Saving Hearts: Reducing Emergency Department Door-to-Electrocardiogram Times

Abstract

Evidence-based Practice Abstract Purpose: The American Heart Association (AHA) recommends that electrocardiograms (EKGs) be obtained on all potential Acute Coronary Syndrome (ACS) patients within ten minutes of Emergency Department (ED) arrival. This recommendation was not being met in one ED, and a need for improvement was identified. Compliance with this standard is required to maintain AHA Chest Pain Center Accreditation for the Medical Center. A bedside nurse with strong leadership potential was engaged to determine cause and solutions for this problem. Design: Project began as a staff development project and progressed to a quality assurance and performance improvement project. Setting: A 24-bed suburban teaching hospital and level-two trauma center with an average of 44,000 visits annually. Participants/Subjects: All patients of all ages who presented to the triage nurse with complaints of chest pain, shortness of breath, syncope or near syncope, weakness, and palpitations during the study were screened as potential ACS patients and an EKG was performed. All patient care staff, both licensed and unlicensed, were given EKG training and expected to participate. Methods: Literature reviews, process observations, and brainstorming sessions were completed to determine areas for improvement to decrease door-to-EKG times. Through direction from both administration and frontline leadership in the ED, a two-week trial was completed. This included staff education, the development of an EKG protocol, entry of an EKG order in triage, telephone notification to staff that an EKG is needed, immediate bedding of patients, purposeful placement of EKG machines, use of timers that went with patients from triage, and completion of the EKG prior to visitor entry. Facilitators were staffed 24/7 to ensure rapid-process change and team compliance. Real-time data was collected and feedback given to staff to motivate and encourage them to continue with the process. Results/Outcomes: The average Door-to-EKG time of 11 minutes was dramatically decreased. An average of 6.1 minutes was achieved during the first seven months with greater than 90% of EKGs completed within the ten minutes in subsequent months. Monthly surveillance is performed to ensure the benchmark continues to be met. Implications: Implementation of these nurse-driven changes to the EKG protocol and related interventions significantly improved door-to-EKG times for ACS patients arriving at the ED, and could be easily applied in similar facilities seeking to meet this critical benchmark. These changes were inspired and implemented by leaders at the bedside and supported by their management.