The Role of Nurses in Improving Emergency Cardiac Care

Summary

Cardiovascular diseases exert a huge burden on individuals and society, with coronary heart disease (CHD) the single most common cause of death in the United Kingdom and other developed countries (British Heart Foundation 2004). Improved clinical care has been responsible for around two fifths of the decline in mortality from CHD in England and Wales over the past decade (Unal et al 2004). This article describes how developments in cardiac care, most of which have closely engaged nurses, have contributed to improvements in care for patients with acute myocardial infarction and other acute coronary syndromes.

Keywords

Cardiovascular system and disorders; Nurse-led services

These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.

THE BRITISH Heart Foundation (BHF) (2004) statistics database sets out in stark detail the burden of cardiovascular diseases in the UK:

* Diseases of the heart and circulatory system are the main causes of death in the UK, responsible for 238,000 deaths, or one in three of all deaths in 2002.

* Half of all deaths from cardiovascular disease are from coronary heart disease (CHD), the single most common cause of death in the UK. CHD is also the commonest cause of premature death (before the age of 75 years), causing more than 40,000 such deaths each year.

* There are an estimated 268,000 episodes of acute myocardial infarction (AMI) in the UK each year, 92,000 occurring in men and women under 65 years of age.

Death rates from CHD have been falling over recent decades, mostly because of reductions m important risk factors, especially smoking. About two fifths of the reduction in deaths resulted from improvements in medical care. In the case of AMI, emergency treatment, particularly early defibrillation, prompt administration of aspirin, and to a lesser extent hospital-based thrombolytic treatment, have made important contributions to improved outcomes (Unal et al 2004).

Goodacre et al (2005) reported that 6 per cent (700,000) of adult accident and emergency (A&E) department attendances in England and Wales annually are due to chest pain and related complaints. While only a minority of patients had electrocardiogram (ECG) changes suggestive of acute coronary syndromes (ACS) at presentation, two thirds were admitted to hospital. The burden of chest pain on health services, whether or not associated with an ACS diagnosis, is therefore substantial.

The coronary care unit

Coronary care units (CCUs) were developed in the 1960s to reduce deaths following AMI. They provided a specialised hospital facility staffed and equipped to monitor patients with suspected AMI and facilitate rapid defibrillation of patients in cardiac arrest (Julian 1987). Nurses trained in resuscitation were crucial in providing 24-hour expertise in rhythm recognition and early defibrillation to patients at the bedside. Despite some early controversy about the effectiveness of coronary care in reducing mortality when compared to home care (Rawles and Kenmure 1980), most acute hospitals maintain a CCU.

The success of the CCU concept was, and remains, highly reliant on the expertise of nurses working in close collaboration with medical colleagues. From the early days of the CCU, there has been recognition of the value of nurses developing specialist knowledge and skill in, for example, ECG interpretation, the understanding of treatment of AMI complications and expertise in cardiopulmonary resuscitation (Meltzer 1964). The formative years of the CCU arguably provide the earliest examples of nurses taking on ‘advanced’ roles, usually the preserve of physicians (Killip and Kimball 1967).

The tradition of developing a highly skilled, expert cadre of CCU nurses to respond immediately in the event of serious complications to benefit vulnerable patients has continued to develop (Quinn 1995, Simoons et al 1997), accompanied by further devolution of such skills to the A&E department and ambulance service (Quinn et al 2002, Quinn and Morse 2003).

Thrombolytic treatment

The advent of thrombolytic therapy – intravenous (IV) medication used to break down or ‘lyse’ blood clots occluding coronary arteries which lead to AMI – brought new opportunities for CCU nurses to develop and use their expertise in patient assessment and ECG interpretation to benefit patients by expediting treatment.

