Aligning the planets: The role of nurses in the care of patients with non-ST elevation myocardial infarction

Background

Studies have shown variation in care for patients with non‐ST elevation myocardial infarction (NSTEMI), including in the roles of specialist and advanced practice nurses in diagnosis, treatment and coordination of care.

Aim

The aim of this study was to describe the roles and responsibilities of specialist and advanced practice nurses in providing care for patients with NSTEMI.

Methods

Secondary analysis of observational field notes and interviews from an ethnographic study of variation in care for NSTEMI patients in 10 UK hospitals conducted 2011–2012. Data were thematically analysed to identify key concepts and themes related to the roles of specialist nurses.

Results

Seven of 10 hospitals had roles for specialist nurses in NSTEMI care. The major theme related to high demand and the complexity of patients and organizations (‘Aligning the planets’). In this theme, nurses contributed to improving services or compensating for deficiencies (‘Making the system work versus making up for the system’). Data collection for audit could take precedence over time with patients (‘Paying worship to the paper’). Nurses expressed a sense of ownership of cardiovascular patients that drove their desire to provide quality of care (‘They are our patients’).

Modified TIMI risk score cannot be used to identify low-risk chest pain in the emergency department: a multicentre validation study

Aim

The Thrombolysis in Myocardial Infarction (TIMI) risk score (range 0–7), used for emergency department (ED) risk stratification of patients with suspected acute coronary syndrome (ACS), underestimates risk associated with ECG changes or cardiac troponin elevation. A modified TIMI score (mTIMI, range 0–10), which gives increased weighting to these variables, has been proposed. We aimed to evaluate the performance of the mTIMI score in ED patients with suspected ACS.

Methods

A multicentre prospective observational study enrolled patients undergoing assessment for possible ACS. TIMI and mTIMI scores were calculated. The study outcome was a composite of all-cause death, myocardial infarction or coronary revascularisation within 30 days.

Results

Of the 1666 patients, 219 (13%) reached the study outcome. Area under the receiver operating characteristic curve for the composite outcome was 0.80 (0.76 to 0.83) for the mTIMI score compared with 0.71 (0.67 to 0.74) for the standard TIMI score, p<0.001, but there was no significant difference for death or revascularisation outcomes. Sensitivity and specificity for the composite outcome were 0.96 (0.92 to 0.98) and 0.23 (0.20 to 0.26), respectively, at score 0 for TIMI and mTIMI. At score <2, sensitivity and specificity were 0.82 (0.77 to 0.87) and 0.53 (0.51 to 0.56) for mTIMI, and 0.74 (0.68 to 0.79) and 0.54 (0.51 to 0.56) for standard TIMI, respectively.

Conclusions

mTIMI score performs better than standard TIMI score for ED risk stratification of chest pain, but neither is sufficiently sensitive at scores >0 to allow safe and early discharge without further investigation or follow-up. Observed differences in performance may be due to incorporation bias.