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What is evidence to support nurseled thrombolysis?
160 Clinical Effectiveness in Nursing
Dear Editor, Re: M.A. Rhodes Clinical Effectiveness in Nursing (I 998) 2, 86-93 W h a t is the evidence to support nurse led thrombolysis? Rhodes concludes this review by recommending that nurses should focus on early identification and assessment of those suitable for thrombolysis, rather than initiating treatment. She cites a lack of evidence to support the safety and efficacy of nurseled thrombolysis as a reason for this. Early thrombolysis in acute myocardial infarction (AMI) is of proven benefit, with benefits being time-dependent. The key to success is early identification and treatment of those most likely to benefit. Nurses are ideally placed to implement this owing to their constant presence with their patients. The majority of thrombolysis is currently administered in coronary care units (CCU) or Accident and Emergency Units (A&E), and this is influenced by a number of factors, i.e. the diagnostic abilities of practitioners and CCU bed availability. Medical staff in A&E may have problems in accurately diagnosing AMI (McCallion 1990), although development of treatment protocols can aid their decision making (Hendrick 1994) and reduce door-to-needle time and inappropriate thrombolysis (Nee et al 1994). Suitably trained nurses, also guided by treatment protocols, can safely identify and assess patients eligible for thrombolysis, and also identify those with equivocal or complex symptoms requiring further medical opinion before treatment. The role of cardiac nurses varies from identifying AMI patients in A&E and arranging their transfer to CCU for treatment (Flisher 1995), to initiating treatment in A&E itself (Caunt 1996). Admission to CCU before treatment relies on bed availability and can lengthen door-to-needle time. Nurse-initiated thrombolysis in A&E has been shown to reduce door-to-needle time and reduce costs through reduction in inappropriate CCU admissions. Nurses in both areas have been shown to make the same intention to treat decisions as their medical colleagues and, when responsible for initiating thrombolysis, do so quicker (Caunt 1996, Quinn 1995). In the small studies available, experienced nurses have safely demonstrated their ability to identify both uncomplicated AMI patients and also
more complex cases requiring further investigation and medical opinion before treatment is initiated. It has been suggested that nurse-led initiatives also lead to quicker thrombolysis than the more traditional 'medical' approach (Caunt 1996). Use of clinical protocols to guide clinical decision making is also evident in much of the literature (Flisher 1995, Quinn 1995, Caunt 1996, Nee et al 1994) I believe this supports the case for development of nurse led thrombolysis for uncomplicated AMI, within clearly defined protocols, which need to be collaborative and involve medical and nursing staff from A&E and CCU. Integrated Care Pathways (ICP) map out the expected care route from admission to discharge and also function as an audit tool. Their use promotes a team approach to management of care. Regular review of any variation from the pathway can be analysed, identifying problem areas. This allows for practice to be modified and new evidence to be integrated. Use of ICPs in AMI have led to more coordinated care and a reduction in in-patient stay for uncomplicated MI (Johnson & Burall 1996). Such an approach would promote a collaborative approach to AMI care, with experienced nurses identifying and initiating treatment for those most likely to benefit, whilst referring more complex cases to senior medical colleagues allowing for more rapid assessment and intervention.
