Door-to-needle time in patients with acute myocardial infarction requiring thrombolytic therapy

Makgoale, Kgahlego Ramathabathe (2015-04)

Thesis (MCur)--Stellenbosch University, 2015.

Thesis

ENGLISH ABSTRACT: A heart attack is a medical emergency and a life threatening disease. Patients with chest pain and a possible diagnosis of myocardial infarction require a detailed assessment and prompt medical management. The aim of the study was to determine the in-hospital delay in administrating thrombolytic therapy to patients with acute myocardial infarction (AMI) A mixed method with convergent parallel design was applied to the study. The population consisted of N=63 case notes of adult patients diagnosed with acute myocardial infarction and who had received thrombolytic therapy. The other population included (n=8) registered professional nurses working in the coronary care unit (CCU) of a tertiary hospital in the Western Cape. A record review was done using a data extraction form and semi-structured interview guide was used for data collection purposes. Reliability and validity was tested by the use of a nurse expert and a statistician. The nurse expert evaluated the data extraction form to ensure that all variables are included. A pilot study was done to test the data extraction form for errors. Ethical approval was obtained from the Health Research Ethics Committee of Stellenbosch University and permission to conduct the study was obtained from the management where the study was conducted. Informed consent was obtained from the participants. Data analysis was done by the researcher and a qualified statistician. Data was presented in the form of tables, histograms and frequencies. Analysis for the qualitative data was done by the researcher and the following themes were identified: cardiovascular nursing care, roles and responsibilities of nurses, scope of practice, perceptions of nurses on DNT and factors influencing DNT. Themes were presented in a form of a table and thereafter discussed extensively. Results: A total of 63 case notes of patients diagnosed with AMI were identified. The case notes were identified from the register kept in the CCU of the tertiary hospital. The case notes were of patients diagnosed with AMI and received thrombolytic therapy between the period of January 2009 to January 2014. A list of identified case notes was sent to Medical Records department for the retrieval of files. Once the files were retrieved, notes were obtained and used for data collection and analysis purposes (record review). Eleven (11) case notes could not be recovered, ten other case notes had incomplete data, two patients were thrombolysed at remote hospitals and one had a negative value after analysis. A total of 24 patients were excluded from the study. Only 39 patients were eligible for the study. The median door-to-needle time (DNT) of 30 minutes with a range between five to eighty five minutes was achieved. A door-to-needle time of 30 minutes or less was achieved in 23 (59.0%) of the patients; 56.25% of the patients arrived by ambulance and 43.75% used private transport. Of all the patients diagnosed, 24.5% had a pre-hospital ECG; more than 50% (n=30, 76.9%) of the population were smokers and 53.8% of the population had a risk factor of hypertension. The predominant infarct was inferior (61.5%), followed by anterior (38.5%). More than 70% of the patients were assessed by a junior registrar and only (23.1%) by the senior. Furthermore, (n=10, 25.6%) of the population was assessed by the junior registered professional nurse (RPN) and (n=29, 74.4%) by the senior RPN. Population had a median length in hospital of four days. Three patients died due to complications. The researcher read through all the transcriptions to achieve an overview of the interview. The aim was for the researcher to become immersed with the data. From the data, the researcher created codes and themes qualitatively and counted the number of times they occurred. Similar themes were grouped together and subthemes that emerged from the main themes were identified. The main themes identified were: cardiovascular nursing care, roles and responsibilities, scope of practice, perceptions of nurses on door-to-needle time (DNT) and factors influencing DNT. Conclusions: The majority of patients (74.4%) were assessed by a senior registered professional nurse (RPN) on presentation, yet (n=16) of the patients were not thrombolysed within 30 minutes. Patient, doctor, personnel, hospital and ECG factors influenced door-toneedle time in this study. Few nurses working in the CCU showed insight into DNT. The majority of the nurses reported that they have never seen a delay in DNT yet not all patients achieved a DNT of 30 minutes or less. No significant relationship was found between DNT and factors associated with DNT. There was no significant relationship between door-toneedle time and length of hospital stay p=0.40. Recommendations were made to improve patient care and management.

