Chest pain in acute myocardial infarction: does weekend onset delay presentation to hospital?

Coronary Health Cure (1998) 2, 28-32 9 1998 Harcourt Brace & Co. Ltd

ORIGINAL A R T I C L E

Chest pain in acute myocardial infarction: does weekend onset delay presentation to hospital? R. Rowe

INTRODUCTION

previous cardiac history (Leitch et al 1989). It is believed that this may be due to patients self-medicating on nitrate therapy.

Prompt administration of thrombolytic therapy improves patient survival following an acute myocardial infarction (AMI) (ISIS 2 1988). Recent initiatives to improve the door-to-needle time include nurse-led thrombolytic administration (Caunt 1996), and chestpain assessment by specialist nurses in the accident and emergency department (A&E) (Mooraby et al 1997). However, it is still up to the patient to realize that he has a problem and to seek timely and appropriate help. The author has noticed that some patients with MI arrive at hospital on a Monday having developed chest pain over the weekend. These patients had not wanted to spoil pre-arranged social events or 'disturb their doctor' out of hours and had arrived too late for thrombolytic therapy. The author investigates the causes of delay of presentation to hospital after the onset of chest pain in patients suffering from MI.

METHODS

A prospective survey of all patients diagnosed with AMI who attended the A&E department of a West Midlands teaching hospital over a six-month period (December 1995-May 1996) was undertaken. MI was diagnosed only after two of the following three diagnostic criteria were fulfilled: a typical history, a diagnostic electrocardiograph (ECG), and elevated cardiac enzymes. Basic demographic information, time delays and the method of seeking medical help were recorded from ambulance and medical records. Short semistructured interviews were conducted with the patients where possible at 2-5 days post admission. Ethical approval for this study was obtained from the Hospital Research and Ethics Committee. Patients with a 'silent' MI were excluded from the cohort. Statistical analysis was performed using 2-tailed ttests and Z~tests.

BACKGROUND LITERATURE REVIEW

A review of previous research on pre-hospital delay in presenting with chest pain identified those known to be at risk of delaying in presenting to hospital and it became apparent that, not only had most of the previous work on this subject been conducted in the USA, but that UK studies (Birkhead 1992) tended to feature audit in their methodology. Women, the elderly and those who first seek help from a general practitioner (GP) are more likely to delay presenting to hospital with chest pain (Reilly et al 1994; Birkhead 1992). Patients who believe their pain to be cardiac in origin tend to seek help more promptly than those who think that their pain is non cardiac (Reilly et al 1994). It is also known that those patients with a history of angina or MI delay longer in seeking help for chest pain than those with no

RESULTS In the six-month period of the study, 159 patients attended the A&E department and were subsequently diagnosed as suffering from AMI. Of these, 121 were males and 38 were female. The mean age was 64.8 (range 40-85). The mean age for males was 62.8 and 70.1 for females. A total of 126 (79%) were white and 38 (21%) were of South Asian origin. The mean age for the Caucasians was 66.3, and 58.3 for South Asians. Interviews were conducted on 74 patients. Symptom onset

Correspondence to: Rachael Rowe MA (ResearchMethodology),

A total of 110 (73%) patients developed chest pain on a weekday (defined as 24:00 hours on Monday until

RN, CardiacNursePractitioner,BirminghamHeartlands Hospital, BordesleyGreenEast, BirminghamB9 5SS,UK. 28

Chest pain in AMI Table 1 Time from onset of chest pain to presentation to hospital Number (%)

Delay in attending hospital

16 (10%) 33 (20.6%) 34 (21.3%) 48 (30.1%) 28 (18.5%)

Less than 1 hour 1-1:59 hours 2-3:59 hours Longer than 4 hours Not accurately documented

Table 3 times

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Means of getting help for chest pain compared to delay Less than 60 rain delay

GP Self-referral 999

61-119 120-239 More than 240 rain delay min delay min delay

1 4 11

9 3 21

14 2 18

33 3 12

Table 4 Delays in getting to hospital in those with previous coronary heart disease

