Effect of triage training on nurses' practice and triage outcomes of patients with acute coronary syndrome

BackgroundAccurate assessment and prompt management of patients with acute coronary syndrome (ACS) is a complex process for emergency department (ED) nurses and has variable clinical outcomes. The aim of the present study was to determine the effectiveness of an educational intervention on nurses' practice during the triage of patients with ACS and the triage outcomes in this group of patients.MethodsIn this quasi-experimental study, a pretest-posttest group of 24 nurses were included by convenience sampling method and 960 patients with ACS were selected by sequential sampling during the pre-intervention (n = 480) and post-intervention (n = 480) phases. A case-based learning (CBL) intervention was performed for nurses for one month considering the role of the triage nurse according to the American College of Cardiology (ACC) and the American Heart Association (AHA) recommendations as well as the factors affecting the proper identification and management of patients with ACS. During patient triage in the pre- and post-intervention phases, the “Triage Nurse Practice Checklist” and the “Medical Electronic Records” were used to assess nurses' practice and the triage outcomes in patients, respectively.ResultsThe overall mean score of the triage nurses' practice and its subscales, including Primary monitoring and assessment, cardiovascular risk factors assessment, evaluation of coronary heart disease (CHD) symptoms, chest pain management, and adherence to the ACC/AHA practice guidelines were significantly improved in the post-intervention phase compared with the pre-intervention phase (p < 0.001). There was no significant difference between the triage outcomes, including in-hospital mortality within 24 hours, death in ED, hospitalization in other wards, and discharge from ED in the pre and post-intervention phases (P = 0.723).ConclusionThe development of a cardiac triage-specific educational program could improve the performance of nurses in the evaluation and management of patients with ACS, but had no effect on the triage outcomes in this group of patients. We recommend a quality improvement project or a critical outcomes-based triage system to assess ACS patients’ care needs in the ED.     

Clinical deterioration of ward patients in the presence of antecedents: A systematic review and narrative synthesis

AimThe aim of this review was to identify and synthesise published accounts of recognising and responding to patient deterioration in the presence of deterioration antecedents.DesignThe systematic review canvassed four electronic databases/search engines for studies of adult ward patients who had altered physiological parameters before developing major adverse events.Synthesis MethodsThe findings were synthesised using a narrative approach.ResultsClinical deterioration can be missed by nurses, even with adequate charting. Delays in recognising and responding to patient deterioration remains an international patient safety concern, and strategies to enhance recognition of patient deterioration have not achieved consistent improvements. The lack of significant and sustained improvement through targeted training suggests the problem may be rooted in human behaviour and local ward culture. Nurses play a pivotal role in recognising and responding to patient deterioration; however, patient records do not facilitate tracking of all nurse decisions and actions, and any undocumented care cannot be easily captured by auditing processes.ConclusionFailure to recognise clinical deterioration was evident even with adequate charting. It is not clear if nurses do not recognise clinical deterioration because they failed to interpret the signs of deterioration or they made a conscious decision not to escalate based on their clinical judgement or they lacked attention at the time of the event. Whatever the reason, focus is warranted for nurses' decision-making after the recording of clinical deterioration signs and the role of human factors in delayed recognition, before maximum benefit of any strategy can be achieved.     

Individualizing and optimizing the use of early warning scores in acute medical care for deteriorating hospitalized patients

