Thrombolysis in Accident and Emergency: the exception not the rule. Are we denying patients lifesaving treatment? T. Quinn
Introduction
Tom Quinn RN MPhil FESC, Honorary Visiting Fellow, Department of Health'Studies, University of York, York, UK.
Correspondenceto 27 Highfield Road, Edgbaston, Birmingham, B15 3DP, UK.
Manuscript accepted: 18 July 1998
A recent report by Hood et al. (1998) that thrombolytic therapy was routinely available in only 35% UK Accident and Emergency (A&E) departments, raises some important issues about the role of A&E staff in the management of patients with acute myocardial infarction. Acute myocardial infarction is a common reason for emergency admission to hospital, and is associated with a considerable mortality. While most fatal events occur in the community, presumably because of fatal arrhythrnia, those patients reaching hospital alive have improved outcome if there is prompt restoration of coronary blood flow, usually through the administration of a thrombolytic agent. Moreover, the early mortality benefit appears to be maintained at 10-year follow-up (Baigent et al. 1998). That thrombolytic therapy is a time dependent intervention, more effective when given within the first 6 hours from symptom onset, and even more effective when administered within the first hour or two (Boersma et al. 1996) is well established. National guidelines recommend that suitable patients should receive treatment within 30 minutes of hospital arrival (the 'door to needle' time) (de Bono & Hopkins 1994), with more recent opinion suggesting that this target could be reduced to 20 minutes in well organized centres (European Society of Cardiology 1996). The lifesaving potential of this treatment is such that patients requiring thrombolytic treatment should probably be afforded the same
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priority as patients in cardiac arrest. Would A&E nurses accept the transfer of patients in cardiac arrest to the cardiac care unit (CCU) before definitive treatment was commenced? Of course not. That the majority of A&E departments do not provide thrombolysis was met with frank disbelief by an American colleague with whom this author recently discussed the Hood et al. (1998) paper. Many factors delay the administration of thrombolytic therapy, not least the actions of patients, carets and pro-hospital health professionals. Birkhead (1992) reported that the major component of delay in a six-centre survey occurred before the patient reached hospital. The focus of this paper, however, is on those delays occurring once the patient enters the hospital system. These are best described using the '4Ds' model developed in the USA (National Heart Attack Alert Program Co-ordinating Committee 1994) and have been adapted for use in the UK by Quinn & Thompson (1995). The 4Ds represent door (triage), data (time to first ECG recording), decision (to initiate thrombolytic therapy) and drug (the overall 'door to needle' time).
Fast track is really slow track A&E nurses will be familiar with the term 'fast track', a system first described by Pellet al. (1992). This system entails rapid identification of A&E patients with suspected myocardial infarction, who are then referred for additional assessment by cardiology or general medical staff prior to commencement of thrombolytic therapy.
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Widely adopted by A&E depai-tments in the UK, it is important to note that in Pell's (1992) series 'door to needle' time was reduced from a median 93 minutes to 49 minutes, still far in excess of the recommended standard of 30 minutes. 'Fast track' as thus described is, in fact, 'slow track'. The reduction in delay to treatment is less impressive than in those centres where duplication of assessment by general medical or cardiology staff has been replaced by A&E doctors making treatment decisions themselves based upon their clinical and ECG findings for individual patients. Kendall & McCabe (1996) reduced 'door to needle' time in A&E from median 110 minutes to 30 minutes following the secondment of a senior CCU nurse to work in the department for a year. Mooraby et al. (1997) reported a reduction in delay from median 75 minutes to 18 minutes following the introduction of a team of three senior CCU nurses to triage cardiac patients in A&E. However, the resources to introduce such specialist nurses are unlikely to be available to every A&E. Direct admission to CCU has been reported to reduce delay when patients bypass A&E altogether (Burns et al. 1989; Prasad et al. 1997; Banerjee & Rhodes 1998), although limited bed availability on CCU may preclude this strategy in many centres. Moreover, even in the presence of a direct admission policy, patients who presented initially in A&E were as likely to require thrombolysis as those taken directly to CCU by ambulance paramedics, and in fact accounted for a greater number of thrombolysis-eligible patients (Quinn 1998, unpublished MPhil thesis).