The introduction of IV thrombolytic treatment into routine clinical practice following a series of large trials in the mid- 1980s ensured a renaissance for the CCU following the controversies described above. The trials provided strong evidence that the sooner patients with AMI were treated with a thrombolytic agent, the better their chances of survival (Fibrinolytic Therapy Trialists’ Collaborative Group 1994). A meta-analysis of hospital and pre- hospital thrombolysis trials reinforced the time-dependent nature of this treatment (Boersma etal!996). Most benefit, in terms of lives saved by thrombolysis, is seen in patients treated within the first hour following symptom onset – the concept of a ‘golden hour’ for thrombolysis has been proposed (Boersma et al 1996).

The importance of very early treatment to open occluded coronary arteries in the context of AMI has been reinforced by more recent studies comparing thrombolytic treatment with primary percutaneous coronary intervention (PPCI), which will be discussed later in this article.

The importance of saving time to reduce deaths from AMI has resulted in the development of standards of care from professional societies and governments in many countries. In England, the National Service framework (NSF) for Coronary Heart Disease (Department of Health (DH) 2000) sets national standards for improved prevention and treatment. For patients with AMI who present with ST-segment elevation or new left bundle branch block on 12- lead ECG, these standards relate to reducing delays to thrombolysis so that patients begin treatment within 60 minutes of the call for professional help, in line with guidelines published by the European Society of Cardiology and European Resuscitation Council (1998). Although in the first few years of implementing the NSF there was a focus on optimising hospital systems so that patients started thrombolysis within 20-30 minutes of arriving at hospital, the national standard for England is now focused on starting treatment within 60 minutes of the patient calling for professional help (DH 2003). Other UK countries have set similar standards for cardiac care (National Assembly for Wales 2001, Scottish Executive Health Department 2002).

The National Audit of Myocardial Infarction Project (MINAP) for England and Wales developed to help improve the quality of acute cardiac care in line with the NSF standards, has recently reported more than three quarters of eligible AMI patients starting thrombolysis within 30 minutes of hospital arrival (Birkhead etal 2004). A major factor in reducing delays has been the shift from CCU to A&E as the main place where thrombolysis is given, since this is where the majority of AMI patients present. Before publication of the NSF, approximately one third of A&E departments were routinely providing this treatment (Hood et al 1998 ). Administering thrombolytic therapy in A&E is feasible and safe, and adverse incidents including cardiac arrest during transfer to CCU are rare (Edhouse et al 1999). Direct admission to CCU, although popular and effective in a minority of hospitals, has largely been superseded by such developments.

The focus has recently shifted to ensuring improvements in care across the whole patient pathway, including pre-hospital care provided by ambulance services, but where primary care and NHS Direct staff also play important roles.

Nurse-led and nurse-initiated thrombolysis

Nurse-led thrombolysis describes a situation where a nurse assesses a patient with suspected AMI for eligibility to receive thrombolysis but the treatment decisions are made by medical staff.

Nurse-initiated thrombolysis refers to a situation where a nurse assesses a patient with suspected AMI for eligibility to receive thrombolysis and administers the treatment under a Patient Group Direction (PGD).

Most of the reports on the safety and efficacy of nurse-led and nurse-initiated thrombolysis have been small-scale observational studies, or associated with clinical audit. Only one randomised trial has been reported, demonstrating a trend towards improved care in a South Australian hospital (Kucia et al 2001).

One small pilot study conducted in York compared CCU nurses’ decision-making regarding patients’ eligibility for thrombolysis with that of junior doctors and found no difference (Quinn 1995). In Scarborough, this was taken a step further in practice by Gaunt (1996) who described the positive impact of empowering suitably competent nurses to administer thrombolytic treatment before the patient was assessed by a hospital doctor. There have been several reports since these early observations of nurses initiating thrombolysis safely and effectively under PGDs or equivalent arrangements.