AimWhile early warning scores (EWS) have the potential to identify physiological deterioration in an acute care setting, the implementation of EWS in clinical practice has yet to be fully realized. The primary aim of this study is to identify optimal patient-centered rapid response team (RRT) activation rules using electronic medical records (EMR)-derived Markovian models.MethodsThe setting for the observational cohort study included 38,356 adult general floor patients hospitalized in 2011. The national early warning score (NEWS) was used to measure the patient health condition. Chi-square and Kruskal Wallis tests were used to identify statistically significant subpopulations as a function of the admission type (medical or surgical), frailty as measured by the Braden skin score, and history of prior clinical deterioration (RRT, cardiopulmonary arrest, or unscheduled ICU transfer).ResultsStatistical tests identified 12 statistically significant subpopulations which differed clinically, as measured by length of stay and time to re-admission (P < .001). The Chi-square test of independence results showed a dependency structure between subsequent states in the embedded Markov chains (P < .001). The SMDP models identified two sets of subpopulation-specific RRT activation rules for each statistically unique subpopulation. Clinical deterioration experience in prior hospitalizations did not change the RRT activation rules. The thresholds differed as a function of admission type and frailty.ConclusionsEWS were used to identify personalized thresholds for RRT activation for statistically significant Markovian patient subpopulations as a function of frailty and admission type. The full potential of EWS for personalizing acute care delivery is yet to be realized.     

Characteristics and outcomes of in-hospital cardiac arrest in adults hospitalized with acute coronary syndrome in China

AimsThis retrospective study aims to analyze and explore the clinical characteristics, risk factors, and in-hospital outcomes - including return of spontaneous circulation (ROSC) and survival to discharge - of hospitalized patients admitted with acute coronary syndrome (ACS) suffering cardiac arrest.MethodsACS patients admitted to three tertiary hospitals in Fujian, China, were evaluated retrospectively from January 1, 2012 to December 30, 2016. Data were collected, based on the Utstein Style, for all cases of attempted resuscitation for IHCA. We analyzed patient characteristics, pre-event variables, event variables, and the main outcomes, including ROSC and survival to discharge, and identified the influencing factors on the outcomes.ResultsThe total number of ACS admissions across the three hospitals during this study period was 21,337. Among these admissions, 320 ACS patients experienced IHCA (incidence: 1.50%); 134 (41.9%) patients experienced ROSC; and 68 (21.2%) survived to discharge. The findings indicated that four factors were associated with ROSC, including age <70 years-old, shockable rhythm, duration of resuscitation (≤15 min and 16–30 min), and PCI. Five factors were associated with survival to discharge, including age <70 years-old, shockable rhythm, the duration of resuscitation (≤15 min and 16–30 min), Killip ≤ II, and CCI ≤ 2.ConclusionYounger age, shockable rhythm, and shorter duration of resuscitation were all factors demonstrated to be a predictor of ROSC and survival to hospital discharge.     

Implementing and sustaining evidence-based nursing practice to reduce pediatric cardiopulmonary arrest

Rapid response teams (RRTs) improve outcomes for patients through early escalation of care. However, subtle signs of clinical deterioration in children may not be consistently recognized by the bedside acute care nurse and therefore the RRT may not be activated. The Pediatric Early Warning Score (PEWS), an evidence-based tool, provides nurses with a mechanism for early detection using quantitative data. We describe our process and outcomes of implementing and sustaining the use of PEWS at the unit and organizational level using the Plan-Do-Check-Act methodology for performance improvement. Our outcome data indicate that cardiopulmonary arrests were reduced by 31% at the pilot unit level and subsequently 23.4% at the organizational level. Data also suggest that bedside nurses effectively escalated patient care needs without activating RRTs (19.4% reduction in RRT activations after PEWS implementation). Strategies to sustain the positive outcomes of PEWS at the unit and organizational levels are also described.     

A call for better doctor–nurse collaboration: A qualitative study of the experiences of junior doctors and nurses in escalating care for deteriorating ward patients

