Timing is all: Therapy within 30 minutes ideal
The ED nurse must act rapidly
Much of the medical-legal activity surrounding use of thrombolytics is focused on the timing of the drugs’ administration. There is no recognized standard for how quickly a nurse should administer in-hospital thrombolytics for acute myocardial infarction (AMI), but the National Heart Attack Alert Program (NHAAP) Coordinating Committee, part of the National Heart, Lung, and Blood Institute in Rockville, MD, has recommended that eligible patients receive treatment within 30 minutes of arrival at a hospital.
That ideal has been labeled the door-to-needle time and is a recommendation, not a reality. Patients who present to the emergency department (ED) early give nurses an opportunity and responsibility to act rapidly. (See chest pain algorithm, p. 5.)
The key to many thrombolytic-related malpractice lawsuits is an allegation of delay in administration, resulting in myocardial injury. In the past, the impact of a reperfusion delay on infarction has been difficult to prove.
However, a growing body of research has found a positive relationship between symptom duration before therapy and final infarction size. Each 30-minute increase in symptom duration before thrombolytic therapy is associated with an increase in infarction size. It has been established that there is typically no additional myocardial injury associated with delay beyond the sixth hour.
How quickly you deliver thrombolytic therapy in the ED is the key to avoiding expensive malpractice suits. Significant strides have been made recently in meeting set parameters, and door-to-needle times at various institutions range from 30 to 90 minutes. Although therapy within a 12-hour window is widely accepted, it’s clear that most benefit comes from treatment within the first few hours of symptoms.1,2
To move a step closer, treatment within the first hour or half-hour of symptoms confers an extraordinary benefit. There is modest but significant benefit for patients whose door-to-needle time for thrombolysis is six to 12 hours after the onset of symptoms.
Whether any benefit exists in treatment beyond 12 hours is the subject of current research. Ongoing research may result in modification of that recommendation, but no research currently shows any benefit for administering the drugs after 12 hours.
Initiatives are under way at cardiac centers across the country to help patients recognize the symptoms of a heart attack sooner so they don't delay getting to EDs for treatment.
The whole point is to reduce delays and expedite time to treatment, says Mary Hand, RN, MSPH, coordinator of NHAAP. In 1991, when NHAAP began, the average door-to-needle time was 60 to 70 minutes. Now it is typically 39 minutes, Hand says.
Early nursing treatment of eligible AMI patients is critical because of the dramatic relationship between the onset of symptoms to coronary artery reperfusion and ultimate outcome. Pooled data from 42 randomized trials comparing thrombolytic therapy with placebo or conservative treatment 44,346 AMI patients and 4692 deaths convincingly demonstrates the strong relationship between time to treatment and the risk of cardiac rupture and death.3
You might want to use as a guide the four D time points critical in the thrombolytic process:
1. Door.
From the moment a patient enters the ED, nurses should have in place protocols to assess the condition rapidly. ED nurses should have an explicit list of chief complaints that require immediate evaluation by a triage nurse. (See Assess AMI Stat box, at right.)
2. Data.
A nurse should obtain an electrocardiogram on potential heart attack patients within five minutes of its order.
3. Decision.
Nurses and the rest of the hospital medical staff responsible for treating AMI patients should share in developing guidelines for initiating thrombolytic therapy.
4. Drug.
ED physicians should delegate authority to nurses to order thrombolytic therapy without having to obtain prior consultation.
Team is formed to answer questions
Late last year, the cardiac service line and ED at St. Francis Hospital and Health Centers in Beech Grove, IN, initiated an action team to better manage their patients presenting with chest pain. Jerri DeVaney, RN, BSN, care manager of the cardiac service line at St. Francis explains, "We wanted the answers to some questions about our pathways, such as, do we automatically send chest pain patients up to the critical care unit, or do we monitor them in the ED?
"Sometimes a pathway is left standing and unchanged," says DeVaney, "simply because that’s the way you’ve always done it, and you’re comfortable with it that way. Cardiac pathways need continual updating. When we started our service line project, we looked at our open-heart DRG pathways and tore them apart. We asked, why are we doing this,’ and Why are we doing it that way instead of another way?’"
Obtain physicians’ support when redesigning protocols, DeVaney suggests. Cardiologists at St. Francis participated in the AMI algorithms development by standardizing their orders. St. Francis’ cardiac service line medical director acts as the department’s champion for change. If, for example, says DeVaney, a patient comes in who should be on an ACE inhibitor and isn’t, and there’s no documentation as to why he or she isn’t, the director will go physician-to-physician and discuss the patient’s care.
"Doctors at St. Francis," she says, "cooperate by discussing costs and benefits of patient outcome guidelines." A group of interventional cardiologists meets monthly to review the latest technologies and the best recommendations for their patients. "They look at outcomes of patients in their group," says DeVaney. "They’re in tune with all the recent studies and guidelines that come down, but if they think their patients can benefit from a protocol, they’ll do it even if a guideline says it’s not cost-effective.
"You can initiate lifestyle modification for a patient who comes to the ED with chest pain, even if it turns out they don’t need to be admitted," says DeVaney. "Talking about smoking cessation attempts, nutrition, and exercise and distributing educational materials costs pennies. In the short run, you may not see savings because they cannot be measured, but in the long run, money is conserved.
"Patients benefit on a personal level as well," continues DeVaney, "because they don’t have to spend any more time in a hospital environment than is absolutely necessary. People do better in their home environments."
References
1. LATE Study Group. Late assessment of thrombolytic efficacy (LATE) study with alteplase 6-24 hours after onset of acute myocardial infarction. Lancet 1993; 342:759-766.
2. EMERAS (Estudio Multicentrico Estreptoquinasa Republicas de America del Sur) Collaborative Group. Randomized trial of late thrombolysis in patients with suspected acute myocardial infarction. Lancet 1993; 342A:767-772.
3. Honan HM, et al. Cardiac rupture, mortality, and the timing of thrombolytic therapy: A meta-analysis. J Am Coll Cardiol 1990; 16:359-367.
Suggested reading
The National Heart Attack Alert Program Coordinating Committee 60 Minutes to Treatment Working Group. Emergency department: Rapid identification and treatment of patients with acute myocardial infarction. Ann Emerg Med 1994; 23:311-329.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content