Progression in Practice and the Use of Thrombolytics - Essay Example

Progression in Practice and the Use of Thrombolytics The purpose of this essay is to evaluate an area of practice, including working in a multi-disciplinary team, identifying changes that may have occurred, and examining the effect this has had on the team. The essay will first discuss changes in the certification and education of ambulance personnel and how it has led to intra-organizational structure as well as interdisciplinary linkages with other healthcare professionals, resulting in better medical services for patients. Following this is a review on the professionalization of ambulance personnel and its professional governing body and the impact this has had on the recognition of ambulance personnel as specialists in their own right, as well as a brief examination on the constantly changing Medical Practice guidelines and the ensuing need for healthcare practitioners to stay in line with these changes. Next will be a review on technological changes and its effect on improving both personnel performance and service providing in medical and logistical terms, as well as its impact on a multidisciplinary team. The second part of the essay will focus on the area of pre-hospital cardiac care, beginning with a historical and multidisciplinary account of treatment scenarios in the past leading to current standard practices, how certain methodologies and techniques have changed between then and now, and the effect of these changes on the team within the organization and its overlap with other health care professionals as well as the wider multidisciplinary team. Finally, the essay will discuss the patient’s medical care pathway, what has changed about it, and what will continue to change as advances in medicine, education, and technology continue to occur. The ambulance and EMT profession has undergone major changes from its inception up to the present time, especially with regards to formal education and training. Prior to being professionalized, EMT and ambulance personnel were composed primarily of volunteers lacking in formal training or qualifications. However, this was changed with the introduction of basic training in haemorrhage control and the inception of guidelines in the 1966 Miller report. This was followed by the creation of the National Health Service (NHS) training manual, and then the Institute of Health and Care Development (IHCD) training. The IHCD training programme was further diversified into two grades: Medical Technician and Paramedic, with the latter being able to use new skills such as invasive techniques of intubation and cannulation and has a greater list of drugs available on their administrative list. These trainings and programs gave the basic fundamentals necessary for improved ambulance services. The introduction of clinical guidelines by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) in 2000 led to standardized ambulance service protocols for the whole of UK. This has allowed ambulance personnel in the UK to undertake training and education to much higher levels, as evidenced by the creation of the Paramedic Science degree. Higher education is beneficial for ambulance and EMT personnel, as they become equipped with a more robust and better level of clinical and physiological knowledge to make improved diagnosis of patient conditions. This enables them to make sound clinical judgments on treatment options, drug administration, and decision-making on the best clinical pathway, which in turn benefits the patient regarding their medical treatment experience and final outcome. The staff from other agencies or departments also gains better patient information and assessment and the higher educated paramedic has earned greater respect from these other groups and also in multidisciplinary settings as well. Prior to the implementation of these guidelines, patients who called for ambulance assistance received no initial assessment but were instead taken directly to the hospital. The ability to make informed clinical decisions has enabled paramedics to use other clinical pathways or even to simply treat the patient on-site, greatly reducing the need for unnecessary hospital admissions. For those taken to the hospital, the correct initial treatment given to the patient can reduce the time spent in hospital and lead to cost savings. Another step forward for paramedics in particular was the introduction of Professional Registration. The Health Professions Council (HPC), established in 2003, regulates fifteen health professions including paramedics. Regulation of a professional body makes the paramedic more individually accountable for their actions. Each individual has a responsibility to keep up to date and continue life learning through Continuous Professional Development (CPD), as one aim of the HPC is “approving and upholding high standards of education and training and