23:59 on Friday) and 49 (27%) at the weekends (24:00 hours on Saturday until 23:59 on Sunday, or Monday in the case of a public holiday). Presentation to hospital Table 1 above shows the period of time between onset of symptoms and presentation to hospital. Thirty four (forty-six per cent) of the interviewed cohort took longer than 4 hours to get to hospital after the onset of chest pain whereas only 20% of the non-interviewed patients delayed presentation (n=12). Twenty-two (Fourteen per cent) patients arrived too late for thrombolysis administration, 14 from the interviewed sample and 12 of the non-interviewed patients. A further 37 did not receive thrombolysis either because of contraindications, death on arrival or a non-diagnostic ECG. To determine the general trend at weekends or weekdays, t-tests were performed to analyse the mean delays from symptom onset to getting help, from getting help to arriving at hospital, and the total delay. Although there were longer mean times at weekends, these were not statistically significant (Table 2). On the basis of 131 cases (documentation inaccurate in 28 cases), 57 patients contacted a GP for help, 12 self-referred to hospital, and 62 dialled 999. A X-" analysis revealed that patients seen and referred by a GP were the main cause of delays of more than 4 hours (P<0.0009) (Table 3). Reasons for delay in coming to hospital It became apparent that other reasons for delay in getting to hospital occurred regardless of the day of the week. Delays in coming to hospital were found to be distributed between those with no known previous coro-

Symptom-to-door time of less than 4h Previous angina Previous MI Previous angina and MI No known previous coronary artery disease Table 5

5 3 5 22

7 1 1 30

Summoning help and delay time in South Asians

GP Self-referral 999 Total Table 6

Symptom-to-door of more than 4h

Less than 60 rain

61-119 rain

120-239 min

1 4 5

1 7 8

1 1

More than 240 rain

Total

10

10 3 12 25

1 11

Summoning help and delay time in white Caucasians

GP Self-referral 999 Total

Less than 60 min

61-119 min

120-239 min

More than 240 min

Total

1 3 7 11

9 2 14 25

14 1 18 33

23 3 11 37

47 9 50 106

nary heart disease and those with known angina. Those with a past medical history of MI or both angina and MI tended not to delay (based on 74 interviewed cases) (Table 4). A cross-tabulation of ethnic background, the type of help and delay times showed that all Asians who contacted a GP also delayed more than 4 hours in getting to hospital (P<0.0008) (Table 5), compared to white patients, where delays were spread over the time spans (P<0.01) (Table 6).

INTERVIEW RESULTS Differences between weekend and weekday delays

Table 2

Delays in presentation to hospital Weekend mean time (min)

Symptom onset to 490.7 getting help Getting help and 278.76 arrival at hospital Total delay time 782.07

Weekday mean time (min)

Significance

398.43

P=0.606

190.82

P=0.576

589.25

P=0.482

From the interviews, there were isolated cases where patients had not wanted to bother medical personnel at the weekend or on a public holiday. 'It was Christmas and I couldn't get to the doctors." 'I didn't want to bother the doctor at the weekend."

Six patients made this type of comment, all of whom were over 60. Two patients called an ambulance,

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Coronary Health Care

as they knew the GP surgery would be closed at the weekend: 'I called an ambulance," my GP is shut at the weekend"

' When Igot thepain my husband said to me there was no point in going back to the doctor because I had to go back anyway for the ECG appointment, and then I would know what was causing all the pain.' (Female patient, too late

for thrombolysis). Previous coronary heart disease Poor understanding of the implications of being an angina sufferer and how to use glyceryl trinitrate (GTN) were shown to delay people in getting help in the case of 6 interviewed patients: 'They said when the pain came I should be putting these tablets under my tongue every five minutes. Now I didn't think that was right. You can't do that with paracetamol so what's the difference with these painkillers?' 'I must have taken four or five during the night and I didn't think that was right. There's no instructions with those things." (Male patient, 82, discharged from

medical ward the previous day). "I took the tablets the doctor gave me but I just couldn't get shot of the pain. So I tried to get back to sleep." (Male

patient, given GTN by his GP) Getting help Although deputizing services, GPs and receptionists were advising patients to dial 999 if they complained of chest pain (7 cases), 5 interviewed patients had been booked into a clinic, all resulting in delays: '1phoned the surgery and the receptionist said she would book me an appointment for the end of the list.' (Male

patient, too late for thrombolysis). An additional feature of those patients delaying in coming to hospital and having GP appointments was found on analysing the interviews. Three of the patients too late for thrombolysis had visited the GP and proceeded to tell the doctor what they thought was wrong with themselves: 'I went to our doctor and I told him my friend has the most terrible indigestion and she takes Gaviscon. It works wonders for her so can I have some of that please.'

