Factors That Delay Thrombolysis Being Given in Acute Myocardial Infarction - Coursework Example

Critically Analyse the Factors That Delay Thrombolysis Being Given in Acute Myocardial Infarction Introduction: Coronary Heart Disease presents a challenge to health care professionals all round the world, as it is the most frequent cause of premature mortality. Mortality due to myocardial infarction makes up a very large portion of these deaths due to Coronary Heart Disease. Drugs and procedures for reducing mortality and morbidity have come into being as a result of advances in science and technology. Even so there is concern that a wide variety of reasons within the health care environment and outside of it lead to delay in the use of these measures and thereby are not able to deliver the full potential of reduction in morbidity and mortality caused by acute myocardial infarction. (Timmis Adam. (1999). Scale of the problem). Acute Myocardial Infarction: The blood supply to the heart muscles is maintained through the coronary arteries. This continuous blood supply is essential for the proper functioning of the heart. Plaque can build up in the coronary arteries. This plaque at some time can burst, tear or rupture and cause a blood clot to form and block the coronary artery. Acute Myocardial Infarction results from this occlusion of the coronary and could result in myocardial death. (Chambers, Ruth. Wakley, Gill and Iqbal, Zafar. (2001). Cardiovascular Disease Matters in Primary Care). Thrombolysis: Thrombolysis is one of the reperfusion techniques that are use in the treatment of acute myocardial infarction. Thrombolysis is the technique that involves the use of clot dissolving agents like streptokinase, urokinase or tissue plasminogen activator to remove the clot in the coronary artery by dissolving it and thus restoring the flow of blood through the artery. The longer the time it takes to initiate action to restore the blood supply through the coronary artery, the greater will be the damage to the cardiac muscles due to the lack of blood supply and this damage cannot be rectified. So the aim of the reperfusion techniques is to restore blood flow through the coronary artery at the earliest and restrict the damage caused by the occlusion of the blood vessel. In the case of Thrombolysis as a treatment technique for myocardial infarction there are different opinions on the time within which it should be started to be effective. A three-hour window from the time of the onset of acute myocardial infarction to the use of the needle to initiate Thrombolysis is accepted delay for the technique to be effective. In any case time is the essence of treatment of acute myocardial infarction and the earlier it is affected the more effective the reperfusion techniques leading to lesser morbidity and mortality. (Heart Attack Treatments). Time as an Important Factor in Thrombolysis: The aim in Thrombolysis is to restore the blood flow in the affected artery as quickly and completely as possible. The success rate of Thrombolysis is based not based on the Thrombolytic agent used but more on the time that has elapsed from the time of onset of the attack to the time of initiating the treatment procedure. The GUSTO-1 angiographic sub study has strongly suggested the time period of ninety minutes for thrombolytic reperfusion of the infracted coronary artery with the reduction in morbidity and mortality rates. The study showed that this ninety-minute time window in the use of Thrombolysis was responsible for 8.9 % thirty-day mortality rate and normal perfusion with four percent mortality rate. These figures confirm the belief that early Thrombolysis enables in preservation of left ventricular function and thereby reduces mortality. The more the time that elapses from the time of onset to the initiating the treatment the less effective is Thrombolysis in the treatment of myocardial infarction and beyond a delay of twelve hours it more or less loses its potency in the treatment of acute myocardial infarction. (White, D. Harvey and Werf, J.J. Van de (1998). Thrombolysis for Acute Myocardial Infarction). With time being so important in the use of Thrombolysis in the treatment of acute myocardial infarction it is necessary to assess the time taken as also the factors that cause delay in the treatment of patients with acute myocardial infarction, so that ways and means to reduce the time interval and thereby the efficiency of the treatment techniques are brought into place. There are two ways in which the time taken is calculated. In the first place there is the calculation on the basis of call to needle time. This is the time that it takes from the time information of a patient with myocardial infarction is received to the time it takes for Thrombolysis to be initiated by injection. This time calculation does not take into consideration the delays that take place due to lack of recognition of an acute myocardial infarction attack by the patient or those around the individual and the need for immediate treatment. Still it does offer the time window from