Nurse-initiated thrombolysis: a systematic review of the literature

The feasibility of nurse-led assessment in acute chest pain admissions by means of coronary computed tomography

BACKGROUND

Cardiac computed tomography (CCT) is a non-invasive imaging technique for the diagnosis of coronary artery disease (CAD). The National Institute for Health and Clinical Excellence (NICE) recommend CCT for selected patients in the assessment of chest pain of recent onset.

AIMS

To assess the feasibility and utility of CCT in a nurse-led, protocol-based assessment of chest pain.

METHODS

Patients admitted over 4 months with suspected angina were assessed for eligibility for CCT by a specialist nurse. Eligibility was defined by: a likelihood of CAD < 90%, no features of acute coronary syndrome, no contra-indications to the scanning process, and the ability to give written consent. An age and sex-matched historical cohort (for whom CCT was unavailable) was compared with the CCT cohort with regard to the diagnosis or exclusion of CAD at 3 months post-discharge from hospital.

RESULTS

Of 198 patients admitted, 98 were identified as eligible for CCT. Of these, 37 were recommended for alternative management on cardiologist review, 18 declined consent, 23 were unable to be scanned within 24 h prior to discharge and 14 underwent CCT. CAD was diagnosed or excluded in 14/14 patients undergoing CCT. CAD was diagnosed or excluded in 11/14 patients investigated without CCT, leaving 3/14 patients with no clear diagnosis.

CONCLUSION

This study suggests nurses may be trained to assess patients for CCT within agreed protocols. In the UK it is likely these protocols will be based on NICE guidance. Despite potential diagnostic utility, CCT appears likely to form a small percentage of cardiac investigations undertaken.

The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services?

Health care is changing rapidly. Unacceptable variations in service access and quality of health care and pressures to contain costs have led to the redefinition of professional roles. The roles of nonphysician clinicians (nurses, physician assistants, and pharmacists) have been extended to the medical domain. It is expected that such revision of roles will improve health care effectiveness and efficiency. The evidence suggests that nonphysician clinicians working as substitutes or supplements for physicians in defined areas of care can maintain and often improve the quality of care and outcomes for patients. The effect on health care costs is mixed, with savings dependent on the context of care and specific nature of role revision. The evidence base underpinning these conclusions is strongest for nurses with a marked paucity of research into pharmacists and physician assistants. More robust evaluative studies into role revision are needed, particularly with regard to economic impacts, before definitive conclusions can be drawn.

Can Australian Nurses Safely Assess for Thrombolysis on EKG Criteria?

INTRODUCTION

According to the Australian Institute of Health & Welfare, 48,700 ischemic heart disease events occurred in Australia in 2001-2002; around half of these were fatal. The National Heart Foundation of Australia recommends that eligible patients presenting with acute myocardial infarction should receive thrombolysis within 30 minutes of presentation if primary angioplasty is not available. In Australia, fewer than 80% of eligible patients were treated within 1 hour in the first half of the year 2000. Literature reveals that a number of hospitals in the United Kingdom use a model of acute myocardial infarction management whereby suitably qualified cardiac nurses initiate thrombolysis where appropriate, prior to the patient being evaluated by medical staff. This practice is safe and effective in reducing the door-to-needle time to below 20 minutes. The questions are threefold: Are Victorian cardiac nurses similarly capable? What are the existing abilities of emergency nurses? What do they think about initiating thrombolysis?

METHOD

Mixed methodology (descriptive comparative and thematic analysis) was used. The survey instrument included EKG vignettes and a questionnaire. Participants were Victorian nurses practicing in a coronary care unit or an emergency department.

RESULTS

Seniority was the only apparent predictor of increased accuracy.

DISCUSSION

Nurses are very accurate and safe in their ability to recognize patients warranting immediate thrombolysis. Nurses' decision making is underpinned by 3 of 4 fundamental patterns of knowing identified by Carper-aesthetic, empirical, and ethical. In view of these findings, a number of recommendations are made for research, education, and benchmarking of quality patient management.

Acute coronary syndrome nurses: Perceptions of other members of the health care team

Acute coronary syndromes (ACS) are a major health care problem and result in a large number of hospital admissions each year. Nurses across the NHS are being empowered to undertake a growing range of responsibilities but little research evidence exists related to the impact on patient care nor working practice with other health professionals. This paper reports part of the evaluation of a British Heart Foundation pilot project to place an 'ACS nurse' in participating hospitals. In each of 5 hospitals, 100 staff across accident and emergency, general medicine and cardiac specialities were sent a questionnaire. The response rate was 33%. Respondents felt that the ACS nurse role was beneficial to patient care and had little overlap with existing roles within the hospital. Support for nurse initiated thrombolysis was high, but comments reflected the on-going debate around accountability and training. Communication and problem solving were identified as key elements of the ACS nurse role. Findings in this study show support for the integration of an ACS nurse role as a way to provide improved care to ACS patients.

Thrombolytic Therapy: Current Clinical Practice

Thrombolytic therapy is an essential tool in the array of therapies designed to reopen arteries and veins occluded with thrombus. As the use of thrombolytic agents has entered mainstream practice, their application has expanded to include a wide variety of indications and settings. Thrombolytic agents are used in patients who have thrombosis of coronary arteries, precerebral and cerebral arteries, the aorta, iliac and mesenteric arteries, and peripheral arteries. The use of thrombolysis in venous thrombosis has included deep venous thrombosis of the upper and lower extremities and vena cava, mesenteric veins, cerebral veins, and central access catheters. Guidelines are available from the American College of Cardiology/American Heart Association regarding thrombolysis in myocardial infarction and from the American Stroke Association regarding thrombolysis in acute ischemic stroke.

The introduction of nurse-initiated thrombolysis in coronary care

Nurse-initiated thrombolysis has emerged as an organizational strategy to improve the delivery of thrombolytic agents to patients suspected of having an acute myocardial infarction. This article will outline the evolution of nurse-initiated thrombolysis on the coronary care unit in the authors' trust and present data on the critical decision-making skills of those nurses who have expanded their practice. Patients who were assessed, and whose thrombolysis was initiated by a nurse designated to deliver this treatment, had "door-to-needle" times consistent with the current targets of the National Service Framework for Coronary Heart Disease (Department of Health (DoH), 2000). A cardiologist acting as a "gold standard" reviewed the assessments of the first 50 patients seen by nurses able to deliver thrombolysis, finding each treatment decision appropriate. This gives support to the notion that appropriately trained and experienced nurses can assess and make treatment decisions in this acute care situation.

The nursing assessment and management of patients with angina

Coronary heart disease (CHD) is a growing problem in the UK. Angina is just one way that CHD manifests itself in the patient, thus challenging the approach that healthcare professionals use to manage these patients. With approximately 2-4% of all accident and emergency admissions presenting with chest pain, it is important that nurses, who are often the first healthcare professionals to assess the patient, have the appropriate knowledge and expertise to distinguish the aetiology of the chest pain. With CHD being the main cause for illness and death in the UK, it is inevitable that nurses at some point in their career will need to assess and manage patients with this presentation.