AFRIKAANSE OPSOMMING: ’n Hartaanval is ’n mediese noodgeval en ’n lewensgevaarlike siekte. Pasiënte met borspyn en ’n moontlike diagnose van miokardiale infarksie benodig ’n gedetailleerde assessering en vinnige mediese bestuur. Die doel van die studie was om die in-hospitaal vertraging in pasiënte met akute miokardiale infarksie (AMI) wat trombolitiese terapie benodig, te bepaal. ’n Gemengde metode is gebruik in die studie. Die populasie het bestaan uit N=63 gevalnotas van volwasse pasiënte wat gediagnoseer is met akute miokardiale infarksie en wat trombolitiese terapie ontvang het. Die ander populasie het bestaan uit (n=8) geregistreerde, professionele verpleegkundiges wat in die koronêre sorgeenheid van ’n tersiêre hospital in die Wes-Kaap werk. ’n Data-ontginningsvorm en semi-gestruktureerde onderhoude is gebruik vir data insamelingsdoeleindes. Betroubaarheid en geldigheid is getoets deur ’n verpleegkundige deskundige en statistikus. Die verpleegkundige deskundige het die dataontginningsvorm geëvalueer om te verseker dat alle veranderlikes ingesluit is. ’n Loodsstudie is onderneem om die data-ontginningsvorm vir foute te toets. Etiese toestemming is verkry van die Gesondheidsnavorsing-etiekkomitee van Stellenbosch Universiteit en toestemming om die studie uit te voer is van die bestuuur van die instansie waar die navorsing uitgevoer is, verkry. Ingeligte toestemming is van die deelnemers verkry. Data-analise is gedoen deur die navorser en ’n gekwalifiseerde statistikus. Data is aangebied in die vorm van tabelle, histogramme en frekwensies. Resultate: ’n Totaal van 63 gevalnotas van pasiënte gediagnoseer met AMI is geïdentifiseer. Elf (11) gevalnotas kon nie verkry word nie en tien ander gevalnotas het onvolledige inligting bevat, twee pasiënte is getrombolitiseer by afgeleë hospitale en een het ’n negatiewe waarde na analise gehad. ’n Totaal van 24 pasiënte is uitgesluit uit die studie. Slegs 39 pasiënte was in aanmerking vir die studie. Die median deur-tot-naald (DTN) tyd van 30 minute is bereik wat strek tussen vyf tot vyf-en-tagtig minute. ’n DTN tyd van 30 minute of minder is bereik in 23 (59.0%) van die pasiënte, 56.25% van die pasiënte het per ambulans aangekom en 43.75% het privaatvervoer gebruik. Van al die pasiënte gediagnoseer het 24.5% ’n prehospitaal EKG gehad, meer as 50% (n=30, 76.9%) van die populasie was rokers en 53.8% van die populasie het ’n risikofaktor vir hipertensie gehad. Die oorhersende infark was minderwaardig (61.5%), gevolg deur anterior (38.5%). Meer as 70% van die pasiënte is deur ’n junior registratrateur geassesser en slegs 23.1% deur die senior registrateur. Verder is 25.6% (n=10) van die populasie deur die junior professionele geregistreerde verpleegkundige geassesseer, en 74.4% (n=29) deur die senior geregistreerde verpleegkundige. Die populasie het ’n median lengte van verblyf van vier dae in die hospitaal gehad. Drie pasiënte is dood as gevolg van komplikasies. Konklusie: Die meerderheid van pasiënte (74.4%) is geassesseer deur ’n senior geregistreerde professionele verpleegkundige tydens aanbieding, alhoewel (n=16) pasiënte nie binne die eerste 30 minute getrombolitiseer nie. Pasiënt, dokter, personeel, hospitaal EKG was faktore wat deur-tot-naald tyd in die studie beïnvloed het. Min verpleegkundiges wat in die koronêre versorginseenheid gewerk het, het insig in DTN getoon. Die meerderheid van die verpleegkundiges het gerapporteer dat hulle nog nooit ’n vertraging in DTN gesien hiet nie, tog het nie alle pasiënte DTN in 30 minute of minder behaal nie. Geen beduidende verhouding is tussen deur-tot-naald tyd en lengte van verblyf in die hospital gevind nie (p=40). Aanbevelings is gemaak om pasiënt-behandeling en –bestuur te verbeter.

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