continuing good practice” (HPC, 2003). The advance in paramedic education discussed earlier is imperative to professional registration. The HPC works to six guiding principles: “protecting the public, transparency, communication and responsiveness, providing a high quality of service, value for money and working collaboratively” (HPC, 2003). Through the aims, visions and guiding principles the HPC sets a standard which the individual is responsible for maintaining. This serves to protect both the service user and the public. Aside from professionalization, another advance in the field of paramedics is those regarding technology and equipment. This is not only in medical diagnostic equipment but also logistical technology including advances in ambulance control Computer Aided Design (CAD) systems and Advanced Medical Priority Dispatch Systems (AMPDS). This allows call takers to ask appropriate questions when the 999 call is made, thus initiating the correct response. All of this information is able to be uploaded to the nearest ambulance resource via in-cab technology. Satellite Navigation is then able to get that resource to the incident in the quickest possible time. Another major improvement in diagnostic technology is the move from 3 lead ECG monitoring to 12 lead monitoring. This clearly gives the paramedic or clinician much more information of activity of the heart in many situations. If the paramedic is unsure of the proper steps to take or needs further advice, telemetry technology such as Bluetooth® enables the paramedic to send copies of the ECG to a Coronary Care Unit or Accident and Emergency departments, allowing specialists, if they are available, to advise over the telephone directly to the vehicle and make decisions prior to arrival at the hospital. The area of pre-hospital coronary care is perhaps one area that helps to contextualise the changes in paramedic education programs and advances in the use of technology. Cardiac care has been greatly boosted with regards to advancement in clinical practice, in particular the way paramedics are able to manage and treat patients suffering from Acute Myocardial Infarction (AMI). Previously, paramedics and technicians were aware of the seriousness of chest pain and the need for the patient to be in definitive care but the early treatment options were limited and basic. The Ambulance Service Basic Training Manual (1988, 8-5-2) suggested some of the following: “Be calm and reassuring, loosen tight clothing, give Entonox if the pain is severe, and oxygen therapy will help with breathing”. Monitoring came via a 3 lead ECG, which gave very limited information but was able to tell the paramedic if the heart was regular or irregular, and give a basic rhythm i.e. bradychardic or tachycardic. It was unable, unless in the case of an obviously inferior infarction, to tell where the site of injury to the heart was located. In responding to a patient with chest pain, if the 3 lead ECG was showing nothing abnormal, it was common to dismiss the possibility of heart attack – a very ill-informed and poorly-educated move. Journeys to the hospital were smooth and quick so as not to stress the patient further. Hospital handovers would give brief and basic information to Accident and Emergency staff, with ambulance staff having little knowledge of what happened to the patient after handover. It was also clear that there was little interaction or teamwork between hospital staff and ambulance staff. The introduction of paramedics has shown clear advantages to care in several ways. Education has improved and paramedics are now equipped with better ECG interpretation skills, although 3 lead ECG monitoring still remained. The Ambulance Service Paramedic Training Manual (1993, 5-2-4) states “This manual does not cover the 12 lead ECG which is used as an aid in the diagnosis of myocardial ischemia, myocardial infarction and many other cardiac symptoms”. The implication of this is that the duty of the paramedic is not to diagnose but to simply have an index of suspicion and a list of symptoms. The paramedic is also in a better position to treat the symptoms. With the invasive skills of cannulation, it is now possible to treat the pain more effectively with intravenous (IV) drugs like Nalbuphine hydrochloride (Nubaine) and more recently, morphine sulphate, an opiod analgesic since it has been shown that “opiod analgesics are usually used to relieve moderate to severe pain, particularly of visceral origin.” (BNF, 2010, pg.255). Other drugs used in the treatment of AMI include a stat dose of aspirin (300mg), and Glyceryl trinitrate spray (GTN), since reducing cardiac workload by effective pain management and dilating coronary arteries with GTN is of great benefit to the patient. Prior smooth journey to the hospital has been changed to a rapid transport option. This is due to awareness of the need to get the patient to definitive care for thrombolysis