The Utility of the Nursing Service - Term Paper Example

Critically Evaluate Improving ‘Door To Needle’ Times With Nurse Initiated Thrombolysis Introduction: The rationale for the selection of this topic is that it is in keeping with the field of practice in health care and more so as it is related to one of the significantly important fields of interest and that is the possible means of improving the health care services to the critically ill, be it in cooperation between all the members of the healthcare services or in the improvement of the means and methods in dealing with emergencies of the critically ill. On of the current concerns is with regard to the critically ill and the reduction in the mortality and morbidity rate that is seen in critically ill patients presenting themselves in hospitals by reducing the period between the time of presenting themselves at the hospital and the initiation of procedures to alleviate their condition. In many critical conditions like Acute Myocardial Infarction (AMI), this time period is critical in reducing the mortality rates of patients presenting themselves with this condition and the initiation of thrombolysis as a means to reperfusion. (Fox, A.A.K. 1995. The Thrombolysis Trials and Clinical Practice). There is increasing interest in the manner in which the services of the nursing profession may be utilised to address the area of concern in the medical profession with regard to the time delay in the critically ill being provided with the necessary medical intervention procedures for alleviating their condition. Nurse led or initiated medical procedures are subject to the influence of several factors and these include the policies of NHS, the hospital environment, the perceived gap in the services provided and the resources available. The earlier trend of making use of the nursing resources in areas of low risk and areas that have clearly defined protocols may have to be examined as the utility of the full potential of the nursing services is not being tapped. (Richardson. A and Cunliffe, L. 2003. New horizons: the motives, diversity and future of 'nurse led' care). This critical study allows for an understanding of the utility of the nursing services in the area of reducing the door to needle times in thrombolysis for patients presenting themselves with AMI and could be expanded to take in the issues related to the extended door to needle times and the role of nurse initiated thrombolysis in the reducing door to needle times. To this end the search for literary works related to the topic was limited to the books and journals and the Internet for articles that provided suitable literature for the topic. The Medscape and Google databases were used and the search terms included, ‘nurse initiated thrombolysis’, ‘door to needle times’, doctor led thrombolysis, ‘busy departments in delays to thrombolysis’, and understaffing in delays to thrombolysis. Articles selected were based on relevance to the study and those rejected were those that provided no meaningful assistance to the study. Evaluation: The study attempts to establish the pertinence of nurse initiated thrombolysis in reducing the door to needle times in the critically ill patients presenting themselves at the chosen hospital with chest pain and suspected myocardial infarction. The objective of the study is clear and the results are in keeping with the several studies undertaken on the subject of the effectiveness and safety of nurse initiated thrombolysis that include the study by Lloyd, G. et al, wherein in a study conducted on 157 patients 151 consecutive patients undergoing 167 episodes of thrombolysis The average door to needle times fell to thirty minutes from sixty minutes, which is similar to the findings of this study in the reduction of door to needle times 25-30 minutes from 50-58 minutes. In both studies sufficient time for has been provided to take into consideration the door to needle time outcomes prior to the introduction of nurse initiated thrombolysis. This study as well as the study conducted by Lloyd, G. et al have been conducted in an adequate manner as to establish the safety aspect of the thrombolysis decisions taken by concerned nurses. (Lloyd, G. et al. 2000. An audit of clinical nurse practitioner led thrombolysis to improve the treatment of acute myocardial infarction). The study under consideration was conducted by nurse-initiated thrombolysis in the ICU and not in the Emergency Department. In comparison the study by Somauroo et al in 1999 establishes the utility of a ‘thrombolysis nurse’ at A&E and the assessment of suitability for thrombolysis and the initiation of thrombolysis