The use of audit to set up a thrombolysis programme in the accident and emergency department

Clinical Audit in Emergency Medicine

Clinical audit is the review of clinical performance against agreed standards, and the refining of clinical practice as a result – a cyclical process of quality improvement in clinical care. The different steps of the clinical audit cycle are discussed. Publications on clinical audit in connection with Emergency Medicine are scarce in the medical literature. Clinical audit should be made compulsory for all healthcare professionals providing clinical care, and emergency physicians are no exceptions.

Door to Needle Times Bulls' Eye or Just Bull? The Effect of Reducing Door to Needle Times on the Appropriate Administration of Thrombolysis: Implications and Recommendations

The provision of thrombolysis in a timely fashion is the mainstay of treatment for acute myocardial infarction. With the publication of the National Service Framework (NSF) for Coronary Heart Disease increasing efforts have been put into the reduction of the ‘pain to needle time’. Of the various parts of the patient journey the time delays in hospital are the easiest to resolve. Published research shows that the time taken for the patient to call for help is intractable at present. Therefore, the obvious target for the reduction in the overall time from pain to treatment is the in hospital portion of the delay (the door to needle time). There are several methods that have been recommended for the reduction of the door to needle time. However, the increasing focus on the door to needle time is leading health care providers away from other issues such as the safety and accuracy of assessment by a non-cardiologist. Furthermore, the standards for audit of the door to needle time have not been set by the NSF and this has led to the presentation of selected data and the avoidance of discussing issues of accuracy and appropriateness.

Preparing nurses to initiate thrombolytic therapy for patients with an acute myocardial infarction - is there a consensus?

Within cardiac practice, one area that has seen much development involves the nurse assessing, diagnosing, and prescribing thrombolytic therapy for patients with a myocardial infarction. Alongside this, a variety of titles aimed at defining these new roles have emerged, but instead of clarifying the situation they have created more confusion about the actual characteristics and functions of nurses engaged in these innovative posts. In addition advice regarding the nature of preparation and training required to ensure the competency of nurses for these specific roles has been sparse and inconspicuous. As posts such as 'acute chest pain nurse', 'thrombolysis nurse', 'nurse-initiated thrombolysis' or 'nurse-led thrombolysis' increase and National Health Service targets tighten, it is timely to critically review the educational preparation for these roles for evidence of coherence. In particular, this paper analyses the literature in order to examine the content of educational programmes, teaching methods and assessment strategies in relation to preparing nurses to initiate thrombolytic therapy. The implications for those managing practice and the higher education sector are discussed. Finally, it is stressed that there is a need for national consultation relating to guidelines, standards and accreditation of practice schemes in this area of patient care.

A review of interventions and system changes to improve time to reperfusion for ST-segment elevation myocardial infarction

OBJECTIVE

Identify and describe interventions to reduce time to reperfusion for patients with ST-segment elevation myocardial infarction (STEMI).

DATA SOURCE

Key word searches of five research databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, and Cochrane Clinical Trials Registry.

INTERVENTIONS

We included controlled and uncontrolled studies of interventions to reduce time to reperfusion. One researcher reviewed abstracts and 2 reviewed full text articles. Articles were subsequently abstracted into structured data tables, which included study design, setting, intervention, and outcome variables. We inductively developed intervention categories from the articles. A second researcher reviewed data abstraction for accuracy.

MEASUREMENTS AND MAIN RESULTS

We identified 666 articles, 42 of which met inclusion criteria. We identified 11 intervention categories and classified them as either process specific (e.g., emergency department administration of thrombolytic therapy, activation of the catheterization laboratory by emergency department personnel) or system level (e.g., continuous quality improvement, critical pathways). A majority of studies (59%) were single-site pre/post design, and nearly half (47%) had sample sizes less than 100 patients. Thirty-two studies (76%) reported significantly lower door to reperfusion times associated with an intervention, 12 (29%) of which met or exceeded guideline recommended times. Relative decreases in times to reperfusion ranged from 15 to 82% for door to needle and 13-64% for door to balloon.

CONCLUSIONS

We identified an array of process and system-based quality improvement interventions associated with significant improvements in door to reperfusion time. However, weak study designs and inadequate information about implementation limit the usefulness of this literature.

Audit: how to do it in practice

Junior doctors can find the process of doing an audit helpful in gaining an understanding of the healthcare process—here’s how to do one

Identifying barriers to prehospital thrombolysis in the treatment of acute myocardial infarction

BACKGROUND AND OBJECTIVES

After an acute myocardial infarction (AMI) prehospital thrombolysis (PHT) reduces mortality compared with inhospital thrombolysis. In practice, a relatively small proportion of the total population with AMI receives PHT. This study was designed to identify the current barriers to PHT.

METHODS

A retrospective practice review of 57 consecutive patients treated in or before arrival at a district general hospital emergency department. All patients received thrombolysis for an AMI.