Recent examples include the empowerment of CCU nurses to initiate thrombolysis following direct admission to CCU (Wilmsh\urst et a/ 2000, Qasimei al 2002). However, the increasing use of A&E departments as the appropriate setting for thrombolytic treatment has resulted in several successful A&E-based schemes. For example, Heath etal (2003) demonstrated the superiority of A&E-based nurse- initiated thrombolysis over the largely redundant ‘fast-track’ processes of transferring patients from A&E to CCU for thrombolysis. In all reported studies thrombolytic treatment was given faster if initiated by nurses under PGD, or similar arrangements, than if patients waited for assessment by a physician. There does not appear to be an increased rate of inappropriate treatment with nurse- initiated thrombolysis compared with medical decision-making. Nurse- initiated thrombolysis accounted for 8.5 percent of hospital thrombolysis in 2003; most decisions to administer thrombolysis are made by emergency department medical staff (Birkhead et al 2004).

Another strategy to reduce delays is for nurses to assess patients presenting with symptoms suggestive of ACS rapidly, record an ECG and, if there are clear ECG changes indicating AMI and the patient does not have obvious contraindications, to ask for urgent medical assessment. In such cases it is medical staff who prescribe the treatment. Several reports of nurse-led thrombolysis have demonstrated the safety and efficacy of this approach (Somauroo et al 1999, Lloyd et al 2000).

It is generally accepted that it is not the job title or profession of the individual initiating thrombolytic treatment that is the key consideration. It is the competence of that individual to safely undertake the intervention. Generic competencies for the assessment and treatment of patients with suspected ACS have therefore been proposed (Box 1 ) (Quinn etal 2002, Skills for Health 2004). An influential report from the British Cardiac Society and Royal College of Physicians (2002) recommends that: ‘All patients with an indication for thrombolysis, and where there is no contraindication, should receive this treatment from the first available qualified person able to provide coronary care, whether this is a primary care physician, paramedic or hospital based clinician.’

On this basis, regulatory changes have been enacted in England (Box 2) and other parts of the UK to facilitate earlier treatment.

BOX 1

Key areas for proposed generic competencies for administration of thrombolysis in acute myocardial infarction

Pre-hospital care

The dramatic reductions in ‘door-to-needle’ times for patients with ST-elevation MI (STEMI) have had a positive influence on patient outcome, given the evidence that the benefits of thrombolysis are time dependent. Around half of all patients eligible to receive immediate thrombolytic treatment do so within 60 minutes of calling for help ( Birkhead et al 2004). This situation has improved markedly since 1995 when just 10 per cent of patients were treated within this time (Quinn et al 2003).

There is growing consensus that further reductions in delay will only be achieved through the widespread introduction of pre- hospital thrombolysis, delivered mostly by paramedics (Boyle 2004). Pre-hospital thrombolysis has been the subject of a meta-analysis which demonstrated a 17 per cent reduction in all-cause mortality (Morrison et al 2000). More recent UK studies have added to the supporting evidence base: Keeling etal (2003) assessed the feasibility of paramedic thrombolysis and concluded that autonomous paramedic pre-hospital thrombolysis seemed feasible and safe and was associated with improved call-to-needle times. Pedley et al (2003) reported that the likelihood of a patient starting treatment within 60 minutes of calling for help was markedly improved when pre- hospital thrombolysis was available, applying this argument to both rural and urban settings. To date more than 2,000 patients in England with AMI have received thrombolysis from a paramedic (Ambulance Service Association 2005). The balance between the risk and benefit of providing pre-hospital thrombolysis in an urban setting with presumed short transport times is, however, subject to debate (Stephenson et al 2002) and the precise model adopted will depend on local circumstances.

BOX 2

Regulatory changes in England

Acquisition and, if possible, transmission of a 12-lead ECG from an ambulance to the receiving hospital, have been shown in several studies to reduce treatment delays and improve care for patients with AMI (Ioannidis et al 2001). The availability of 12-lead ECG machines as part of advanced life support facilities is recommended by international guidelines on emergency cardiac care (Antman et al 2004). In England, provision of this equipment on emergency ambulances has been made possible by investment from the New Opportunities Fund (part of the National Lottery).

