Nurse-initiated thrombolysis in coronary care

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.

Can Australian Nurses Safely Assess for Thrombolysis on EKG Criteria?

INTRODUCTION

According to the Australian Institute of Health & Welfare, 48,700 ischemic heart disease events occurred in Australia in 2001-2002; around half of these were fatal. The National Heart Foundation of Australia recommends that eligible patients presenting with acute myocardial infarction should receive thrombolysis within 30 minutes of presentation if primary angioplasty is not available. In Australia, fewer than 80% of eligible patients were treated within 1 hour in the first half of the year 2000. Literature reveals that a number of hospitals in the United Kingdom use a model of acute myocardial infarction management whereby suitably qualified cardiac nurses initiate thrombolysis where appropriate, prior to the patient being evaluated by medical staff. This practice is safe and effective in reducing the door-to-needle time to below 20 minutes. The questions are threefold: Are Victorian cardiac nurses similarly capable? What are the existing abilities of emergency nurses? What do they think about initiating thrombolysis?

METHOD

Mixed methodology (descriptive comparative and thematic analysis) was used. The survey instrument included EKG vignettes and a questionnaire. Participants were Victorian nurses practicing in a coronary care unit or an emergency department.

RESULTS

Seniority was the only apparent predictor of increased accuracy.

DISCUSSION

Nurses are very accurate and safe in their ability to recognize patients warranting immediate thrombolysis. Nurses' decision making is underpinned by 3 of 4 fundamental patterns of knowing identified by Carper-aesthetic, empirical, and ethical. In view of these findings, a number of recommendations are made for research, education, and benchmarking of quality patient management.

Changing the skill-mix of the health care workforce

OBJECTIVE

Changing workforce skill-mix is one strategy for improving the effectiveness and efficiency of health care. Our aim was to summarise available research into the success or failure of skill-mix change in achieving planned outcomes.

METHODS

A systematic search for existing reviews of research into skill-mix was conducted. Databases searched included: MEDLINE, CINAHL, PsychINFO, Cochrane Library, HMIC, Centre for Reviews and Dissemination, and Department of Health Research Findings Register. Search terms included keywords defining the type of publication, clinical area, type of health personnel and the focus of the article (role change, skill-mix, etc.). English language publications from 1990 onwards were included. Two reviewers independently identified relevant publications, graded the quality of reviews and extracted findings. In addition, the wider literature was scanned to identify which factors were associated with the success or failure of skill-mix change.

RESULTS

A total of 9064 publications were identified, of which 24 met our inclusion criteria. There was a dearth of research, particularly for role changes involving workers other than doctors or nurses. Cost-effectiveness was generally not evaluated, nor was the wider impact of change on health care systems. The wider literature suggested that factors promoting success include: introducing 'treatments' of proven efficacy; appropriate staff education and training; removal of unhelpful boundary demarcations between staff or service sectors; appropriate pay and reward systems; and good strategic planning and human resource management. Unintended consequences sometimes occurred in respect of: staff morale and workload; coordination of care; continuity of care; and cost.

CONCLUSIONS

In order to make informed choices, health care planners need good research evidence about the likely consequences of skill-mix change. The findings from existing research need to be made more accessible while the dearth of evidence makes new research necessary.

Myocardial infarction: nursing responsibilities in the first hour

The aim of this article is to provide a comprehensive review of the physiological processes that occur during the first hour following a myocardial infarction (MI). It will identify the general principles and the physiological processes that occur in response to a MI, outlining the consequences of cellular hypoxia to the heart. The implications for clinical practice and how they link to the physiological processes are detailed. Understanding the physiological principles involved in a MI is important for identification and to ensure patient management is initiated. This, together with prompt diagnosis and interventions, will assist in reducing mortality within the first hour following a MI.