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Developing a chest pain team to fast track AMI patients.

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VOL: 101, ISSUE: 08, PAGE NO: 34

Phil Hill, BSc, RN, Dip Management, is emergency unit practitioner, medical emergency admissions unit, Llandough Hospital, Penarth.

Although the UK death rate from coronary heart disease (CHD) is falling, 270,000 AMIs occur each year and CHD is the most common cause of death in the UK (Webb et al, 1999; NAW, 2002). In some parts of Wales, the death rate from AMIs is the highest in western Europe.

Although the UK death rate from coronary heart disease (CHD) is falling, 270,000 AMIs occur each year and CHD is the most common cause of death in the UK (Webb et al, 1999; NAW, 2002). In some parts of Wales, the death rate from AMIs is the highest in western Europe.

The most significant complication of AMI is primary cardiac arrest, with 75 per cent of deaths occurring before hospitalisation. Overall, 75 per cent of all AMI deaths occur within 24 hours (NAW, 2002). Patients may experience very few warning symptoms before the development of cardiac arrest (Waalewijn et al, 1998) and where they do occur they may not recognise the symptoms as an AMI.

Emergency medical care
The importance of public education has been heavily emphasised to ensure people access emergency care as soon as possible after the onset of any symptoms (Dixon et al, 2002; NAW, 2002; Webb et al, 1999). Dixon et al (2002) suggest that only 44 per cent of people had reasonable knowledge regarding the signs and symptoms of AMI, and only 20 per cent knew the difference between a heart attack and cardiac arrest.

It is estimated that every 60-second delay in thrombolytic treatment will lead to a loss of 11 days of life (NAW, 2002) so the fast-tracking of AMI patients to reduce the door-to-needle time is vital.

Effective AMI care can be categorised into five stages:

- Recognition and activation of assistance by the patient or those nearby;

- Basic cardiac first aid, including optimal positioning (for comfort and to aid breathing) and the administration of 300mg aspirin. This may also involve the use of oxygen therapy and automated external defibrillators by appropriately trained individuals;

- Pre-hospital and in-hospital advanced life support ensuring effective analgesia, symptom control and monitoring;

- The definitive care phase includes early administration therapies such as thrombolysis to ensure adequate restoration of blood flow to the myocardium. Currently thrombolytics are administered in controlled clinical environments, although in future they may be administered during pre-hospital care (Quinn, 2004). Definitive care includes confirmation of diagnosis using biochemical markers. In some centres, other invasive interventions may be necessary;

- Prevention of complications and cardiac rehabilitation (including behaviour modification) are important to patient survival (NAW, 2002; Webb et al, 1999).

Background
The historical method of fast-tracking AMI patients was to assess them in the medical emergency admissions unit and then transfer them to a reserved cardiac care unit thrombolysis bed. In 2003 a clinical audit disproved the belief that the close proximity of a medical emergency admissions unit and critical care unit made fast-tracking more easily achievable.

Delays in treatment resulted from a lack of communication between the ambulance service, the medical emergency admissions unit and the critical care unit. Some delays were due to the misinterpretation of borderline or unconvincing ECGs. Previous experience has demonstrated the need for serial ECGs in some patients, as singular recordings meant evolving AMIs could get missed. Finally, there was no formally agreed, documented policy on fast-tracking.

Some of these issues have been identified by the DoH Emergency Services Collaborative (DoH, 2003). Smith (2000) suggests that a patient's condition can deteriorate as the result of failure to establish appropriate and preventative actions. And following clinical governance presentation of audit data, it became clear that this situation had to change. A chest pain project team was developed to investigate the changes necessary to ensure door-to-needle times were improved.

Clinical leadership and change
The DoH (2003) claims clinical leadership is a key component for improving emergency care, and identifies consultants as leaders that may be able to effect major changes. Whereas A 'and E departments offer lead consultant-led care, medical emergency admissions units often do not. And while many physicians are keen to embrace emergency medical care within their specialty and on a patient-specific basis, the NHS has yet to employ a lead consultant for each medical emergency admissions unit. Emergency unit physicians might discharge some of the non-emergency admissions, enabling staff to concentrate their efforts on true medical emergencies such as AMIs. Wanklyn (1997) suggested that even a resident registrar might decrease medical admissions. Rhys-Jones and Randall (2003) describe one service where the resident physician was able to discharge 700 patients with immediate emergency outpatient access.

The impact on patient care
In July 2003, a 73-year-old woman presented to her GP who requested an emergency ambulance transfer as he suspected an AMI. Within 15 minutes, the ambulance had responded and the medical emergency admissions unit was pre-alerted. Medical emergency admissions unit staff then informed the critical care unit staff, in accordance with the chest pain team protocol for reducing door-to-needle times to within 20 minutes (Tables 1, 2 and 3). She was then brought into the medical emergency admissions unit where she had a 12-lead ECG recorded. The ECG changes that were present met the criteria for thrombolytic therapy and she was fast-tracked to the critical care unit according to the newly implemented chest pain team procedure. She was thrombolysed within 20 minutes of reaching the unit.

The chest pain team project group continued to monitor progress throughout the first year and in June 2004, an 80-year-old woman was also admitted by her GP via emergency ambulance. She was nursed and monitored in a crash room in view of her chest pain, hypotension and bradycardia. Although the chest pain team was present throughout, she did not meet the criteria for thrombolysis on her first two ECG recordings. It was only on the second repeat-ECG (following administration of IV opiate analgesia and atropine sulphate) that the changes were remarkable enough to initiate transfer to the critical care unit. She received her thrombolysis within 10 minutes of the ECG. This demonstrated the importance of serial ECG recordings.

The evidence that the Llandough Hospital chest pain team is effective is documented by the Myocardial Infarction National Audit Project Steering Group for the Royal College of Physicians (RCP). They suggest that Llandough is only one of four Welsh hospitals (out of a total of 18) that has achieved the national service framework goal of achieving a door-to-needle time of under 30 minutes in 75 per cent of appropriate patients (RCP, 2004).

Conclusion
Awareness that delays in treatment are detrimental to an AMI patient's well-being is vital when examining current systems within emergency care. Despite the close proximity of the medical emergency admissions unit and critical care unit in Llandough hospital, various factors -including a lack of communication - meant that fast-track thrombolysis could be problematic.

Measures are required for improving pain-to-needle times - there is an urgent need for increased public education related to the signs and symptoms of AMI.

If patient care is to be improved, a collaborative approach is required, educating the public and developing emergency cardiac care skills within primary care, the ambulance and secondary care.

This article has been double-blind peer-reviewed. For related articles on this subject and links to relevant websites see www.nursingtimes.net

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