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PEER  TO  PEER: A New Model for Improving Guideline- and Evidence-Based ACS Care - Schedule Your ACS CME Teleconference

WHAT IS PEER TO PEER?
Med-IQ's complimentary, certified continuing medical education (CME) activity,
Peer to Peer: A New Model for Improving Guideline- and Evidence-Based ACS Care, is connecting healthcare professionals from across the country. This exciting, first-of-its-kind CME series provides participants with access to acute coronary syndrome (ACS) faculty experts during personalized sessions focusing on improving ACS patient care in their practices. This real-time exchange of ideas has helped address some of the major challenges that clinical practices face in managing ACS cases.

WHAT ARE E-BRIEFS?
Each month, Med-IQ will publish a short e-brief to highlight real-world questions, opportunities for improvement, and front-line perspectives gained from these ACS Peer to Peer teleconferences. Below, you'll find the eleventh of these e-briefs; in this installment, our expert faculty answer questions commonly encountered in the ED setting.

A Focus on Improving Care in Regional Hospitals

—In this E-Brief——

Route of Administration for Enoxaparin

Antithrombin Agent in the Cath Lab Versus the Referring Facility

Order for Administering Medications in Patients With ACS Receiving Fibrinolysis

Potential Protocol for Improving Door-to-ECG Times

Christopher P. Cannon, MD

Faculty Advisor:
Christopher P. Cannon, MD
Senior Investigator
TIMI Study Group
Cardiovascular Division
Brigham and Women's Hospital
Boston, MA


Writer:
Katherine Kahn
Huntington, MA


Although the joint ACC/AHA guidelines on STEMI and UA/NSTEMI provide detailed recommendations for patient management in the emergency department (ED), there are often practical barriers to implementing them in clinical practice. Below, our faculty explore some common ED-setting considerations, including the route of administration for enoxaparin, the cath lab's choice of antithrombin agent versus the referring facility's antithrombin choice, the best order for administering adjunct pharmacologic treatment in patients receiving fibrinolysis, and a practical approach to improving door-to-ECG times.

Route of Administration for Enoxaparin
Question: I practice in a community hospital, and our protocol uses subcutaneous enoxaparin only instead of an initial enoxaparin IV bolus. Should we consider changing our protocols?

Answer: The joint ACC/AHA guidelines for the ED management of STEMI recommend the use of enoxaparin 30 mg IV bolus, followed by enoxaparin 1 mg/kg administered subcutaneously 15 minutes later and every 12 hours thereafter (Class 1A recommendation) in patients who are to undergo percutaneous coronary intervention (PCI) or fibrinolysis. Administering enoxaparin by the subcutaneous route only is likely to result in variable absorption and an unpredictable response, especially in STEMI patients. This can be a complicating factor for the cath lab when determining optimal downstream doses for antithrombin agents. Subcutaneous enoxaparin without the IV bolus is guideline-recommended only in patients 75 years of age and older.1,2

Enoxaparin IV can certainly be administered safely in the community hospital setting, and it is worthwhile to incorporate its use as an ACS quality improvement strategy. This may involve presenting the current evidence to various stakeholders and developing preprinted order sets that allow for the identification of patients in whom enoxaparin IV is appropriate and in whom it is contraindicated. The labeling for enoxaparin has been updated to include the ability to administer IV bolus in STEMI patients, which should also help facilitate the adoption of this new dosing regimen.

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Antithrombin Agent in the Cath Lab Versus the Referring Facility
Question: The cath lab where we send our PCI patients uses unfractionated heparin (UFH), but our hospital uses low-molecular-weight heparin (LMWH). Should we be using UFH in our ACS patients, including those who are initially managed conservatively but who may end up going to the cath lab? Does the use of LMWH set these patients up for a higher risk in the cath lab because of the need for a transition?

Answer: In the management of ACS, the ACC/AHA guidelines allow clinicians to choose from four antithrombotic agents for patients undergoing invasive strategies—UFH, enoxaparin, fondaparinux, or bivalirudin (Class 1 recommendation). In the conservatively managed patient, enoxaparin, UFH, or fondaparinux are recommended (Class 1A recommendation), with enoxaparin being favored (Class IIA recommendation).1,2 It's important to note that fondaparinux is not FDA-approved for use in ACS, and an increased risk of catheter-related thrombus formation has been seen in patients undergoing PCI in clinical trials of fondaparinux. Currently, it is not widely used in the United States.

