Quality improvement report: Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction

Qasim, Asif; Malpass, Kerry; O'gorman, D. J.; Heber, Mary E.

doi:10.1136/bmj.324.7349.1328

Cited by 43 publications

(65 citation statements)

References 6 publications

(4 reference statements)

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“…Prehospital personnel can accurately identify ST-segment elevation from the 12-lead ECG. 47,50,[61][62][63][64][65][66][67][68][69][70][71][72][73][74] If providers are not trained to interperet the 12-lead ECG, field transmission of the ECG or a computer report to the receiving hospital is recommended (Class I, LOE B).…”

Section: Prehospital Ecgs (Figure 1 Box 2)mentioning

confidence: 99%

Part 10: Acute Coronary Syndromes

O’Connor¹,

Brady²,

Brooks³

et al. 2010

Circulation

240

167

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Section: Prehospital Ecgs (Figure 1 Box 2)mentioning

confidence: 99%

Part 10: Acute Coronary Syndromes

O’Connor¹,

Brady²,

Brooks³

et al. 2010

Circulation

240

167

View full text Add to dashboard Cite

“…care unit nurses, triage nurses could be trained to interpret ECGs, 27 and computerized ECG readings have been used in the prehospital setting, with a high specificity of STEMI detection. 28,29 Further research is needed to elucidate the benefits and drawbacks of triage ECGs; however, they are one potential solution to gaining further reductions in door-to-ECG times, particularly for a very early target such as 4 minutes.…”

Section: Discussionmentioning

confidence: 99%

Effect of time to electrocardiogram on time from electrocardiogram to fibrinolysis in acute myocardial infarction patients

Atzema

Austin²,

Tu³

et al. 2011

CJEM

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Objective: The American Heart Association (AHA) recommends a benchmark door-to-electrocardiogram (ECG) time of 10 minutes for acute myocardial infarction patients, but this is based on expert opinion (level of evidence C). We sought to establish an evidence-based benchmark door-to-ECG time.Methods: This retrospective cohort study used a populationbased sample of patients who suffered an ST elevation myocardial infarction (STEMI) in Ontario between 1999 and 2001. Using cubic smoothing splines, we described (1) the relationship between door-to-ECG time and ECG-to-needle time and (2) the proportion of STEMI patients who met the benchmark door-to-needle time of 30 minutes based on their door-to-ECG time. We hypothesized nonlinear relationships and sought to identify an inflection point in the latter curve that would define the most efficient (benefit the greatest number of patients) door-to-ECG time. Results: In 2,961 STEMI patients, the median door-to-ECG and ECG-to-needle times were 8.0 and 27.0 minutes, respectively. There was a linear increase in ECG-to-needle time as the door-to-ECG time increased, up to approximately 30 minutes, after which the ECG-to-needle time remained constant at 53 minutes. The inflection point in the probability of achieving the benchmark door-to-needle time occurred at 4 minutes, after which it decreased linearly, with every minute of door-to-ECG time decreasing the average probability of achievement by 2.2%. Conclusions: Hospitals that are not meeting benchmark reperfusion times may improve performance by decreasing door-to-ECG times, even if they are meeting the current AHA benchmark door-to-ECG time. The highest probability of meeting the reperfusion target time for fibrinolytic administration is associated with a door-to-ECG time of 4 minutes or less.

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“…Eight observational studies reported that nurses can diagnose STEMI in the context of nurse-initiated fibrinolysis programs (LOE D3 121 ; LOE D4 116,[122][123][124] ; LOE D5 [125][126][127] ). The literature largely describes the ability of nurses to avoid false-positive diagnosis in fibrinolysis programs without substantial evidence about false-negative decisions, which may affect true overall diagnostic accuracy.…”

Section: Consensus On Sciencementioning

confidence: 99%

Part 9: Acute Coronary Syndromes

Bossaert

O’Connor²,

Arntz³

et al. 2010

Circulation

103

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These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non-ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-ofhospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005. 1,2• The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.• In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.• The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.• Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.• Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.• STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.• Intravenous (IV) ␤-blockers should not be give...

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Quality improvement report: Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction

Abstract: Thrombolysis started by nurses is safe and effective in patients with acute myocardial infarction. It may provide a way by which the national service framework's targets for door to needle times can be achieved.

Cited by 43 publications

References 6 publications

Part 10: Acute Coronary Syndromes

Part 10: Acute Coronary Syndromes

Effect of time to electrocardiogram on time from electrocardiogram to fibrinolysis in acute myocardial infarction patients

Part 9: Acute Coronary Syndromes

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