Improvement of Door-to-Electrocardiogram Time Using the First-Nurse Role in the ED Setting

A Nationwide Study of Emergency Nurses' Triage Decisions for Potential Acute Coronary Syndrome

INTRODUCTION

This study aimed to identify the symptoms used to assess angina, determine how emergency nurses make triage decisions for potential acute coronary syndrome, and determine emergency nurses' initial actions.

METHODS

This was a cross-sectional, survey-based design. Emergency nurses were recruited through a posting on the Emergency Nurses Association website and through postcards. Measures included demographic data, assessment of angina, and the Nurses' Cardiac Triage Instrument. Data were analyzed using descriptive statistics and ordinal logistic regression.

RESULTS

A total of 414 registered nurses with a mean age of 41.7 (SD = 12.0) years participated. They were predominantly female (80.7%), had a baccalaureate degree (60.1%), and worked as a registered nurse for a median 10.0 years. Common terms used to assess angina were chest pain (79.5%), chest pressure (77.3%), chest tightness (72.9%), and chest discomfort (72.5%). The severity of chest pressure (median 5.0, interquartile range 1.0) and nature of chest pain (median 5.0, interquartile range 1.0) had the highest overall median scores to support initial cardiac triage decisions. Associated symptoms of diaphoresis, fatigue, and shortness of breath along with health history contributed to decision making.

DISCUSSION

Emergency nurses primarily used chest symptoms and health history when deciding to evaluate for acute coronary syndrome in the emergency department. Associated symptoms of diaphoresis, fatigue, and shortness of breath, along with health history, also contributed to decision making. Initial registered nurse actions were to obtain an electrocardiogram, prepare the patient for the cardiac catheterization laboratory, and notify the emergency physician of the patient's admission.

Effect of triage training on nurses' practice and triage outcomes of patients with acute coronary syndrome

BACKGROUND

Accurate assessment and prompt management of patients with acute coronary syndrome (ACS) is a complex process for emergency department (ED) nurses and has variable clinical outcomes. The aim of the present study was to determine the effectiveness of an educational intervention on nurses' practice during the triage of patients with ACS and the triage outcomes in this group of patients.

METHODS

In this quasi-experimental study, a pretest-posttest group of 24 nurses were included by convenience sampling method and 960 patients with ACS were selected by sequential sampling during the pre-intervention (n = 480) and post-intervention (n = 480) phases. A case-based learning (CBL) intervention was performed for nurses for one month considering the role of the triage nurse according to the American College of Cardiology (ACC) and the American Heart Association (AHA) recommendations as well as the factors affecting the proper identification and management of patients with ACS. During patient triage in the pre- and post-intervention phases, the "Triage Nurse Practice Checklist" and the "Medical Electronic Records" were used to assess nurses' practice and the triage outcomes in patients, respectively.

RESULTS

The overall mean score of the triage nurses' practice and its subscales, including Primary monitoring and assessment, cardiovascular risk factors assessment, evaluation of coronary heart disease (CHD) symptoms, chest pain management, and adherence to the ACC/AHA practice guidelines were significantly improved in the post-intervention phase compared with the pre-intervention phase (p < 0.001). There was no significant difference between the triage outcomes, including in-hospital mortality within 24 hours, death in ED, hospitalization in other wards, and discharge from ED in the pre and post-intervention phases (P = 0.723).

CONCLUSION

The development of a cardiac triage-specific educational program could improve the performance of nurses in the evaluation and management of patients with ACS, but had no effect on the triage outcomes in this group of patients. We recommend a quality improvement project or a critical outcomes-based triage system to assess ACS patients' care needs in the ED.

Electrocardiogram interpretation competency among undergraduate nursing students: A quasi-experimental study

BACKGROUND

Cardiac diseases are highly prevalent. Electrocardiogram (ECG) is a noninvasive, rapid, safe, and low-cost procedure that is commonly used by nurses in clinical settings to diagnose a variety of cardiac arrhythmia. However, there is a limited number of studies that have assessed nursing students' competencies in electrocardiogram interpretation in Saudi Arabia. This study aimed to assess the electrocardiogram interpretation competency among undergraduate nursing students and to evaluate the effectiveness of the electrocardiogram interpretation educational program.

METHODS

A quasi-experimental pre-post-test design was conducted. A pre-post-test self-administered standardized questionnaire was completed by a convenient sample of 79 nursing students who enrolled in an educational program. Data were analyzed using descriptive and inferential statistics with p < .05 was assumed. The study hypothesized that ECG competency scores of nursing students who are enrolled in an educational program will be higher in post-test than their pre-test scores.

