Nurse led thrombolysis

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Nurse- led thrombolysis How is the evidence base
evolving?
Marie Sloman, Staff nurse, Cardiology CEPPL
Graduate Fellow and Dr G R Williamson,
Lecturer, Adult Nursing, FHSW
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NICE (2002)

• 240,000 people experience an Acute Myocardial
  Infarction
• 50 of AMI patients die 30 days after treatment
• Around 50,000 AMI patients receive thrombolysis
  treatment
• NICE recommends early thrombolysis
• administration by any relevant clinician.

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• National Service Framework for Coronary Heart
  Disease (2000)
• 12 standards 1 relates to the treatment of
  people suffering AMI and states that the eligible
  patients should be treated with thrombolysis as
  soon as possible after they develop symptoms.
• The Planning and Priorities framework
  (2003-2006)
• Set a target of a 10 improvement per annum in
  the proportion of eligible patients in reviving
  thrombolysis within 60 minutes of calling help.

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• Department of Health (2003)
• Endorses the 60 minute call to needle time.
  Standards recommended thrombolysis be given
  within 30 minutes of arrival at the hospital.
  This target was reduced to 20 minutes in April
  (2002).
• Myocardial Infarction National Audit Project
  (MINAP)
• The recent MINAP report (2007) shows that 83 of
  the eligible patients receive thrombolysis
  treatment within 30minutes of arrival at hospital
  compared with 44 during 2001.

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60 minute golden hour for giving thrombolysis
Within 12 hours of a heart attack saves between
20 and 30 lives per 1000 within the first hour
saves 65 lives per 1000 but within two hours
only 37 lives per 1000 patients treated every
minutes delay costs 11 days of life every half
hours delay is equivalent to a year of life lost
The Task Force on the Management of Acute
Myocardial Infarction of the European Society of
Cardiology (2003)
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Delays

• Pre-hospital
• In hospital

Patient delay in seeking help
Transportation
Transfer from ED to CCU
Doctors to diagnose and treat
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Literature review

• Rhodes (1998)
• Nurse interventions reduce delays in
  door-to-needle time but there is little evidence
  to support these benefits. They remain unproven.
• Quinn (1999)
• Respondents felt that the ACS role was
  beneficial and had little overlap with existing
  roles. Support for nurse initiated thrombolysis
  was high. However, Quinn reflected on the ongoing
  debate around accountability and training.
  Communication and problem solving were identified
  as key elements of the ACS nurse role.
• Smallwood (2004) states that studies have
  demonstrated reduction in door-to-needle times as
  a result of nurse led thrombolysis. However, the
  studies he found were methodologically poor and
  their outcomes lacked validity and
  generalizability.

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Aim

• To assess the evolution of the evidence base
  for nurses leading and initiating thrombolysis
  treatment in the UK.

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Objectives

• To review systematically the literature since
  2003
• To evaluate the research evidence since 2003
• To track the development of this evidence base
  in relation to previous systematic reviews
• To present findings in the form of meta analysis
  

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Search

• SwetsWise
• Blackwell Synergy
• Medline
• AMED (EBSCO)
• Science Direct (Elseivier)
• CINHAL Plus
• British Nursing Index
• ASSIA (CSA)
• Cochrane
• Search terms used were acute myocardial
  infarction, nurse-initiated thrombolysis,
  nurse-led thrombolysis, and thrombolysis.

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Inclusion criteria

• Research studies clearly indicating study design
  methods, and finding sections
• Systematic literature reviews, where the authors
  clearly indicate search strategy, search terms
  and a rationale for retrieval of papers
• Articles must state that nurses assess, supply
  and administer thrombolytic therapy to patients
  with an AMI
• All methodologies are included
• From 2003 to present day
• Papers written in English, relating to the UK
  hospital-based health services.

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Findings
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• Methodological quality all the studies included
  were small scale qualitative or descriptive
  quantitative research, or literature reviews of
  such studies. Therefore the evidence base is
  questionable as the research is not high on the
  hierarchy of evidence.

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• Evolution of the evidence base
• Specific policy drivers in the NSF (2000), DOH
  (2003), NICE (2002) have enabled nurse led
  thrombolysis to become widespread, allowing
  hospital trusts to improve door to needle times
  and meet national targets.

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Conclusion

• The research suggested that nurse-led
  thrombolysis is clinically safe and reduces door
  to drug times
• thrombolysis administered in the Emergency
  department is effective
• Support for the integration for ACS nurses role
  is a way to improve care for ACS patients.

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Reference list

• Rhodes, M. (1998) What is the evidence to support
  nurse led thrombolysis? Clinical Effectiveness in
  Nursing. 2 69-77
• Department of Health (2000) National Service
  framework for Coronary Heart Disease. London
  Stationary Office
• National Institute of Clinical Excellence (2002)
  Guidance of the use of drugs for early
  thrombolysis in the treatment of acute myocardial
  infarction. London National Institute of
  Clinical Excellence. 521-25
• Department of Health (2002) Improvement,
  Expansion and reform the next three years.
  Priorities and Planning framework. London
  Stationary Office
• Department of Health (2003) Review of early
  thrombolysis faster better treatment for heart
  attack patients. London Stationary Office

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• Albarran, J. (2004) Preparing nurses to initiate
  thrombolytic therapy for patient with an acute
  myocardial infarction is there a consensus.
  Nurse Education in Practice. 4 60-68
• Loveridge, N. (2004) Nursing Diagnostics and
  electrocardiogram interpretation in relation to
  thrombolysis. Emergency nurse. 12 (5) 27-34
• Smallwood, A. (2004) Nurse-initiated
  thrombolysis a systematic review of the
  literature. Nursing in Critical Care. 9 (1) 4-12
  
• The Task Force on the Management of Acute
  Myocardial Infarction of the European Society of
  Cardiology (2003) European Heart Journal. 24.
  28-66 Heath, S. Bain, R. Andrews, A. Chida, S.
  Kitchen, S. Walters, M. (2003) Nurse initiated
  thrombolysis in the accident and emergency
  department safe, accurate, and faster than fast
  tract Emergency medical journal. 20418-420

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• Jones, I. (2005) Thorombolysis nurses Time for
  review. European Cardiovascular Nursing. 4
  129-137
• Dunkley, M. Quinn, T. Dickson, R. Jayram, R.
  Wright, C. McDonald, R. (2006) Acute coronary
  syndrome nurse Perceptions of other members of
  the health care team. Accident and Emergency
  Nursing. 14 204-209
• Smallwood, A. and Humphreys, M. (2007) Nurses
  perceptions and experiences of initiating
  thrombolysis and qualitative study. Nursing in
  Critical Care. 12 (7) 132-140

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