the time of call for assistance to initiation of treatment and whether the time window permits the use of Thrombolysis as an effective means to reduce morbidity or mortality in the case. (Hillis, W.S. Acute treatment of Myocardial Infarction). Door to Needle Times: The door to needle times is the time that is taken from the time the patient reaches the hospital to the time it takes for the reperfusion treatment of acute myocardial infarction to be initiated. The door to needle times is within the control of the hospital authorities and health care professionals and is the area that immediate results in reducing the time delay in treatment of acute myocardial infarction can be brought about. This become more relevant in the view that more and more patients with acute myocardial infarction present themselves at hospital doors after considerable period of time and thereby reducing the efficiency of the treatment procedures. (Sheifer, E.Staurt, Rathore, S.Shaif. Gersh, J Bernard. Weinfurt, P. Kevin. Oetgen, J William, Breall A. Jeffrey and Schulman A. Kevin. (2000). Time to Presentation With Acute Myocardial Infarction in the Elderly). Rush at the Emergency Department causes pressure on the healthcare professional’s emergencies and this has led to the necessity to triage patients presenting themselves to identify those patients that need immediate attention like those presenting themselves with acute myocardial infarction. Lack of such facilities may cause a delay in the needle to door times for patients presenting themselves with acute myocardial infarction. Triage nurses have been utilised for this but there have been instances where patients presenting themselves with myocardial infarction have not been identified leading to severe delay in the required attention. There are suggestions that triage is better done by doctors to prevent such occurrences. (Derlet, Robert. (2004). Triage). Another reason for likely delay in the door to needle times is the identification of the suitability of the patient for Thrombolysis. Thrombolysis is the accepted mode of treatment in ST elevated acute myocardial infarction and the patient has been presented within the effective time for Thrombolysis. There are other parameters also that need evaluation like bleeding disorders, previous Thrombolysis and other contra-indications. The choice between the more relevant reperfusion intervention between Thrombolysis and primary angioplasty needs to be made by a specialist health care professional. This could lead to delay and therefore the presence of trained specialists to handle these emergencies is required. Absence of these trained specialists could lead to delay in identification of the suitability of the patient for Thrombolysis and cause delay in the door to needle times. (Majio, J. David and Rumsfeld, S. John. (2001). Treatment Delay in Myocardial Infarction. A Timely Topic). One of the measures that have been tried out in hospitals with a large degree of success in reducing the time taken in door to needle times is the moving of Thrombolysis as an intervention measure in acute myocardial infarction to the emergency department from the Intensive Cardiac Care Unit. Besides the speed at which suitable patients can be identified for Thrombolysis the delay in the transfer of such patients from the Emergency environment to the Intensive Cardiac Care Unit for initiating the Thrombolysis can be avoided. Thus this time delay can be nullified by having the procedure done in the Emergency Department after identification of its suitability. (Doyle, Frank. Harpe, De, La, Davida. McGee, Hannah. Shelley, Emer and Conroy, Ronan. (2005). Nine-year comparison of presentation and management of acute coronary syndromes in Ireland: a national cross-sectional survey). The study conducted Crosshouse Hospital, Kilmarnock and Southern General Hospital in the United Kingdom on the shifting of the intervention by Thrombolysis in suitable patients with acute myocardial infarction to the emergency department confirmed the reduction in door to needle times and thereby reduced morbidity and mortality in the patients. (Corfield, A.R. Graham, C.A. Adams, J.N. Booth.I and Mcguffie, A.C. (2004). Emergency department thrombolysis improves door to needle times). Previous Thrombolysis of Patient: A patient with acute myocardial infarction, who has already undergone Thrombolysis, needs to be screened for bleeding time and other parameters and this time requirement for these tests to be carried out. In addition these tests are seldom available at the Emergency Department and the patient would need to be moved for these tests. Thrombolysis cannot be initiated till such time the patient has been found suitable for Thrombolysis as a result of the tests conducted. This leads to extension of door to needle times for such patients. (White, D. Harvey and Werf, J.J. Van de (1998). Thrombolysis for Acute Myocardial Infarction). Nurse Led Thrombolysis: In an attempt to reduce the door to needle times the concept of a trained nurse led Thrombolysis has been tried out. A study conducted at