 12 lead ECG performed by nurses while pt. is still on ambulance stretcher and they go straight to Cath lab. The only time they will come off the ambulance stretcher is outside normal staffing hours (if cath lab staff haven't arrived) or if they are crashing. Consultant and a nurse from ED will go with them and stay if necessary (ie: invasive airway / actively resuscitating etc.). Specialist paramedics can lyse pre-hospital in certain circumstances and we will often give some oral meds in ED but that's about it.

It's a pretty smooth system- time is tissue. Cardiology / ED doc. get verbal consent when they arrive if they can and worry about paperwork later. I've never seen a pt. wait more than 15 minutes (arrival to cath) even outside hours, they will pull staff from CCU etc. if they have to and the interventional cardiologist usually gets there when the pt. does and are happy to just go home if by some miracle it isn't a real STEMI. These protocols can be difficult to implement as it requires co-ordination and co-operation from emergency pre-hospital crews, cardiology and ED and largely depends on hospital / emergency services policies. This protocol or similar is in place in most tertiary emergency departments in Australia and I will try and find a link for you. I was amazed about the paperwork issues you had, and what was expected prior to definitive intervention, worrying about labs/foley/meds and so on. If they don't get their cath in time the lab results aren't going to matter much because they'll be dead! The last one we had was (fortunately) during the day- 40y female, tiny, very fit and healthy- had a bath then couldn't get out of it- called her husband who called an ambulance. No chest pain, just vomiting and unable to move, diaphoretic and ST elevation everywhere. She had started dissecting two arteries by the time she got to cath lab and narrowly missed having her chest cracked- if we stuffed around in ED for more than 5 minutes they would have had to. Will see what I can find.

[Altra, BSN, RN]

Though we do not have a kit or box put together with meds (I think that is a great idea, BTW), our STEMIs are generally quick, smooth encounters.

Patient is identified pre-hospital as having a clinical presentation/EKG which is concerning - EKG is faxed to us. If clearly a STEMI, the STEMI alert page goes out then to the ED, Cardiology, & the cath lab.

Patient arrives - we revert to charting on paper so there is no waiting for registration/fussing with the computer system. EKG, vitals, get patient undressed, get IV access if 2 lines not already established, CXR. Cardiology is usually in the ED within a few minutes of patient's arrival.

Evaluation by ED MD and Cardiology. Meds given. Cardiology obtains consent.

Patient goes to cath lab. Our door to balloon times are generally less than 40 minutes. We recently had a patient in and out of the ED in 9 minutes. :)

[That Guy, BSN, RN, EMT-B]

When EMS reports a STEMI inbound it gets paged over head that we have a STEMI alert and we get the various deprtments, our RRT nurse and usually an ICU nurse to show up so that we have the extra hands necessary to give meds, chart, consents, all that fun stuff that goes along with the whole process. It is almost too much for one person to handle.

[Esme12, ASN, BSN, RN]

dedicated orders prevent this sort of controversy and minimizes the risk of error. having everyone on the same routine and page increases quality outcomes. a word of caution. inherent cultures and routines are very difficult to change as nurses as a whole are creatures of habit and are reluctant to change.........it is within habit/ocd we minimize errors just by the routine alone.

making standard orders which has an inclusive checklist needs to be presented by pharmacy therapeutics, nursing, and chief of medicine/cardiology to then be approved. if you are seeking a checklist it may be just as difficult to have other nurses on board and need to be approved through nursing/pharmacy/cardiology approval. you can check with local surrounding emergency departments for their examples as well. not everyone will share......i always did.

just like the government nothing is ever simple.

these are some excellent references to resource from.....

http://www.scpcp.org/accreditation/shared-practices/element2/ excellent all inclusive resource

[color=#1122cc]stemi standing orders

[color=#1122cc]stemi standing orders - vte critical pathways

[color=#1122cc]stemi standing orders - strivecme.com

[color=#1122cc]regional stemi program

[rjflyn, ASN, RN]

I can say its about universal everyone has a STEMI box. Paperwork, we catch up later- ours is computerized as is the orders. Consent is the MDs to get, if the need a witness the are required to ask us for it. As for all the stuff we do to the patient himself- thats streamlined too- lines 2 IV's generally, Nitro drip, hardly ever because "we just stop it as soon as we get them in the lab", same goes for the heparin drip so we just give the bolus. ASA, Plavix or Effiuient and Morphine is about all thats left along with O2- the EKG was done at triage though sometimes we have the machine attached and are doing serial.

[thelema13]

Grab the STEMI box, 362mg ASA to chew/down NG, 600mg Plavix PO, 4000 Units heparin IVP, metoprolol 25mg PO, nitro drip, NS @ 100 mL/hr, minimum 2 large bore IV, O2 @ 5-10 lpm via non-rebreather, shaved, pacer pads, cath lab 'clear' electrodes, multiple EKG's, out to cath lab, consented by cardiology. We strive to get them out of the ED no more than 20 minutes, if we have a heads up by EMS or local hospital without a cath lab. Team responds rather quickly, all cath lab team members have to live within 5 miles of hospital.

We have a STEMI med sheet in our STEMI box, with all protocol meds in the box printed on the sheet, with info regarding dosage, admin, and time given. We scribble our notes on the back of the STEMI sheet and CPOE verbal order everything in FirstNet after we get them out. Since we are the only approved STEMI/Stroke alert facility within a 60 mile radius, we get quite a few of them, so we are all pretty used to it by now.

[Medic2RN, BSN, RN, EMT-P]

I appreciate everyone's input - thank you.