(Female patient, too late for thrombolysis). 'My mother had indigestion and I've got exactly the same thing.' 'I went to the doctor and ! told him, with all this pain I'm getting l'm convinced I've got an ulcer.' (Male patient,

too late for thrombolysis).

Patients already under investigation for coronary heart disease or on waiting lists Five of the interviewed patients who had delayed longer than 4 hours in getting to hospital had previously contacted a doctor about their chest pain and were either awaiting tests or results of investigations, or waiting for coronary artery bypass surgery. In two cases, the patients arrived too late for thrombolysis:

'1 read the letter that came ( A P P O I N T M E N T FOR A N E X E R C I S E TEST) and l said to the wife- they won't get me doing that because I've got to do the slightest thing and I get that pain in my chest." (Male patient, too

late for thrombolysis). South Asian patients Interviewed patients from the South Asian community differed from white Caucasian patients in two ways. Those who came to hospital as a self-referral or 999 call tended to come within 1-2 hours of symptom onset. The 10 patients who contacted a GP all delayed more than 4 hours in coming to hospital. Six interviewed patients had contacted a GP about the pain earlier as had one of the non-interviewed cases. None was sent directly to hospital and they were given antacids by the GP. Four patients were too late for thrombolysis, the others having well-established MIs on arrival at hospital: 'Doctor gave me white medicine and told me to take it easy" 'I had eaten chips and milk. And then I get the pain." 'I think something is stuck in my throat.' (3 Asian

patients, not sent directly to hospital with chest pain). In addition, South Asian patients tended to perceive their chest pain as either indigestion(4), musculoskeletal pain(3), or did not know(5). Only one patient who had a previous MI believed his pain to be cardiac. In Caucasians, the pain perceptions were distributed between cardiac(19), indigestion(21), musculoskeletal(6), did not know (9), and fear of dying(5). Carers for dependants An additional feature of patients delaying in coming to hospital with their chest pain occurred in those looking after chronically ill spouses at home. The two cases were too late for thrombolysis: 'I look after my wife and I do all the chores." "My wife has Alzheimer's so there was no one to ask for help.' (Male patients, carers, too late for thrombolysis).

CONCLUSION Delays in getting to hospital with an A M I are not influenced by weekday or weekend symptom onset. However, patients waiting for investigations, South Asians consulting a GP, self-diagnosers, patients with angina, and those caring for chronically ill spouses delayed in coming to hospital, irrespective of the day of the week.