Aintree Cardiac Centre, University Hospital, Aintree, Liverpool, has shown that there could be useful reduction in door to needle times where the concept of using a trained nurse led Thrombolysis was put into practice. Three hundred and sixty five patients were studied and two hundred and eighty nine were identified with definite myocardial infarction. The door to needle times prior to the presence of Thrombolysis was zero percent within thirty minutes, seven percent at within forty-five minutes and thirty four percent within sixty minutes. Thrombolysis nurses on duty changed this picture dramatically to fifty eight percent in thirty minutes, ninety one percent in forty-five minutes and hundred percent in sixty minutes. This shows that there was dramatic saving of thirty-six minutes in median door to needle times with Thrombolysis nurses on duty. This reduction in door to needle times with Thrombolysis nurses need to be considered from the viewpoint that every minute saved in door to needle times reduces the damage to the cardiac muscles and reduces the morbidity and mortality rates with acute myocardial infarction. (Somauroo, J.D. McCarten, P. Appleton, B. Amadi, A. Rodrigues, E. Effectiveness of a 'thrombolysis nurse' in shortening delay to thrombolysis in acute myocardial infarction). The usefulness of nurse led Thrombosis is further confirmer from another study showed not only distinctive reduction in door to needle times but also a fall in the inappropriate use of Thrombolysis. One hundred and fifty one patients that underwent nurse led Thrombolysis were studied. The drop in the median door to needle times was thirty minutes. In addition the inappropriate use of Thrombolysis fell from seventy three percent to thirty percent. This study also concluded that trained nurse led thrombosis is extremely useful in door to needle times. (Lloyd, G. Roberts, A. Bashir, I. Mumby, M. Kamalvand, K. Cooke, R. (2000). An audit of clinical nurse practitioner led thrombolysis to improve the treatment of acute myocardial infarction). Doctor Led Thrombolysis: The reduction in median door to needle times with a trained nurse is indicative of the unavailability of specialist doctors for Thrombolysis, when patients are presented. This is because the trained cardiac specialist is invariably at the Intensive Cardiac Care Units and may not be available immediately when a patient with acute myocardial infarctions arrives at the Emergency Department. The Emergency Department has become the focal point for intervention with Thrombolysis in the case of acute myocardial infarction. To position a cardiac specialist to handle emergency cases of acute myocardial infarction may put too much pressure on the cardiac specialist availability in the coronary care units. In this the alternative to reduction in door to needle times in doctor led Thrombolysis, is to have a trained emergency physicians handle Thrombolysis in the Emergency departments. A trained emergency physician can reduce the median door to needle times for Thrombolysis at the Emergency Department by thirty-one minutes in comparison with Thrombolysis by a cardiologist in the coronary care units. Inappropriate use of Thrombolysis would also not be there. (Irwani, I. Seet, C.M and Manning P.G. (2004). Emergency physician versus cardiologist initiated thrombolysis for acute myocardial infarction: a Singapore experience). Pre-hospital 12 Lead Cardiogram: One of the preliminary screening done on a patient with acute myocardial infarction is the Electrocardiogram. Many patients with acute myocardial infarction are brought to the hospital in ambulances with trained para-medics available in these ambulances. Training these paramedics in the use of the 12 lead ECG so that this screening can be done in the transit time of the patient to the hospital will reduce the door to needle times at the hospitals, as the time spent on the ECG after arrival at the hospital can be saved. In fact the American College of Emergency Physicians encourages the use of pre-hospital 12 lead ECG to reduce the door to needle times for Thrombolysis. (Out-of-Hospital 12-Lead ECG. (1999)). Busy Departments: Overcrowding in Emergency Departments has been a problem that has existed for a very long period of time, with serious repercussions on the healthcare provided to patients presenting themselves for emergency treatment. This leads to the Emergency department being overstretched and this is true in the case of door to needle times in Thrombolysis too. The resultant delay in providing immediate response to a patient presenting at the door of the hospital with acute myocardial infarction has a role to play in the morbidity and mortality in acute myocardial infarction. Governments, health authorities and hospital administrations are yet to wake up to this and take necessary action. (Drummond, J. Alan. (2002). No room at the inn: overcrowding in Ontario’s emergency departments). Understaffed: The pressure due to overcrowding can only be handled by increasing the presence of nurses and health care professionals at the Emergency