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Thrombolysis: why time is of the essence

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Mike Hayward, RN, MSc, BSc (Hons), DipHE.

Professional Nurse Advisor, Acute Care, Royal College of Nursing

ACUTE MIs

ACUTE MIs
Treating people for thrombolysis within the first hour of an acute myocardial infarction (MI) makes a crucial difference to the patient's survival - and even more so if they are treated within the first 20 minutes. This is reflected in the requirements of the National Service Framework for Coronary Heart Disease (DH, 2000). Various initiatives show that the targets can be achieved, but there is a long way to go before they are reached in every hospital.

A quarter of a million people a year in England and Wales have an acute MI (NICE, 2000). Around 50% of patients die within 30 days of symptom onset, with half of these deaths occurring before the patient reaches hospital. A patient's mortality risk is highest within 60 minutes of onset of symptoms, and around a third of all acute MI deaths occur in the first hour (NICE, 2000).

Thrombolytic drugs break down the thrombus in the blocked coronary artery and help maintain the blood supply to the heart. Treatment is warranted up to 12 hours after onset of symptoms, but is most effective when administered within three hours.

Eleven days of life are lost for every minute's delay to thrombolysis in this three-hour period (Rawles, 1997) and treatment within the first hour saves 65 whole lives per 1000 patients, compared with just 37 per 1000 for treatment within one to two hours, and 26 per 1000 for thrombolysis carried out within two to three hours of onset of symptoms (Boersma et al, 1996).

Data such as these prompted the Department of Health to include its thrombolysis standard in the National Service Framework for Coronary Heart Disease (DH, 2000).

The NSF has 12 standards for improved prevention, diagnosis, treatment, and rehabilitation for coronary heart disease patients. Standard 6 states that people thought to be suffering from a heart attack should be assessed professionally and, if indicated, receive aspirin. Thrombolysis should be given within 60 minutes of calling for professional help.

The document sets challenging targets. It says 75% of eligible patients should receive thrombolysis within 30 minutes of hospital arrival (door-to-needle time) by April 2002, and within 20 minutes by April 2003.

Although the NSF relates to English clinicians, similar targets have been set in the rest of the UK. The National Assembly for Wales reiterated these door-to-needle times exactly (2001), while the Health Technology Board for Scotland issued advice based on the National Institute for Clinical Excellence technology appraisal on thrombolytic drugs (NICE, 2000).

A progress report, Delivering Better Heart Services, last year examined data from the Myocardial Infarction National Audit Project. While 79% of patients were receiving thrombolysis within 30 minutes, only 48% were being treated within the 20-minute target. Just 43% of patients were treated within 60 minutes of calling for professional help (DH, 2003a).

The National Director for Heart Disease, Roger Boyle, recommended methods of delivering faster and better thrombolysis (DH, 2003b). He recognised that, in the three years since the NSF launch, improvements had been made but reiterated the government's endorsement of the 60-minute call-to-needle standard.

He highlighted the major benefits of collaborative working and stated that, wherever possible, local solutions should be developed to achieve more efficient service delivery.

He said significant scope remained for reducing delays at all stages of the acute MI patient-care pathway. Local health communities should meet a planning and priorities framework target of a 10% improvement a year in the number of eligible patients receiving thrombolysis treatment within 60 minutes of onset of symptoms. The report stressed a need for multidisciplinary care and called for a greater role for paramedics and A&E staff, thus emphasising a shift in responsibility for initial patient care from coronary care units to A&E departments and ambulance trusts.

A&E CHANGES
A study of 125 acute hospitals in England revealed that 82% had introduced strategies to reduce delays in thrombolysis (Rhodes et al, 2002). It found that 63% of the strategies cited entailed administering thrombolysis at entry to hospital, with 23% entailing a specific nursing intervention, mainly nurse-led thrombolysis.

In the 1990s, Birkhead (1992) and Pell et al (1992) asserted that the most appropriate place to begin thrombolytic therapy was A&E. However, at the time thrombolytic fast-track systems in coronary care units (CCUs) were the norm. Now, the NSF targets have led to a progressive shift in responsibility, with the introduction of many A&E-centred thrombolysis initiatives in the UK (DH, 2003c).

Tameside General Hospital's A&E department has introduced a dedicated chest-pain assessment area. Previously, patients were seen in the main trolley area, the time of their first electrocardiogram (ECG) varied considerably, and thrombolysis was not routinely undertaken until the patient arrived in CCU. Converting a relatively underused area of A&E enabled immediate ECG recording and thrombolysis, managed by two chest-pain nurses. Patients presenting with chest pain are now ensured an ECG within five minutes of arrival (NHS Modernisation Agency, 2003).

At Doncaster Royal Infirmary, thrombolysis administration by A&E staff has led to a dramatic decrease in door-to-needle time. Previously, patients admitted to A&E received thrombolysis only if a specialist chest-pain nurse was available. Now treatment is routinely administered by an A&E senior house officer or nurse, before the patient is moved to CCU.