BackgroundDespite the widespread implementation of medical emergency teams (METs) in hospitals to provide immediate interventions to deteriorating ward patients, little is known about how junior doctors and nurses escalate care for deteriorating ward patients in hospitals with established MET services.ObjectivesThe objective of this research study was to explore the experiences of junior doctors and nurses in escalating care for clinically deteriorating patients in general wards.MethodsTwenty-four individual interviews were conducted with 10 junior doctors and 14 registered nurses of a 1000-bed acute general hospital with the most established MET service in Singapore. Interviews were transcribed verbatim and analysed using an interpretive thematic analysis approach.FindingsThree salient themes emerged from thematic analysis: (1) MET activations versus the primary team doctors' reviews, (2) challenges in obtaining medical reviews, and (3) unspoken rules of the escalation of care. Participants' decisions to call the MET or to escalate to the primary team doctors not only depended on the severity of a patient's deterioration and their perceptions of the primary team doctors' capacity to manage the patient but also were largely influenced by sociocultural factors that were shaped by the hierarchy of medical professions. Key challenges faced by nurses in obtaining medical reviews from junior doctors for patients with early deterioration included presenting “convincing” evidence of patient deterioration and “packaging” information about patient deterioration.ConclusionsThe decision to call a MET or the primary team doctors is a complex judgement that is greatly influenced by the dynamics of perceived hierarchy between the medicine and nursing professions and within the medicine profession. Educational and organisational changes that enhance doctor–nurse interprofessional and intraprofessional collaboration among all levels of doctors may improve the process of the escalation of care for deteriorating patients and thus improve patient safety for hospitalised patients.     

Development and validation of an instrument for measuring junior nurses’ recognition and response abilities to clinical deterioration (RRCD)

BackgroundNurses of all levels are expected to be competent in managing clinical deterioration. Given their limited experience and basic-level knowledge, there is a concern about junior nurses' clinical and patient management skills. However, junior nurses’ abilities to recognise and respond to clinical deterioration have not been adequately explored because of the absence of a comprehensive tool.ObjectivesThe aim of this study was to develop a new self-assessment scale to assess the junior nurses’ recognition and response abilities to clinical deterioration and to examine its reliability and validity.MethodsScale items were based on literature reviews and interviews. The preliminary scale was generated through two rounds of expert review. A panel of five experts evaluated content validity. After a pilot study, the questionnaire was distributed to 168 junior nurses via convenience sampling. Subsequent statistical analysis of results included construct validity, internal consistency, and test–retest reliability.ResultsSix factors were included, and 69.310% of the total variance was explained by the 25 items comprising the scale. The Cronbach's alpha coefficient was 0.905 (95% confidence interval [CI]: 0.812–0.979) for the overall scale and 0.655–0.838 for its subscales. The Guttman split-half reliability was 0.856 (95% CI: 0.806–0.894). The test–retest reliability of the scale was 0.878 (95% CI: 0.836–0.911).ConclusionWe developed a scale for measuring the abilities of junior nurses to recognise and respond to clinical deterioration and confirmed its reliability and validity. More experimental studies are needed to further evaluate this instrument.     

Colchicine as a Novel Therapy for Suppressing Chemokine Production in Patients With an Acute Coronary Syndrome: A Pilot Study

PurposeExisting literature reports that colchicine inhibits inflammasome activation and downstream inflammatory cytokine production and stabilizes coronary plaque. However, colchicine's effect on chemokines, which orchestrate multiple atheroinflammatory pathways, is unknown.MethodsPatients with acute coronary syndrome (ACS) were randomly assigned to colchicine (1.5 mg PO) (n = 12; mean age, 65.2 years) or no treatment (n = 13; mean age, 62.2 years). Blood samples were collected during cardiac catheterization within 24 hours of colchicine administration from the coronary sinus, aortic root, and right atrium. Patients with colchicine-naive stable angina (SAP) (n = 13; mean age, 66.8 years) were additionally sampled. Serum chemokine levels were analyzed with ELISA. In parallel, monocytes from healthy donors were isolated and subjected to colchicine treatment.FindingsTranscoronary (TC) levels of chemokine ligand 2 (CCL2) and C-X3-C motif chemokine ligand 1 (CX3CL1) were significantly elevated in patients with ACS versus patients with SAP (P < 0.01). TC chemokine ligand 5 (CCL5) levels were not significantly (P = 0.084) elevated in patients with ACS versus patients with SAP. Colchicine treatment markedly reduced TC levels of CCL2, CCL5, and CX3CL1 in patients with ACS (P < 0.05). In vitro colchicine suppressed CCL2 gene expression in stimulated monocytes (P < 0.05). Colchicine treatment reduced the intracellular concentration of all 3 chemokines (P < 0.01) and impaired monocyte chemotaxis (P < 0.05).ImplicationsHere, we report for the first time that short-term colchicine therapy significantly reduces the local production of coronary chemokines, in part by attenuating production of these mediators by monocytes. These data provide further evidence of colchicine's beneficial role in patients with ACS.     