RESULTS

The main barriers to delivery of PHT appear to be the inclusion and exclusion criteria laid out in the ambulance service central guidelines. Despite recent widening of the inclusion criteria, 54% of patients eligible for immediate treatment on arrival in hospital either received or were eligible for PHT.

CONCLUSION

To increase the number of patients who are eligible for PHT these guidelines need to be revised further in line with inhospital criteria for thrombolysis.

Improving Door-to-Drug time and ST segment resolution in AMI by moving thrombolysis administration to the Emergency Department

BACKGROUND

We describe a combination of measures to reduce Door-to-Drug (DTD) time and improve the Emergency Department (ED) management of ST elevation MI (STEMI): appointment of a Cardiology Nurse Specialist, application of the American College of Cardiology and the American Heart Association (ACC/AHA) guidelines, changing the site of thrombolysis from the CCU to the ED, the introduction of a single bolus thrombolytic agent.

METHODS

The 12-month period before and after the introduction of the measures were retrospectively reviewed. One hundred and sixty patients were discharged from the CCU with the diagnosis of myocardial infarction confirmed by ECG and enzyme criteria. Eighty patients had STEMI and fulfilled criteria for thrombolytic therapy at the time of presentation to hospital. A full data set was available on 35/38 of patients in the 12 months prior to the measures (Year 1), and 39/42 in the 12 months subsequent (Year 2).

RESULTS

Median DTD time fell from 80 to 22 min after institution of the measures. Median Pain-to-Drug time also fell from 270 to 140 min. Thrombolytic agent given in the ED rose from 3% in Year 1, to 72% in Year 2. IV beta-blocker administered in the ED rose from 12% to 79%, resulting in median time to receiving IV beta-blocker falling from 63 to 19 min. Elevated ST segments resolved by >/=70% in <2 h in 53% of Year 2 patients, compared with 23% of Year 1 patients. Combined major in-hospital adverse clinical events were reduced from 49% to 15%.

CONCLUSION

This combination of measures reduces DTD time, improves speed to delivery of important concomitant medications, and significantly improves the time to ST segment resolution and outcome in STEMI.

Nurse initiated thrombolysis in the accident and emergency department: safe, accurate, and faster than fast track

OBJECTIVE

To reduce the time between arrival at hospital of a patient with acute myocardial infarction and administration of thrombolytic therapy (door to needle time) by the introduction of nurse initiated thrombolysis in the accident and emergency department.

METHODS

Two acute chest pain nurse specialists (ACPNS) based in A&E for 62.5 hours of the week were responsible for initiating thrombolysis in the A&E department. The service reverts to a "fast track" system outside of these hours, with the on call medical team prescribing thrombolysis on the coronary care unit. Prospectively gathered data were analysed for a nine month period and a head to head comparison made between the mean and median door to needle times for both systems of thrombolysis delivery.

RESULTS

Data from 91 patients were analysed; 43 (47%) were thrombolysed in A&E by the ACPNS and 48 (53%) were thrombolysed in the coronary care unit by the on call medical team. The ACPNS achieved a median door to needle time of 23 minutes (IQR=17 to 32) compared with 56 minutes (IQR=34 to 79.5) for the fast track. The proportion of patients thrombolysed in 30 minutes by the ACPNS and fast track system was 72% (31 of 43) and 21% (10 of 48) respectively (difference=51%, 95% confidence intervals 34% to 69%, p<0.05).

CONCLUSION

Diagnosis of acute myocardial infarction and administration of thrombolysis by experienced cardiology nurses in A&E is a safe and effective strategy for reducing door to needle times, even when compared with a conventional fast track system.

Managing thrombolysis in the accident and emergency department

The optimal management of acute myocardial infarction (AMI) today is founded upon the 'open artery' theory and driven by the need for early reperfusion strategies. Numerous randomised controlled trials demonstrate the unequivocal benefit of thrombolytic therapy in reducing mortality and improving long-term prognosis. These benefits are most striking when the thrombolytic therapy is given early. The National Service Framework for Coronary Heart Disease introduced national standards to reduce both 'call to needle' and 'door to needle' times to further augment early treatment. Subsequently many hospitals established 'fast track', 'nurse-led' or 'nurse initiated' thrombolysis within both the Accident and Emergency and Coronary Care Departments. This paper reviews these strategies and considers the benefits and limitations associated with the role of the 'thrombolysis nurse'. Thrombolysis nurses work to agreed protocols and play a fundamental role in the assessment and appropriate management of patients with acute MI. The evidence suggests that thrombolysis nurses are safe and effective in their practice and make a significant contribution to patient outcomes and enhance interprofessional education and practice.

Effect of audit on door-to-inflation times in primary angioplasty/stenting for acute myocardial infarction

We found that after audit and physician-guided changes in our protocol, the door-to-inflation times for primary angioplasty/stenting were markedly reduced. Because our preaudit mean time was similar to the national average, this may have wide applicability.