Clinical governance issues arise from the transmission of 12- lead ECGs, and it is important that clear arrangements are in place to maintain patient safety by, for example, recording advice given by hospital staff and actions taken by paramedics when such technology is used. Recent data from Australia suggest that ECG transmission and pre-alerting hospitals that an AMI patient is en route are worthwhile and help to reduce delay (Goodacre et al 2004a), particularly in less urban settings. These findings confirm to some extent those of a recent UK report by Gamon et al (2004).

Pharmacological or mechanical treatment of myocardial infarction

Thrombolytic therapy has several limitations. Occluded coronary arteries associated with AMI are fully reopened in only a minority of patients given streptokinase, and although this is not such a concern with newer agents such as reteplase and tenecteplase, mechanical treatment with primary coronary intervention (angioplasty and stenting) or PPCI is reported to produce better results. A meta- analysis of trials comparing PPCI versus hospital thrombolysis suggested significantly lower death rates in the PPCI-treated patients. Patients treated with PPCI also had less adverse events including haemorrhagic stroke and the need for repeat angiography than those who had received thrombolysis (Keeley et al 2003).

There are concerns, however, that this analysis may not reflect modern UK practice where thrombolysis is given promptly. For example, in MINAP 60 per cent of patients were treated within three hours of symptom onset (Birkhead etal 2004). Moreover, PPCI has not been proven superior to very early thrombolysis. A Cochrane Review of the evidence concluded (Cucherat etal2003): ‘Angioplasty provides a short-term clinical advantage over thrombolysis which may not be sustained. Primary angioplasty, when available promptly at experienced centres, may be considered the preferred strategy for myocardial reperfusion. In most situations, however, optimal thrombolytic therapy should still be regarded as an excellent reperfusion strategy.’

A PPCI approach may reduce overall costs compared to thrombolysis in patients who are within one hour travel time from a hospital able to provide this intervention (Machecourt et al 2005). This is a rapidly developing field of research and clinical practice. The secretary of State for Health (DH 2004b) has established a project led jointly by the National Director for Heart Disease and the British Cardiac Society, evaluating whether provision of a PPCI service is feasible in England.

Patients with atypical presentations

While the focus of national and international guidelines has generally been on expediting care for patients who meet standard eligibility criteria for thrombolysis based on clinical and ECG evidence, it is important to recognise the higher morbidity and mortality observed in patients with ACS who present without chest pain, but whose main symptom is syncope, nausea and vomiting, or dyspnoea. These patients, often older and/or with diabetes, are frequently misdiagnosed and undertreated (Brieger et al 2004). There is also evidence that patients from certain minority ethnic groups are more likely to present with non-classic features (Barakat et al 2003). Nurses and others (for example, paramedics) involved in early assessment and triage processes should have a low threshold of suspicion for recording a 12-lead ECG in these circumstances.

Patient help-seeking behaviour

The NSF (DH 2000) and related standards for ‘call-to-needle time’ measure the time from a patient with AMI calling for professional help to the time that thrombolytic treatment, where indicated, is administered. While this part of the patient pathway has improved over recent years, patients are taking longer to call for help following symptom onset. The complex reasons for this phenomenon are outside the scope of this article. A recent systematic review concluded that there was little evidence that media or public education interventions reduced delay, and there is some evidence that they may result in an increase in emergency switchboard calls and A&E department visits (Kainth et al 2004).

The changing role of coronary care units

Most thrombolysis is now given outside the CCU environment, representing a major and effective change in practice since publication of the NSF (DH 2000). While many CCU nurses have been fully engaged in supporting A&E departments in safely delivering, assessing and treating ACS patients, thrombolytic treatment is increasingly the preserve of emergency staff and will devolve to paramedics, ensuring further benefits for patients.