RESULTS

The vast majority of students (96.2%) expressed their interest to enroll in more ECG training sessions. The study results showed that students' mean ECG interpretation competency was 4.16 (1.88) and 7.43 (2.38) in pre- and post-tests, respectively, with a statistical significance of p < .001.

CONCLUSION

Overall performance of nursing students was limited. Study results confirm the primary hypothesis that the educational program was effective in improving students' ECG interpretation competencies. More ECG contents and programs should be integrated into nursing curricula and more follow-up studies are recommended. This study highlighted the significance of equipping nursing students with ECG interpretation competencies through education and training to ensure safe practice.

Implementing "Chest Pain Pathway" Using Smartphone Messaging Application "WhatsApp" as a Corrective Action Plan to Improve Ischemia Time in "ST-Elevation Myocardial Infarction" in Primary PCI Capable Center "WhatsApp-STEMI Trial"

BACKGROUND

ST-elevation myocardial infarction (STEMI) is a life-threatening medical emergency that requires immediate medical attention. Each hospital should implement a clinical pathway with the main objective to reduce ischemia time from diagnosis to revascularization (because this has shown to save myocardial tissues and, subsequently, patients' lives), utilizing the most evidence-based approach and the most up-to-date management protocol. In this study, we aimed to assess the utility of structuring chest pain pathway (CPP) with the instantaneous case-by-case feedback protocol using WhatsApp and its impact on improving 2 major key performance indicators-the impact on initial emergency room (ER) door-to-electrocardiogram (ECG) time, and door-to-balloon time-in a predefined 6-month corrective action period.

METHODS

A prospective, quality improvement plan was set to reduce door-to-first-ECG and door-to-balloon times to less than 10 and 90 minutes, respectively, in all acute coronary syndrome cases (including STEMI cases), from August 2020 to April 30, 2021. Several measures were done to attain the goal, including strict compliance to CPP with documentation, ruling out possible mimickers, and reducing false activation and time delays in ER. Direct feedback on cases was provided using WhatsApp messaging app on smartphones; protocol and results of time lines were accessed by all healthcare providers associated with CPP, including ER nurses, ER doctors, Cardiology residents, specialists, Catheterization laboratory nurses, technicians, and interventionalists. Bimonthly meetings with all stake holders were reinforced, and minutes of meeting were reviewed and corrective actions were implemented the next day. On a daily basis, all cases were analyzed and tabulated by a dedicated nurse and a doctor from ER, and another nurse and doctor from the quality assurance department.

RESULTS

After a 6-month period of implementing improvement plan and sticking to a comprehensive chest pain clinical pathways strategy with a case-by-case review on a shared smartphone messaging application, the rate of door-to-first-ECG improved from 76% to 93% in patients with chest pain, and the door-to-balloon time targeting less than 90 minutes improved significantly from only 77% to 92% in STEMI patients. This was statistically significant with a P value of 0.0001 and 0.001, respectively, and the rate of false activation was reduced from 23% to 16% and 10% 3 and 6 months of time, respectively, with a significant P value of <0.01. Finally, a strict 100% rate of timely documentation on patients with chest pain was achieved.

CONCLUSIONS

An improvement plan of implementing the CPP, cut-time policy, and using smartphone WhatsApp messaging for a case-to-case instantaneous feedback has significantly improved key performance indicators and, subsequently, ischemia time in acute coronary syndrome patients (including STEMI patients) in 6 months time, indicating that this strategy works.

Capability of emergency nurses for electrocardiogram interpretation

INTRODUCTION

Electrocardiogram is the first-line diagnostic imaging modality for evaluating patients with chest pain. The present study aimed to determine the capability of emergency nurses for electrocardiogram interpretation by using a more appropriate questioning method.

METHODS

This was a cross-sectional descriptive survey. A convenience sample of 96 emergency nurses was obtained from two emergency departments in Hong Kong. The electrocardiogram-interpretation capability of the emergency nurses was determined using a self-developed well-designed questionnaire comprising 10 questions on electrocardiogram interpretation. Each question carried one point, such that the maximum score was 10 points. The higher the score, the more capable was the emergency nurse at electrocardiogram interpretation.

RESULTS

The mean score achieved by the participants was 7.7 ± 1.8. Only 12.5% of the participants were able to answer all questions correctly. A considerable proportion of the participants were unable to recognize first-degree heart block (74.0%), second-degree heart block type I (52.1%), or third-degree heart block (39.6%). Gender, electrocardiogram training, nursing experience, and emergency department experience had significant associations with mean score.

CONCLUSIONS

The electrocardiogram-interpretation capability of the emergency nurses was fair. Better training should be implemented to help emergency nurses recognize potentially fatal heart blocks, enabling prompt and appropriate patient treatment.