Changing the site of delivery of thrombolytic treatment for acute myocardial infarction from the coronary care unit to the emergency department greatly reduces door to needle time

OBJECTIVE

To quantify the change in door to needle time when delivery of thrombolytic treatment of acute myocardial infarction was changed from the coronary care unit to the emergency department.

DESIGN

A comparative observational study using prospectively collected data.

SETTING

Coronary care unit and emergency department of an Australian teaching hospital.

PARTICIPANTS

89 patients receiving thrombolysis in coronary care unit between June 1994 and January 1996, and 100 patients treated in the emergency department between April 1997 and May 1998.

INTERVENTIONS

From April 1997, by agreement between cardiology and emergency medicine, all patients with acute myocardial infarction receiving thrombolysis were treated by emergency physicians in the emergency department.

MAIN OUTCOME MEASURE

Door to needle time measured from time of arrival at the hospital to start of thrombolysis. Other outcomes included pain to needle time and mortality.

RESULTS

Median door to needle times were less for patients treated in the emergency department than in the coronary care unit (37 minutes, 95% confidence interval (CI) 33 to 44 v 80 minutes, 95% CI 70 to 89, respectively; p < 0.0001). Door to needle time was under 60 minutes in 83% of emergency department patients and 26% of coronary care unit patients (57% difference, 95% CI 45% to 69%; p < 0.0001). Median pain to needle time was less for emergency department patients than for coronary care unit patients (161 minutes, 95% CI 142 to 177 v 195 minutes, 95% CI 180 to 209; p = 0.004); times of less than 90 minutes occurred in 18% of emergency department patients v 1% of coronary care unit patients (17% difference, 95% CI 9% to 25%; p < 0.05). Overall mortality was similar in patients treated in the emergency department and the coronary care unit.

CONCLUSIONS

With a collaborative interdepartmental approach, thrombolytic treatment of acute myocardial infarction was more rapid in the emergency department, without compromising patient safety. This should improve the outcome in patients with infarcts treated with thrombolytic agents.

Reducing time delay in the thrombolysis of myocardial infarction: an internal quality improvement project. ARIAM Project Group. Analisis del Retraso en Infarto Agudo de Miocardio

The objectives of this study were to improve thrombolytic therapy in acute myocardial infarction by reducing the "door-to-needle" time in a 285-bed university hospital in Spain. A quality management approach was used involving all the relevant staff. Target standard was set at 35 minutes. Baseline data, intervention effect, and continuous monitoring were analyzed using x control charts. Analysis of baseline data showed a wide out-of-control variation and 72 minutes' average delay. Cause analysis revealed organizational and clinical problems that were subjected to intervention. Postintervention data showed a stable process, with an average of 30 minutes. Continuous monitoring showed further improvement in average time and predictable variation. The template of the current control chart has an average of 26 minutes. Quality management methods, particularly staff involvement in problem analysis and intervention design, and the use of control charts were useful to understand, solve, and continuously monitor an important clinical problem whose existence was evident only after it was measured.

Determining patients' suitability for thrombolysis: coronary care nurses' agreement with an expert cardiological 'gold standard' as assessed by clinical and electrocardiographic 'vignettes'

BACKGROUND

Thrombolytic therapy is an established treatment for acute myocardial infarction, the benefits of which are time-dependent. Coronary care nurses are often the first professionals to assess patients with suspected myocardial infarction on hospital admission, and there are a number of reports of nurseled practices for immediate assessment and 'cardiac triage'.

OBJECTIVE

To assess coronary care nurses' ability to determine patients' suitability for thrombolysis as judged by an expert cardiological 'gold standard'.

METHODS

Ten coronary care units in the Northern and Yorkshire region of England were sent packs comprising 10 sets of 10 'vignettes' and accompanying electrocardiograms together with a questionnaire regarding treatment decisions. An expert 'gold standard' for correct responses to the questionnaire was derived following independent assessment of the vignettes by three nurse specialists and three consultant cardiologists. Respondents' treatment decisions were subsequently compared with the 'gold standard'.

RESULTS

Of 42 (42%) completed sets of questionnaires returned for analysis, 37 (87%) of respondents indicated management decisions in absolute agreement with the 'gold standard'. Where there was not absolute agreement, most treatment decisions were acceptable as safe practice.

CONCLUSION

The majority of nurses indicated safe and appropriate management decisions. These limited data provide further support for ongoing developments of nurse-initiated thrombolysis, although there is a need for further, larger trials to determine the safety and efficacy of such an approach to patient care.

Assessment of the patient with chest pain in the accident and emergency department

This article will review measures enabling emergency staff to identify patients with chest pain who are likely to need admission to a cardiac care unit, in particular those with manifestations of acute ischaemic heart disease--acute myocardial infarction and unstable angina. Other non-cardiac causes of chest pain will also be discussed.