Chest pain in AMI DISCUSSION Pre-hospital delay in patients with chest pain requires regular evaluation and research, not only to monitor the effectiveness of public health campaigns but also to identify groups of the population at risk. Previous studies have shown delays in presenting to hospital at weekends (Moss 1969), and more delays during the week (Wielgosz et al 1988). In addition, Birkhead (1992) found that all those calling for help between the hours of 08.00 and 12.00 called their GP, further delaying attendance at hospital, and the shortest response times were to those calls made between 20:00 and 24:00. Although this study showed no significant difference in delays in getting to hospital at the weekend or weekday there are isolated incidents where people do not seek help out of working hours, and this should be discouraged in health promotion advice about cardiac-sounding chest pain. Health education has been effective in the rehabilitation of patients suffering an AMI but needs to be extended to those with angina so that they may fully understand the implications of the disease, and their medication. Written instructions on how to take GTN should be given to patients. Patients under investigation and those on cardiac waiting lists should be given advice on how to get help if their symptoms worsen, as they may be unaware of the implications of their pain. Advice on how to deal with unrelieved chest pain should be given out with appointment cards, and at clinics. Effective health promotion on cardiac pain is needed in the Asian community in order that patients receive appropriate help. In addition, education of health professionals in pain assessment in ethnic minorities may benefit both the public and medical and nursing staff. It is known that Asians associate illness with an imbalance of humours within the body, which can be balanced by food and medicine (Orwin 1996). When an Asian talks about food and his pain it may not necessarily mean he has indigestion. Health care professionals should be wary of the 'self diagnoser' who proceeds to tell the doctor what is wrong followed by a diagnosis. Indeed, they may be correct, but may also be blissfully unaware of other potential problems. Those looking after the chronically ill at home require care as well, and to a certain extent are a hidden population. Although it may be difficult to identify when problems occur, one solution may be to include the welfare of the carer in routine visits to the chronically ill. The problems of GP referred patients who have experienced unacceptable delays in getting to hospital with AMI should be highlighted to GPs both through education programmes and by audit in order that all patients suspected of suffering an MI can receive the appropriate treatment as quickly as possible.

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Although most of the data gathered could be considered quantitative in nature, as a result of the interviews some qualitative elements are present that have supported the analysis. This is a study which has used between-method triangulation (Denzin 1987) in that different research strategies have been used to illuminate the same phenomenon. Denzin (1987) states that the rationale for this type of methodology is that, by combining methods, the flaws of using one may be highlighted by another. In this case, reasons for delay have been identified which may not have been detected by audit. LIMITATIONS The study has limitations in that the whole cohort of patients with AMI could not be interviewed due to critical illness or death within 48 h of arrival. One Pashto-speaking patient could not be interviewed as there was no interpreter available. In addition, the interviews were conducted in either a high-dependency environment or ward area, which may have inhibited some patient's responses to the questions. Although a local health promotion campaign had taken place as the study began to encourage the public to seek help rapidly for typical cardiac chest pain and may have resulted in more people coming to hospital promptly, the question remains as to whether the health campaign reached all of the population at risk. ACKNOWLEDGMENTS The author wishes to thank the following people who assisted and gave support at various stages of the project: Mrs Paula McGee of the Nursing Research Unit, University of Central England, Birmingham; Dr Gordon Bancroft, University of Stafford, for statistical support; Mr A. Bleetman, Consultant in the A & Emergency Department, Birmingham Heartlands Hospital for editing and computing support; NHS Executive, West Midlands for funding the project as an Innovation in Nursing Practice Award. REFERENCES Birkhead JS (on behalf of the Joint Audit committee of the British Cardiac Society and a cardiology committee of the Royal College of Physicians) 1992 Time delays in provision of thrombolytic therapy in six district general hospitals. British Medical Journal 305:445458 Caunt J 1996 The advanced nurse practitioner in CCU. Care of the Critically I11 12:4,136-139 Denzin N 1987 The Research Act: A Theoretical Introduction to Sociological Methods, 3rd ed. Prentice Hall, New Jersey ISIS 2 1988 Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17 187 cases of suspected acute myocardial infarction. Lancet 2:349-360 Leitch JW, Birbara T, Friedman B e t al 1989 Factors influencing the time from onset of chest pain to arrival at hospital. Medical Journal of Australia 150 (1): 6-10 Mooraby R, Rowe R, Walsh F, Beattie JM, Murray RG: 1997 Closing the audit loop: nurse led thrombolytic therapy. Heart 77; supplement 1:192 Moss A, Wagner B, Goldstein S 1969 Delay in hospitalisation during the acute coronary period. American Journal of Cardiology 24:659~66 Orwin R 1996 Health promotion for patients with CAD. Professional Nurse 12(3): 170-172

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Reilly A, Dracup K, Dattolo J 1994 Factors influencing pre hospital delay in patients experiencing chest pain. American Journal of Critical Care 3(4): 300-306 Wielgosz ATZ, Nolan RP, Earp JA, Wielgosz MB 1988 Reasons

for patients delay in response to symptoms of acute myocardial infarction. Canadian Medical Association Journal 139:853-857