Acute Coronary Syndrome From Green Snake Envenomation

BackgroundSnake bite is a grossly underreported public health issue in subtropical, tropical suburban, and rural areas of Africa and South Asia. In literature, ophitoxemia (snake bite envenomation) as a cause of acute coronary syndrome (ACS) is limited to very few case reports. Viper envenomation is the most common cause of ACS among snake bites. We report the first case of unstable angina caused by Colubridae snake bite (Ahaetullanasuta, commonly called green snakes) in a young man without comorbidities.Case ReportA young healthy man had a green snake bite that was camouflaged in the green fodder. He was managed elsewhere with anti-snake serum. He developed acute chest pain and breathlessness on day 3 of his treatment. Electrocardiogram (ECG) showed biphasic T wave inversions suggestive of type A Wellens pattern in the anterior chest leads (V1–V4). He was treated for ACS medically outside and was referred to our institute for further management on the following day. ECG and cardiac enzymes were normal. The echocardiogram showed no regional wall motion abnormality. Computed tomography coronary angiography showed normal epicardial coronaries. He was discharged in stable condition and asymptomatic at 2 months follow-up.Why Should an Emergency Physician Be Aware of This?ACS after a snake bite is not limited to venomous snakes. The diagnosis should be considered promptly even with a nonvenomous snake bite, especially in those with typical symptoms and ECG changes. The time interval between snake bite and development of ACS can be long and warrants prolonged medical supervision.     

急性冠状动脉综合征患者经皮冠状动脉介入治疗围术期死亡原因分析

目的：探讨急性冠状动脉综合征（ACS）患者经皮冠状动脉介入治疗（PCI）围术期死亡原因。方法：2002年1月—2006年3月在复旦大学附属中山医院接受PCI的3 806例冠心病患者中36例ACS患者发生围术期死亡。其中男性23例,女性13例;年龄24~85岁（平均年龄69±23岁）,包括急性心肌梗死（AMI）29例、不稳定心绞痛7例,其中既往有陈旧性心肌梗死史者7例、PCI治疗史者4例、冠状动脉旁路移植术（CABG）史者1例、脑卒中史者4例,合并有高血压病者20例、脂代谢紊乱者11例、糖尿病者6例、慢性阻塞性肺病者4例。结果：36例ACS患者中,因AMI行急诊PCI者24例,ACS行择期PCI者12例（包括AMI5例、不稳定心绞痛7例）。冠状动脉造影显示,26例有2支及以上多支血管病变,10例为单支血管病变。36例ACS患者PCI围术期死亡原因为心力衰竭或（和）心源性休克16例（44.4%）,室颤和（或）心脏骤停8例（22.2%）,多脏器功能衰竭4例（11.1%）,心脏破裂4例（11.1%）,急性或亚急性支架内血栓形成3例（8.3%）,消化道大出血1例（2.8%）。急诊PCI因泵衰竭死亡的12例患者中,广泛前壁AMI7例、下壁＋后壁AMI3例,下壁＋右室AMI2例。结论：ACS患者PCI围术期死亡的主要原因为泵衰竭、室颤和（或）心脏骤停、多脏器功能衰竭、心脏破裂及支架内血栓形成。     

Dedicated,Proactive, Nurse Practitioner Rapid Response Team Eliminating Barriers

Rapid response teams (RRT) have become an expected component in response to acute clinical deterioration of patients outside of the intensive care unit. Even with this support, many RRTs are not activated despite a high level of nursing concern that patients are decompensating. Bedside nurses may be discouraged from appropriately activating RRT due to fear of reprimand. Instituting a proactive, dedicated RRT of nurse practitioners who developed relationships and improved communication with nurses led to an increase in RRT activations for general nursing concern. Early recognition of acute clinical change allowed for prompt intervention by the RRT and decreased intensive care unit transfers.     