REFERENCES
Caunt J 1996 The Advanced Nurse Practitioner in CCU. Care of the Critically III 12(4): 136-139 Flisher D 1995 Fast-track: early thrombolysis. British Journal of Nursing 4(10): 563-565 Johnson S, Burall K 1996 Pathway to the heart. Nursing Management 3(4): 24-25 Kendrick J 1994 The challenge of myocardial infarction in Accident and Emergency nursing. Accident and Emergency Nursing 2:160-166 McCallion W e t al 1990 Interpretation of the electrocardiogram in the accident and emergency department. British Heart Journal 304:83-87 Nee P, Gray A, Martin M 1994 Audit of thrornbolysis in an accident and emergency department. Quality in Health Care 3(1): 29-34 Quinn T 1995 Can nurses safely assess suitability for thrombolytic therapy? A pilot study. Intensive and Critical Care Nursing l h 126 129
Sarah Fisher
Dear Editor, Re: M.A. Rhodes Clinical Effectiveness in Nursing (I 998) 2, 86-93 W h a t is the evidence to support nurse led thrombolysis? Rhodes concludes this review by recommending that nurses should focus on early identification and assessment of those suitable for thrombolysis, rather than initiating treatment. She cites a lack of evidence to support the safety and efficacy of nurseled thrombolysis as a reason for this. Early thrombolysis in acute myocardial infarction (AMI) is of proven benefit, with benefits being time-dependent. The key to success is early identification and treatment of those most likely to benefit. Nurses are ideally placed to implement this owing to their constant presence with their patients. The majority of thrombolysis is currently administered in coronary care units (CCU) or Accident and Emergency Units (A&E), and this is influenced by a number of factors, i.e. the diagnostic abilities of practitioners and CCU bed availability. Medical staff in A&E may have problems in accurately diagnosing AMI (McCallion 1990), although development of treatment protocols can aid their decision making (Hendrick 1994) and reduce door-to-needle time and inappropriate thrombolysis (Nee et al 1994). Suitably trained nurses, also guided by treatment protocols, can safely identify and assess patients eligible for thrombolysis, and also identify those with equivocal or complex symptoms requiring further medical opinion before treatment. The role of cardiac nurses varies from identifying AMI patients in A&E and arranging their transfer to CCU for treatment (Flisher 1995), to initiating treatment in A&E itself (Caunt 1996). Admission to CCU before treatment relies on bed availability and can lengthen door-to-needle time. Nurse-initiated thrombolysis in A&E has been shown to reduce door-to-needle time and reduce costs through reduction in inappropriate CCU admissions. Nurses in both areas have been shown to make the same intention to treat decisions as their medical colleagues and, when responsible for initiating thrombolysis, do so quicker (Caunt 1996, Quinn 1995). In the small studies available, experienced nurses have safely demonstrated their ability to identify both uncomplicated AMI patients and also
more complex cases requiring further investigation and medical opinion before treatment is initiated. It has been suggested that nurse-led initiatives also lead to quicker thrombolysis than the more traditional 'medical' approach (Caunt 1996). Use of clinical protocols to guide clinical decision making is also evident in much of the literature (Flisher 1995, Quinn 1995, Caunt 1996, Nee et al 1994) I believe this supports the case for development of nurse led thrombolysis for uncomplicated AMI, within clearly defined protocols, which need to be collaborative and involve medical and nursing staff from A&E and CCU. Integrated Care Pathways (ICP) map out the expected care route from admission to discharge and also function as an audit tool. Their use promotes a team approach to management of care. Regular review of any variation from the pathway can be analysed, identifying problem areas. This allows for practice to be modified and new evidence to be integrated. Use of ICPs in AMI have led to more coordinated care and a reduction in in-patient stay for uncomplicated MI (Johnson & Burall 1996). Such an approach would promote a collaborative approach to AMI care, with experienced nurses identifying and initiating treatment for those most likely to benefit, whilst referring more complex cases to senior medical colleagues allowing for more rapid assessment and intervention.
REFERENCES
Caunt J 1996 The Advanced Nurse Practitioner in CCU. Care of the Critically III 12(4): 136-139 Flisher D 1995 Fast-track: early thrombolysis. British Journal of Nursing 4(10): 563-565 Johnson S, Burall K 1996 Pathway to the heart. Nursing Management 3(4): 24-25 Kendrick J 1994 The challenge of myocardial infarction in Accident and Emergency nursing. Accident and Emergency Nursing 2:160-166 McCallion W e t al 1990 Interpretation of the electrocardiogram in the accident and emergency department. British Heart Journal 304:83-87 Nee P, Gray A, Martin M 1994 Audit of thrornbolysis in an accident and emergency department. Quality in Health Care 3(1): 29-34 Quinn T 1995 Can nurses safely assess suitability for thrombolytic therapy? A pilot study. Intensive and Critical Care Nursing l h 126 129
Sarah Fisher