Practice m u s t c h a n g e t o save lives The current suboptimal arrangements for the management of patients with acute myocardial infarction within the A&E environment present an important challenge for A&E nurses. Failing to provide thrombolysis in A&E in 1998, in the face of a wealth of evidence for the time-dependent nature of tl~is lifesaving treatment, is probably indefensible, whether viewed from a professional, moral or legal perspective. Clear guidelines for patient assessment, choice of agent and administration within A&E should be drawn up in every department, in collaboration with
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CCU colleagues. Fax machines should be available in every resuscitation room to provide rapid access to CCU for support in decision making, where necessary. Assessment of patients with suspected myocardial infarction or ischaemia should be a core component of A&E staff training. Appropriate medications and equipment should be readily available as a standard component of the resuscitation room inventory. The recent White Paper on the NHS (Secretary of State for Health 1997) demonstrates the Government's commitment to ensuring that patients receive the right treatment at the right time, and that the professionals get it right 'first time, every time'. This general statement applies, it is suggested by this author, to the management of patients with acute myocardial infarction presenting to A&E, who deserve the chance to benefit from prompt administration of thrombolytic treatment where it is clearly indicated. References Baigent C, Collins R, Appleby P, Parish S, Sleight P, Peto R 1998 ISIS-2: 10-year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both or neither. BMJ 316:1337-1343 Banerjee S, Rhodes W E 1998 Fast tracking of myocardial infarction by paramedics. Journal of the Royal College of Physicians of London 32:36-38 Birkhead J S 1992 on behalf of the joint audit committee of the British Cardiac Society and a cardiology committee of the Royal College of Physicians of London. Time delays in provision of thrombolytic treatment in six district hospitals. BMJ 305:445-448 Boersma E, Maas A C P, Deckers J W, Simoons M L 1996 Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 348: 771-775 de Bono D P, Hopkins A 1994 The management of acute myocardial infarction: guidelines and audit standards. Report of a workshop of a joint audit committee of the British Cardiac Society and the Royal College of Physicians of London. Journal of the Royal College of Physicians of London 28:312-317 Burns L M A, Hogg K J, Rae A P, Hillis W S, Dunn F G 1989 Impact of a policy of direct admission to a coronary care unit on use of thrombolytic therapy. British Heart Journal 61:322-325 European Society of Cardiology 1996 Task Force on the management of acute myocardial infarction. Acute myocardial infarction: pre-hospital and in-hospital management. European Heart Journal 17:43--63 Hood S, Bimie D, Swan L, Hillis W S 1998 Questionnaire survey of thrombolytic treatment in accident and
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emergency departments in the United Kingdom. BMJ 316:274 Kendall J M, McCabe S E 1996 Use of audit to set up a thrombolysis programme in the accident and emergency department. Journal of Accident and Emergency Medicine 13:49-53 Mooraby A, Rowe R, Walsh F, Beattie J M, Murray R G 1997 Closing the audit loop: nurse-led thrombolytic therapy. Heart 77; supplement 1:192 (abstract) National Heart Attack Alert Program Co-ordinating Committee 1994 Emergency department: rapid identification and treatment of patients with acute myocardial infarction. Annals of Emergency Medicine 23:311-329
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Pell A C H, Miller H C, Robertson C E, Fox K A A 1992 Effect of 'fast track' admission for acute myocardial infarction on delay to thrombolysis. BMJ 304:83-87 Prasad N, Wright A, Hogg K J, Durra F G 1997 Direct admission to the coronary care unit by the ambulance service for patients with suspected myocardial infarction. Heart; 78:462-464 Quinn T, Thompson D R 1995 Administration of thrombolytic treatment to patients with acute myocardial infarction. Accident and Emergency Nursing 3:208--214 Secretary of State for Health 1997 The New NHS: Modern, Dependable. NHS Executive, London
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