Departments. Unfortunately this has not happened and instead there is a shortage of adequately trained emergency nurses in the Emergency Departments. This has been made worse with the practice in some hospitals to reduce costs by using part-time nurses at the Emergency Departments. This has led to larger nursing staff turn over in the Emergency Department or the migration of these trained full time staff to other departments in the hospital. We have already seen the advantage of trained nursing staff in nurse led Thrombolysis. Unavailability of such trained staff in the Emergency departments can lead to increased door to needle times in acute myocardial infarction. (Drummond, J. Alan. (2002). No room at the inn: overcrowding in Ontario’s emergency departments). Availability of Drugs and Equipment: In the Emergency department the availability of all the drugs and therapeutic equipment is not satisfactory. This is made worse with the developments that have led to greater use of diagnostic testing with the advances in science. Delays in getting results from these diagnostic aids, which are not available at the Emergency Departments only adds to the time interval between the arrival of the patient with acute myocardial infarction and the initiation of Thrombolysis. ((Drummond, J. Alan. (2002). No room at the inn: overcrowding in Ontario’s emergency departments). Conclusion: Certain aspects that have led to the delay in door to needle times for Thrombolysis have been attended to and need to be practices by all hospitals with emergency care. There are still aspects that have to be attended to if the door to needle times is brought down further and thereby reducing the morbidity and mortality in acute myocardial infarction. Literary References Chambers, Ruth. Wakley, Gill and Iqbal, Zafar. (2001). Cardiovascular Disease Matters in Primary Care. Radcliffe Medical Press Ltd. Oxon. Corfield, A.R. Graham, C.A. Adams, J.N. Booth.I and Mcguffie, A.C. (2004). ‘Emergency department thrombolysis improves door to needle’. Emer. Med. Journal. [Online]. Available at: http://emj.bmjjournals.com/cgi/content/full/21/6/676. Derlet, Robert. (2004). ‘Triage’. emedicine. [Online]. Available at: http://www.emedicine.com/emerg/topic670.htm. Doyle, Frank. Harpe, De, La, Davida. McGee, Hannah. Shelley, Emer and Conroy, Ronan. (2005). ‘Nine-year comparison of presentation and management of acute coronary syndromes in Ireland: a national cross-sectional survey’. Research article. BMC Cardiovascular Disorders. [Online]. Available at: http://www.biomedcentral.com/content/pdf/1471-2261-5-5.pdf. Drummond, J. Alan. (2002). ‘No room at the inn: overcrowding in Ontario’s emergency departments’. CJEM.JCMU. [Online]. Available at: http://www.caep.ca/004.cjem-jcmu/004-00.cjem/vol-4.2002/v42-091.htm. ‘Heart Attack Treatments’. American Heart Association. [Online]. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4601. Hillis, W.S. (1998). ‘Acute treatment of Myocardial Infarction’ in Current Issues in Cardiology. Management Strategies. ed. McEwan, R.Jean. BMJ Publishing Group. London. Irwani, I. Seet, C.M and Manning P.G. (2004). ‘Emergency physician versus cardiologist initiated thrombolysis for acute myocardial infarction: a Singapore experience’. Singapore Medical Journal. [Online]. Available at: http://www.sma.org.sg/smj/4507/4507a1.pdf. Lloyd, G. Roberts, A. Bashir, I. Mumby, M. Kamalvand, K. Cooke, R. (2000). ‘An audit of clinical nurse practitioner led thrombolysis to improve the treatment of acute myocardial infarction’. Journal of Public Health. [Online]. Available at: http://jpubhealth.oxfordjournals.org/cgi/content/abstract/22/4/462. Majio, J. David and Rumsfeld, S. John. (2001). ‘Treatment Delay in Myocardial Infarction. A Timely Topic’. [Online]. Available at: http://www.acponline.org/journals/ecp/sepoct01/magid.pdf. ‘Out-of-Hospital 12-Lead ECG’. (1999). American College of Emergency Physicians. [Online]. Available at: http://www.acep.org/webportal/PracticeResources/IssuesByCategory/EmergencyMedicalServices/PREPOutofHospital12LeadECG.htm. Sheifer, E.Staurt, Rathore, S.Shaif. Gersh, J Bernard. Weinfurt, P. Kevin. Oetgen, J William, Breall A. Jeffrey and Schulman A. Kevin. (2000). ‘Time to Presentation With Acute Myocardial Infarction in the Elderly’. Clinical Investigation and Reports. American Heart Association. [Online]. Available at: http://circ.ahajournals.org/cgi/content/full/102/14/1651. Somauroo, J.D. McCarten, P. Appleton, B. Amadi, A. Rodrigues, E. ‘Effectiveness of a 'thrombolysis nurse' in shortening delay to thrombolysis in acute myocardial infarction’. Pubmed. NCBI. [Online]. Available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10192070&dopt=Abstract. Timmis Adam. (1999). ‘Scale of the problem’ in Key advances in the effective management of Myocardial Infarction. ed. Holdright, D and Timmis, A. The Royal Society of Medicine Press Limited. London. Pp. 53. White, D. Harvey and Werf, J.J. Van de (1998). ‘Thrombolysis for Acute Myocardial Infarction. Clinical Cardiology: New Frontiers. 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