The role of CCU nurses, which has continued to evolve since the advent of the CCU more than 40 years ago, is changing and requires further evaluation to define the modern scope of practice and the competencies required. So-called ‘thrombolysis nurses’, while effective in reducing door-to-needle time, are unlikely to be a cost- effective use of valuable resources if they focus solely on assessing and treating patients with MI (DH 2003). Their role is arguablyakin to that of the resuscitation training officer, establishing systems and processes, including training of relevant staff, to ensure that patients receive optimal care irrespective of who is on duty. The key challenge facing CCU nurses in the future is how best to care for patients with other manifestations of ACS.

In routine clinical practice, nurses and their paramedic colleagues will assess and record a 12-lead ECG on patients with chest pain and related symptoms who are not eligible for thrombolysis, many of whom will have an ACS diagnosis ultimately excluded. A recent Scottish study reported that rates of AMI admissions were declining while ‘chest pain’ was increasingly the discharge diagnosis (Murphy et al 2004) and the total number of A&E department attendances in England and Wales with chest pain is estimated at 700,000 per annum – a minority of these patients having sustained AMI (Goodacre et al 2005). Patients with a final diagnosis of ACS who present with ST-depression on admission have been shown to have worse outcomes than those with ST-segment elevation (Savonitto etal 1999) and it is possible that this group of patients will form the main population admitted to CCU in future years, for intensive management with powerful medications including antiplatelet and antithrombotic therapies.

Whether all patients with suspected ACS should be admitted directly to a hospital with interventional cardiology facilities is a matter of debate (Van de Werf et al 2005). Management of this group of patients in the UK differs from that observed in other countries: while more UK patients with AMI receive reperfusion than elsewhere, and statin use is higher, patients outside the UK are more likely to receive revascularisation (bypass surgery or angioplasty ) for other manifestations of ACS, and more likely to receive glycoprotein Ilb/IIIa inhibitors (Carruthers et al 2005). Hospital mortality rates do not, however, differ between the UK and elsewhere, although worse outcomes are observed for UK patients at six-month follow up. Significant delays in transferring patients to an interventional centre following admission to a hospital without such facilities have been reported (Miller ei al 2003).

It is possible that other functions of the CCU, including the ongoing assessment of patients with acute chest pain, will at least in part be devolved to specialist ‘chest pain observation units’ within A&E departments (Goodacre et al 2004b). All such changes are occurring as worldwide debate continues about what clinical and pathological characteristics now constitute an AMI and the implications for patients (Fox et al 2004).

Conclusion

This article has provided an overview of recent developments in the care of patients with AMI and other manifestations of ACS. It has not, however, been possible to address pathophysiology or pharmacology in depth. Nor have the wider aspects of cardiac care such as management of arrhythmias, shock or heart failure, or the management of patients successfully resuscitated from cardiac arrest, been addressed. Cardiac care continues to evolve rapidly, as it has done since the advent of the CCU more than 40 years ago. The next few years are likely to see further developments including:

* More (probably most) reperfusion in ambulances or cardiac catheter laboratories.

* More patients bypassing general hospitals for specialised centres following assessment by paramedics.

* Most patients with chest pain being assessed in A&E departments.

* More use of online 12-lead ECGs and telemedicine.

* More online decision support facilitating outof-hospitalcare.

* Point of care testing, for example, cardiac markers and other risk assessment, in ambulances.

* Further refinement of the definition of AMI.

* Improved access to timely angiography and intervention where required.

These developments should result in further reductions in treatment delays and help to save lives following an acute event. The further development of nurses and other health professionals, including paramedics, in terms of assessment skills, prescribing and decisionmaking will be essential to collaborate with other members of the healthcare team in achieving better care for patients

Quinn T (2005) The role of nurses in improving emergency cardiac care. Nursing Standard. 19, 48, 41-48. Date of acceptance: April 29 2005.

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Author

Tom Quinn is professor of cardiac nursing, Coventry University, Coventry, and consultant cardiac nurse. Email: [email protected]

Copyright RCN Publishing Company Ltd. Aug 10-Aug 16, 2005