in A&E prior to transfer to the ICU leading to a saving of thirty six minutes in door to needle times. (Somauroo et al. 1999. Effectiveness of a ‘thrombolysis nurse’ in shortening delay to thrombolysis in acute myocardial infarction). This conclusion of the reduction in door to needle times by using a nurse to initiate thrombolysis in A&E was further confirmed by a study conducted by Heath, et al. In this study conducted using an Acute Chest Pain Nurse Specialist (ACPNS) to assess patients and initiate thrombolysis in A&E and find out the reduction in door to needle times, this procedure was found to reduce the median door to needle times to twenty three minutes from the early median of fifty six minutes even when the patients were fast tracked and compares very well with the study of Somauroo et al. (Heath, S.M. et al. 2003. Nurse initiated thrombolysis in the accident and emergency department: safe, accurate, and faster than fast track). Several studies have clearly established that door to needle times are reduced by the assessment and initiation of thrombolysis in the ED itself by cardiologists instead of moving the patient to the ICU for thrombolysis. This needless to say necessitates the availability of all necessary equipment and drugs at the ED itself. Corfield et al in a study conducted on this aspect at a Scottish hospital, wherein the prior norm of initiating thrombolysis at the ICU was changed to initiating thrombolysis at the ED itself to study the effect on the door to needle times in 2000, found that the median time for door to needle times for the pre-change group consisting of 321 thrombolysed patients was sixty four minutes, while after the change the median door to needle times in 324 thrombolysed patients was thirty five minutes providing for a reduction in median door to needle times by twenty nine minutes. (Corfield et al. 2004. Emergency department thrombolysis improves door to needle times). The findings of this study were further augmented by a subsequent study conducted by Gilby et al in 2001 in their attempt to find means to reduce the door to needle times in keeping with the thrombolysis goals set by the National Service Framework from 2003 onwards. This study concluded that emergency teams might be more useful in processing patients that are in need of thrombolysis. (Gilby et al. 2003. Meeting National Service Framework goals for patients presenting with acute myocardial infarction). This preference for thrombolysis at the ED in place of the ICU is gaining popularity in many parts of the world as can be seen from the results of the study by Goodacre, et al in Australia, which cane to the conclusion that hospital pre-notification and thrombolysis at the ED reduced time delays in thrombolysis even though the mortality impact was modest. (Goodacre et al. 2004. Potential impact of interventions to reduce times to thrombolysis). The research article being studied thus provides utility from the point of view of reduced door to needle times by using nurse initiated thrombolysis and the safety of the procedure in an ICU environment. With the reduced door to needle times objectives of NSF, this research article adds one more reliable study on the effect on door to needle times by nurse initiated thrombolysis to reach this objective. However it remains deficient in that the study was conducted by moving patients directly to the ICU and does not make it clear if the reduced door to needle times was based on the evidence of earlier door to needle times of thrombolysis at the ED or at The ICU. With the growing evidence of reduction in door to needle times by initiating thrombolysis at the ED in preference to thrombolysis at the ICU the relevance of this research article is restricted to those hospitals that are reluctant to make the change over in the site for initiating thrombolysis. There is growing concern over the errors that occur in the treatment of the critically more so when the care is provided by either inexperienced clinicians or unsupervised trainees. Under these circumstances the safety aspect in the use of nurse-initiated thrombolysis comes under the magnifying glass. (Bion, J.F. and Heffner. J.E. 2004. Challenges in the care of the critically ill). There is also concern that the concentration currently is on the speed of intervention without taking care of the safety and accuracy aspects concerned in the decision of the type of medical intervention, especially when the medical intervention come from non-cardiologist in the case of thrombolysis. (Clare, C and Bullock, I. 2003. Door to needle times bulls' eye or just bull? The effect of reducing door to needle times on the appropriate administration of thrombolysis: implications and recommendations). This is especially true besides the other contraindications, in the case of elderly patients presenting at the hospital doors with myocardial infarction, as the eligibility for thrombolysis decreases with age. (Berger, K.A. 2003. Thrombolysis in Elderly Patients With Acute Myocardial Infarction). In addition the cost effectiveness of nurse led medical interventions are coming under the scanner in areas of activity that are considered suitable for them. (Raftery, P.J. et al 2005. Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomized controlled trial). The counter points in the first place the shortage of emergency doctors is expected to continue for many years more and the means of providing care to the critically ill is a moot point to the safety concerns. (Watts, G. 2004. Shortage of emergency doctors will take eight years to rectify). In addition to this there is the factor of the increasing demands made on the health service and in particular the emergency services. The emergency care nurses do have a role to play in providing better service in this aspect nurse led thrombolysis does provide for quicker service to those presenting themselves for emergency coronary care. (Perrin, J. 2003. Working together, sharing the burden). This research article has utility and relevance in reinforcing the role nurses in providing better service through nurse led thrombolysis and also addresses the safety concerns by evaluating the safety of decisions made by the trained nursing staff in the choice of thrombolysis as the medical intervention procedure of choice among patients that present themselves with chest pain at emergency centres. The research article would have been even more useful if there was more clarity on the issue of whether ambulance pre-alert calls were used or not, as there is evidence to support the reduction in door to needle times with the use of ambulance pre-alert calls. (Learmonth et al. 2006. Does initiation of an ambulance pre-alert call reduce the door to needle time in acute myocardial infarct?). The research article does provide a clear patient assessment form in the appendix that was used in the trial. There remains one lacuna in that a checklist that would be useful for management for the thrombolysis nurse as seen in the Somauroo et al study is more comprehensive. Yet all in all the study is useful from the narrow window of utility of the nurse-initiated thrombolysis to reduce door to needle times with the safety aspects addressed. Discussion: The issue of delay in providing medical intervention to the critically presenting themselves at hospital doors with chest pain and the suitability of the patients for thrombolysis has been a problem for some time now. The quicker the medical intervention the lesser the morbidity and mortality rates of these patients is an accepted reality in the medical world. The problem is even more compounded when there is the likelihood of the patients presenting themselves at the hospital after considerable delay from the onset of the pain. To address these concerns on call to needle times the National Service Framework has set standards that require thrombolysis be available for suitable patients within sixty minutes of calling for medical assistance. In addition the NHS Trusts are called upon to put in place systems or protocols that enable people that are admitted into hospitals with myocardial infarction are provided with adequate means of assessing their condition and provided with suitable medical care that is cost effective and diminishes the chances of morbidity and mortality. (Gilby et al. 2003. Meeting National Service Framework goals for patients presenting with acute myocardial infarction). In addition to this by the 2003 the NSF has targeted a door to needle time of twenty minutes from arrival at the for 75% of the patients eligible for thrombolysis. (Qasim et al. 2002. Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction). To this end several means of reducing the door to needle times, which are in the control of the hospitals have been tried and studied. These efforts include nurse initiated thrombolysis, thrombolysis at the ED in place of ICU, Pre-hospital call alerts, 12 lead ECG in the ambulance, triage at the ED, presence of a cardiac specialist at the ED, besides adequate availability of equipment and drugs at the ED. This research article is useful in reinforcing the utility of nurse-initiated thrombolysis to reduce the door to needle times in keeping with the NSF standards and in an adequately safe manner too. The relevance of this research article is that it is one of the many studies conducted on various aspects of reducing door to needle times to provide patients presenting themselves with chest pain at hospital doors prompt and adequately safe medical intervention and thereby providing them better chances of survival. Conclusion: The findings of the research study is in keeping with other research studies that have been conducted on the issue of the reduction in door to needle times by the use of a nurse initiated thrombolysis and has demonstrated adequate reduction in door to needle times in keeping with the other studies conducted. This study also demonstrates adequate safety in the use of nurse initiated thrombolysis and thus reinforces the possibility of introducing nurse led thrombolysis as a means of achieving the standards and targets set by NSF. Literary Works Berger, K.A. 2003. Thrombolysis in Elderly Patients With Acute Myocardial Infarction. Retrieved February 2006, from The American Journal of Geriatric Cardiology. Vol. 12. Issue. 4. Pp. 251-256. Web site: http://www.medscape.com/viewarticle/460852_1. Bion, J.F. and Heffner. J.E. 2004. Challenges in the care of the critically ill. The Lancet. Vol. 363. Pp 970-975. Clare, C and Bullock, I. 2003. Door to needle times bulls' eye or just bull? The effect of reducing door to needle times on the appropriate administration of thrombolysis: implications and recommendations. Retrieved February 25, 2006, from European Journal of Cardiovascular Nursing. Vol. 2. Issue 1. Pp. 39. Web site: http://www.medscape.com/medline/abstract/14622647?queryText=door%20to%20needle%20times. Corfield et al. 2004. Emergency department thrombolysis improves door to needle times. Retrieved February 25, 2006, from, Emergency Medicine Journal. 2004. Vol. 21 Pp. 676-680. Web site: http://emj.bmjjournals.com/cgi/content/full/21/6/676. Fox, A.A.K. 1995. The Thrombolysis Trials and Clinical Practice. In Ball G.S. (Ed.), Myocardial Infarction. FROM TRIALS TO PRACTICE. Pp. 102-103. Wrightson Biomedical Publishing Ltd. Hampshire. Gilby et al. 2003. Meeting National Service Framework goals for patients presenting with acute myocardial infarction. Retrieved February 25, 2006, from, Emergency Medicine Journal. 2003. Vol. 20 Pp. 156 – 157. Web site: http://emj.bmjjournals.com/cgi/content/full/20/2/156. Goodacre et al. 2004. Potential impact of interventions to reduce times to thrombolysis. Retrieved February 25, 2006, from, Emergency Medicine Journal. Vol. 21. Pp. 625-629. Web Site: http://emj.bmjjournals.com/cgi/content/full/21/5/625. Heath, S.M. et al. 2003. Nurse initiated thrombolysis in the accident and emergency department: safe, accurate, and faster than fast track. Retrieved February 25, 2006, from Emergency Medicine Journal. 2003. Vol. 20. Pp 418-420. Web site: http://emj.bmjjournals.com/cgi/content/full/20/5/418. Learmonth et al. 2006. Does initiation of an ambulance pre-alert call reduce the door to needle time in acute myocardial infarct? Retrieved February 25, 2006, from Emergency Medicine Journal. 2006. Vol. 23. Pp. 79-81. Web Site: http://emj.bmjjournals.com/cgi/content/abstract/23/1/79. Lloyd, G. et al. 2000. An audit of clinical nurse practitioner led thrombolysis to improve the treatment of acute myocardial infarction. Retrieved February 25, 2006, from Journal of Public Health Medicine. Vol. 22 Pp. 462-465. Web Site: http://jpubhealth.oxfordjournals.org/cgi/content/abstract/22/4/462. Perrin, J. 2003. Working together, sharing the burden. Retrieved February 25, 2006, from, Emergency Medicine Journal. 2003. Vol. 20. Pp. 398. Web site: http://emj.bmjjournals.com/cgi/content/full/20/5/398. Qasim et al. 2002. Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction. Retrieved February 25, 2006, from, British Medical Journal. Vol. 324. Pp. 1328-1331. Web site: http://bmj.bmjjournals.com/cgi/content/full/324/7349/1328. Richardson. A and Cunliffe, L. 2003. New horizons: the motives, diversity and future of 'nurse led' care. Retrieved February 25, 2006, from Journal of Nursing Management 2003; Vol.11 Issue. 2. Pp. 80-4. Web site: http://www.medscape.com/medline/abstract/12581395?queryText=nurse%20led%20thrombolysis. Raftery, P.J. et al 2005. Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomized controlled trial. British Medical Journal. 2005. Vol. 330. Pp. 707-709. Somauroo et al. 1999. Effectiveness of a ‘thrombolysis nurse’ in shortening delay to thrombolysis in acute myocardial infarction. Journal of the Royal College of Physicians of London. Vol. 33 No.1999. Pp 46-50. Watts, G. 2004. Shortage of emergency doctors will take eight years to rectify. British Medical Journal.2004. Vol. 329 Pp. 994. Read More