treatment as soon as possible. The sooner this is done the better the outcome for the patient. Keeling et al. (2003) states that “The benefits of thrombolysis in patients with acute myocardial infarction are time dependent, with a potential 48% reduction in mortality if treatment is received within an hour of onset of symptoms”. This rapid transport also includes a pre-alert to hospital. The increase in communication is the start of a more multidisciplinary team approach to the care of the patient suffering AMI. The paramedic is now actively aware of the benefit of thrombolysis, although this remains a hospital-based procedure, since “The value of pre-hospital administration of thrombolytic agents is still under trial and it would be advisable in the foreseeable future for ambulance staff to administer these drugs, except under direct medical supervision” (Ambulance Service Paramedic Training, 1993, 8-4-2). Recently, the gain of new skills by paramedics have now raised the question of whether paramedics may be doing more harm than good, by wasting time at the address or scene of pick-up, using their skills rather than getting the patient to the hospital where they can get the treatment they need. This was overcome partially by encouraging paramedics to do as much as possible within the limits of safety en route to the hospital. Major changes and advancement in the treatment of patients suffering AMI have been made. The first is the introduction and widespread use of 12 lead ECG monitoring. This allows the paramedic more views of sections of the heart and enables them to more accurately determine the location of the infarction. This ability to use 12 lead ECG monitoring was essential to the introduction of paramedics carrying out pre-hospital thrombolysis. The JRCALC position statement claims “The case for pre-hospital fibrinolytic (thrombolytic) therapy is strong. Most would regard it as uncontroversial as an option in suitable circumstances, and in particular where ambulance transport times are relatively long and where no incompatibility exists with a local policy for Primary Coronary Intervention (PCI)” (JRCALC, 2004). This move forward required a great deal of education, training, and organizational planning. In respect to 12 lead ECGs the paramedic would require even greater ECG interpretation skills. Alongside the paramedic’s ability to interpret the information, the technology would also have to be robust to enable ECGs to be sent wirelessly to the Coronary Care Unit (CCU). The paramedic is now able to call the CCU to discuss the patient and findings. This discussion can then help him to make an informed independent decision of whether or not to use the thrombolytic agent, showing the paramedic’s role in the Multidisciplinary team (MDT) system. They are actively involved in the decision of the best course of treatment for the particular patient. The use of thrombolytic therapy is not without dangers, however. Again further education is required for the paramedic to reduce these dangers. The clot-busting drug Tenecteplase is widely used in the pre-hospital setting as “Fibrinolytic drugs act as thrombolytics by activating plasminogen to form plasmin, which degrades fibrin and so breaks up thrombi.” (BNF, 2010, p.150). It is used legally by paramedics under Patient Group Direction (PGD). “Patient Group Directions (PGDs) are documents, which make it legal for medicines to be given to be given to groups of patients – for example in a mass casualty situation – without individual prescriptions having to be written for each patient. They can also be used to empower staff other than doctors (for example paramedics and nurses) to legally give the medicine in question.” (Department of Health, 2011). The entire process takes a great deal of time and the on scene time is increased to ensure that the procedure is carried out methodically and safely. Once completed the patient can be transported carefully and unhurried to CCU. This reverts back from rapid transport as the so-called “call to needle time” has already been achieved, with pre-hospital thrombolysis (PHT) reducing call to needle time by around 60 minutes. An alternative to thrombolytic therapy for the patient is Primary Percutaneous Coronary Intervention (PPCI). PPCI is a procedure to insert a stent into the blocked coronary artery. The circulatory system is entered via the groin. Once the stent is at the required position a small balloon inflates to position the stent. The balloon is removed leaving the stent in place. The patient usually remains awake during the procedure and can watch what is happening on a monitor. As more PPCI centres open across the country, PHT has become less common. However, the paramedic remains an important link in the MDT approach. The contact between the CCU staff and paramedic is still in place, and it still remains the paramedics’ job to recognise an AMI and initiate treatment. Despite the