Education and debate

Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction

Asif Qasim, specialist registrar,  Kerry Malpass, ward manager, coronary care unit,  Daniel J O'Gorman, consultant cardiologist,  Mary E Heber, consultant cardiologist. 

Cardiology Department, Princess Royal Hospital, Apley Castle, Telford TF6 6TF

Correspondence to: A Qasim dr{at}asifqasim.freeserve.co.uk

Problem: Delay in starting thrombolytic treatment in patients arriving at hospital with chest pain who are diagnosed as having acute myocardial infarction.
Design: Audit of "door to needle times" for patients presenting with chest pain and an electrocardiogram on admission that confirmed acute myocardial infarction. A one year period in each of three phases of development was studied.
Background and setting: The goal of the national service framework for coronary heart disease is that by April 2002, 75% of eligible patients should receive thrombolysis within 30 minutes of arriving at hospital. A district general hospital introduced a strategy to improve door to needle times. In phase 1 (1989-95), patients with suspected acute myocardial infarction, referred by general practitioners, were assessed in the coronary care unit; all other patients were seen first in the accident and emergency department. In phase 2 (1995-7), all patients with suspected acute myocardial infarction were transferred directly to a fast track area within the coronary care unit, where nurses assess patients and doctors started treatment.
Key measures for improvement: Median door to needle time in phase 1 of 45 minutes (range 5-300 minutes), with 38% of patients treated within 30 minutes. Median door to needle time in phase 2 of 40 minutes (range 5-180 minutes), with 47% treated within 30 minutes
Strategies for change: In phase 3 (1997-2001), all patients with suspected acute myocardial infarction were transferred directly to the fast track area and assessed by a "coronary care thrombolysis nurse." If electrocardiography confirmed the diagnosis of acute myocardial infarction, the nurse could initiate thrombolytic therapy (subject to guidelines and exclusions determined by the consultant cardiologists).
Effects of change: Median door to needle time in phase 3 of 15 minutes (range 5-70 minutes), with 80% of patients treated within 30 minutes. Systematic clinical review showed no cases in which a nurse initiated inappropriate thrombolysis.
Lessons learnt: 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.