Northwick Park Hospital, Middlesex, has also made strides. Before changing its procedures, 30% of patients received thrombolysis within 30 minutes. One problem was the time taken to find a cardiologist to confirm diagnosis and transfer the patient to CCU. Although 30% of patients were thrombolysed in A&E, staff were reluctant to take on this responsibility.

The first step involved a change to the A&E rota to ensure at least one nurse per shift had experience of administering thrombolysis. Training days were held, data collected daily, and all patient notes were regularly reviewed by a multidisciplinary team. A cardiac navigator nurse, with a remit to troubleshoot problems, was appointed to co-ordinate these actions. The hospital now comfortably reaches its NSF 20-minute door-to-needle target (RCP, 2003).

Many time-saving changes are simple. In Bolton, acute MI drug boxes are now sited in A&E, while in Rotherham drugs are stored in the chest-pain bay for ready access.

Similarly, in Birmingham, improved access to thrombolysis drugs and equipment, and the introduction of a dedicated infusion pump, has allowed staff to access and administer thrombolytic agents easily and promptly.

JOINT INITIATIVES
These projects show the importance of joint initiatives between A&E and ambulance staff. Homerton Hospital in London runs a multidisciplinary training course involving both groups of health professionals. The course is designed to improve understanding, minimise handovers and eliminate unnecessary delays.

In a four-year pilot involving A&E staff at the Royal London Hospital, more than 750 paramedics across London were trained in the use of 12-lead ECG machines. Where crew used them to diagnose the type and severity of heart attacks, and relayed the results to the hospital, an average of nearly 25 minutes was saved on the time to administer thrombolysis.

At Good Hope Hospital in Sutton Coldfield, pre-alert calls are sent by paramedics to hospital staff to inform them the patient is known to have had or suspected of having had an acute MI. Door-to-needle times have since improved.

In the Black Country, ambulance crew also use alert criteria alongside ECG-driven, paramedic diagnosis. If a patient is suspected of having had an acute MI, the paramedics alert the hospital either by alert-phone or bleeper, providing A&E with an estimated time of arrival.

Hope Hospital in Manchester has gone a step further. As well as introducing courtesy calls from inbound paramedics, it has created an acute MI reception team, comprising a nurse and doctor from each A&E shift. Once the call comes in, these staff are quickly mobilised without causing major disruption in A&E. The scheme has seen the proportion of 20-minute thrombolysis rise from 25% to 52%.

Blackpool Royal Infirmary implements a joint-working initiative. Standby forms are used to record patient details, received via a courtesy call from ambulance staff. The thrombolysis nurse and/or A&E staff member can check relevant patient notes, ECGs or diagnoses before arrival. Copies of the standby forms and notes go with the patient to CCU.

PROTOCOLS
A practical, adaptable management protocol can make a major difference to the accuracy and efficiency of working practices. In January 2001, a nurse-led thrombolysis trial was initiated in A&E, Queen Alexandra Hospital, Portsmouth. Funding was obtained for two G-grade cardiac nurse practitioners (CNPs) to work in A&E for one year (see box, above left, for examples of best practice in this project). The CNPs spent three months in a non-clinical role developing the operational policy, writing patient group directions and steering a drug change from alteplase to reteplase through the drugs and therapeutics committee.

The trial, supported by clinical audit, resulted in the CNP service being extended to a seven-day-a-week service that employs five G grades. During the trial, thrombolysis performance improved between July 2000 and April 2003 from 40% of the 30-minute door-to-needle time to 100% of the NSF 20-minute target. This was achieved by a robust operational policy, use of an integrated care pathway and the change of thrombolytic drug from infusion to bolus.

SUMMING UP
The challenging thrombolysis targets set by UK government bodies require efficient multidisciplinary work. Where possible, protocols should be developed in association with representatives of every health-care stakeholder involved in AMI care. It is vital that each care centre invests thoroughly in staff training, to increase confidence in the short term, and lead to long-term clinical and economic benefits. Any system involving community health professionals (such as paramedics) should be rolled out to as many hospitals in the area as possible, to ensure continuity. Ideally, all local clinicians should follow the same evidence-based procedure.

Staff members should constantly endeavour to improve protocols as no system is perfect, and nobody can rest on their laurels in this dynamic and challenging environment.

Author's contact details
Mike Hayward, RN, MSc, BSc (Hons), DipHE, Professional Nurse Advisor, Acute Care, Royal College of Nursing (formerly Senior Nurse for Emergency Care, Royal Hampshire County Hospital, Winchester); email: firmrhayward@hotmail.com

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Boersma, E., Maas, A.C., Deckers, J.W., Simoons, M.L. (1996)Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 348: 771-775.

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