highly skilled and educated paramedic, the development of pre-hospital PPCI is highly unlikely. The previous analysis of the stages of progression of just one area of paramedic practice shows the advancement and maturation of the ambulance service. Although the education and knowledge base of early paramedics may not have been equal to other medical professionals like nurses or doctors, the same cannot be said for the paramedic of today. The new educational pathways open to paramedics have made them highly educated and knowledgeable. This rapid turnaround has been helped and complimented by professional registration via the HPC. Now that there is higher education, paramedics must remain highly educated, and although taking on lifelong learning may be challenging, it is nevertheless necessary. Medicine advances and changes rapidly. Paramedics and technicians must stay up-to-date and informed of all movements in practice, and learn to embrace change and adjust accordingly. However, it is not only education and knowledge that have improved – the paramedic’s skill set has also grown. Invasive techniques such as cannulation, intubation, and needle decompression to name a few, have had a positive impact on patient care. As the example of practice has shown, all elements have played a big part in the patients’ outcome. This example shows how PHT has improved patient outcome, “The pre-hospital delivery of a bolus thrombolytic by a paramedic properly trained in the use of 12-lead electrocardiogram equipment in the treatment of patients with STEMI. Evidence of the benefit of Pre-Hospital Thrombolysis (PHT) over in-hospital thrombolysis is unequivocal. It has been estimated that Pre-Hospital Thrombolysis (PHT) offers a survival benefit (over in-hospital thrombolysis) of 17% of patients with acute STEMI” (Kendall, 2007). It also shows how the paramedic has changed from treating symptoms to making firm diagnosis of the patient’s condition, as well as initiating treatment with a wide range of drugs. The National Institute of Clinical Excellence gives guidance to the NHS in England and Wales on the use of thrombolytic drugs. The drugs available include alteplase, reteplase, streptokinase, and tenecteplase. However, the only drugs recommended for pre-hospital settings are reteplase or tenecteplase. This is because there is currently no way of confirming previous clinical history at present and it is ineffectual to administer streptokinase if it has been used previously (within 6 months). It could be argued that with the sharing of clinical data this problem could be easily eradicated. Could it therefore be due to the difference in cost between streptokinase (£80-£90 per patient) and tenecteplase (£700 to £770 per patient)? Or could it be considered that the creation of thrombolytic centres is of more benefit to the patient? This debate should be brought to a close quickly, particularly if it is about considerations of cost versus quality of care. The importance of timely treatment is without debate because from the approximately quarter of a million people who have a major heart attack in England and Wales each year one third of the deaths from heart attacks happen in the first hour. Education and extended ability to administer a wider range of drugs has led to the paramedic becoming more professional and gaining greater respect from peers across the National Health Service. This is highlighted by being accepted in the multidisciplinary team. Not only have they been accepted, but also their opinions are heard and taken seriously. The ambulance service has come a long way in a relatively short period of time. Today’s paramedic is highly motivated, highly skilled, highly educated, and highly respected. Bibliography Ambulance Service Basic Training (1988) Bristol. Belmont Press. Ambulance Service Paramedic Training (1993) Bristol. Swindon Press. British National Formulary (2010) London. BMJ Group. Department of Health (2011) PGD retrieved Feb. 15th, 2012 from http://www.dh.gov.uk/en/managingyourorganisation/emergencyplanning/patientgroupdirections/index.htm HPC (2003) Aims & Vision. Available from HPC website: [Accessed February 6th, 2012] HPC (2003) Guiding Principles. Available from HPC website: [Accessed February 6th, 2012] JRCALC (2004) Prehospital Thrombolytic Therapy. Available from JRCALC website: [Accessed February 13th, 2012] Keeling, P. Hughes, D. Price, L. Shaw, S. Barton, A. (2003) Safety and Feasibility of Prehospital Thrombolysis carried out by paramedics. Available from [Accessed February 6th, 2012] Kendall, J. (2007) The Optimum Reperfusion pathway for ST elevation acute myocardial infarction - development of a decision framework. Available from [Accessed February 15th, 2012] The National Institute for Clinical Excellence (2002) on the use of drugs for early thrombolysis in the treatment of acute myocardial infarction. Available from [Accessed February 12th, 2012] Read More