Although there has been some variation in the results of clinical trials comparing enoxaparin and UFH, the differences between the efficacy and safety of these two agents are small. If the cath lab is using UFH, it would be beneficial if the referring hospital also uses UFH so that conversion in the cath lab is not necessary. However, this is contingent upon the close monitoring of partial thromboplastin times (PTTs) and the timely adjustment of UFH doses, which may be stumbling blocks for some facilities. Ultimately, discussing this issue with the referring hospital and agreeing to a standard approach is best.

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Order for Administering Medications in Patients With ACS Receiving Fibrinolysis
Question: Many times, I am the only physician in the ED and have only one nurse to assist. In this situation, in what order should we administer medications to patients with ACS who will receive fibrinolysis?

Answer: Because aspirin is usually readily available, it’s logical to give this first. Because you should be aiming for a medical contact-to-needle time of less than 30 minutes for patients who are to receive fibrinolysis, the fibrinolytic agent should be given next.1 Clopidogrel may then be given, followed by an antithrombotic agent (either enoxaparin or UFH). However, because clopidogrel is a pill (or 4, if giving a loading dose), it could be administered when aspirin is given; or, if there is a delay in drawing up the fibrinolytic agent, it’s reasonable to give clopidogrel before the fibrinolytic. Timing is least important for the administration of a beta-blocker.

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Potential Protocol for Improving Door-to-ECG Times
Question: The ED where I work has a difficult time obtaining ECGs within the recommended 10-minute period in some outlier patients—usually ambulatory patients with chest pain as a primary symptom. Is there an effective protocol to reduce this time?

Answer: Often this is an issue of excess patient volume and a lack of resources or personnel. The Door-to-Balloon (D2B) Alliance recognizes that improving time to treatment in STEMI requires senior management support and an organizational environment that fosters and sustains change.3 Thus, the first step is to discuss improving times to ECG as a key quality metric with hospital staff and administration. Then, the facility should create a protocol where resources are devoted to improving door-to-ECG times. This can be accomplished by having the greeter or registration personnel at the ED ask all patients whether they are having chest pain. If the patient answers “yes,” this should trigger ECG or ED technicians to immediately perform an ECG—before any medical screening examination or patient registration. The protocol should include a backup list of personnel, such as triage nurses or physicians, who can perform the ECG if others are not available. For patients presenting to the ED by ambulance, an ECG can be immediately requested by the charge nurse or unit assistant as the patient is being assigned a room, again reducing any potential delays in ECG acquisition.4 Implementing this protocol initially as a pilot study may help convince hospital administration of the need for allocation of enhanced resources to improve ECG times and, hopefully, patient outcomes.

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REFERENCES

1. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. J Am Coll Cardiol. 2004;44(3):671-719.

2. Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction. J Am Coll Cardiol. 2008;51(2):210-247.

3. Krumholz HM, Bradley EH, Nallamothu BK, et al. A campaign to improve the timeliness of primary percutaneous coronary intervention: door-to-balloon: an alliance for quality. JACC Cardiovasc Interv. 2008;1(1):97-104.

4. Levis JT, Mercer MP, Thanassi M, et al. Factors contributing to door-to-balloon times of ≤ 90 minutes in 97% of patients with ST-elevation myocardial infarction: our one-year experience with a heart alert protocol. Perm J. 2010;14(3):4-11.

Educational Strategies in Atrial Fibrillation: Improving Guideline-Based Care at the Practice Level

Register today for your personalized, certified CME teleconference in atrial fibrillation (AF).

This exciting new CME series allows you to discuss guideline- and evidence-based care regarding rate and rhythm control in AF with a faculty expert. For more information, call (toll-free) 866 858 7434 or e-mail concierge@med-iq.com, or you can register today by completing this brief online form.

 

This activity has been approved for AMA PRA Category 1 Credit™.
This activity is supported by an educational grant from sanofi-aventis U.S.

This activity is supported by an educational grant from sanofi-aventis U.S.

sanofi-aventis

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