Implementation evaluation of a rapid response system in a regional emergency department: a dual-methods study using the behaviour change wheel

BackgroundFailure to recognise and respond to clinical deterioration is a major cause of high mortality events in emergency department (ED) patients. Whilst there is substantial evidence that rapid response teams reduce hospital mortality, unplanned intensive care admissions, and cardiac arrests on in-patient settings, the use of rapid response teams in the ED is variable with poor integration of care between emergency and specialty/intensive care teams.ObjectivesThe aim of this study was to evaluate uptake and impact of a rapid response system on recognising and responding to deteriorating patients in the ED and identify implementation factors and strategies to optimise future implementation success.MethodsA dual-methods design was used to evaluate an ED Clinical Emergency Response System (EDCERS) protocol implemented at a regional Australian ED in June 2019. A documentation audit was conducted on patients eligible for the EDCERS during the first 3 months of implementation. Quantitative data from documentation audit were used to measure uptake and impact of the protocol on escalation and response to patient deterioration. Facilitators and barriers to the EDCERS uptake were identified via key stakeholder engagement and consultation. An implementation plan was developed using the Behaviour Change Wheel for future implementation.ResultsThe EDCERS was activated in 42 (53.1%) of 79 eligible patients. The specialty care team were more likely to respond when the EDCERS was activated than when there was no activation ([n = 40, 50.6%] v [n = 26, 32.9%], p = 0.01). Six facilitators and nine barriers to protocol uptake were identified. Twenty behaviour change techniques were selected and informed the development of a theory-informed implementation plan.ConclusionImplementation of the EDCERS protocol resulted in high response rates from specialty and intensive care staff. However, overall uptake of the protocol by emergency staff was poor. This study highlights the importance of understanding facilitators and barriers to uptake prior to implementing a new intervention.     

Understanding how medications contribute to clinical deterioration and are used in rapid response systems: A comprehensive scoping review

BackgroundIn hospitals, rapid response systems (RRSs) identify patients who deteriorate and provide critical care at their bedsides to stabilise and escalate care. Medications, including oral and parenteral pharmaceutical preparations, are the most common intervention for hospitalised patients and the most common cause of harm. This connection between clinical deterioration and medication safety is poorly understood.ObjectivesTo inform improvements in prevention and management of clinical deterioration, this review aimed to examine how medications contributed to clinical deterioration and how medications were used in RRSs.Review methodsA scoping review was undertaken of medication data reported in studies of clinical deterioration or RRSs in diverse hospital settings between 2005 and 2017. Bibliographic database searches used permutations of “rapid response system,” “medical emergency team,” and keyword searching with medication-related terms. Independent selection, quality assessment, and data extraction informed mapping against four medication themes: causes of deterioration, predictors of deterioration, RRS use, and management.ResultsThirty articles were reviewed. Quality was low: limited by small samples, observational, single-centre designs and few primary medication-related outcomes. Adverse drug reactions and potentially preventable medication errors, involving sedatives, analgesics, and cardiovascular agents, contributed to clinical deterioration. While sparsely reported, outcomes included death and escalation of care. In children, administration of antibiotics or nebulised medications appeared to predict subsequent deterioration. Cardiovascular medications, sedatives, and analgesics commonly were used to manage deterioration but further detail was lacking. Despite reported potential for patient harm, evaluation of medication management systems was limited.ConclusionsMedications contributed to potentially preventable clinical deterioration, with considerable harm, and were common interventions for its management. When assessing deteriorating patients or caring for patients who require escalation to critical care, clinicians should consider medication errors and adverse reactions. Studies with more specific medication-related, patient-centred end points could reduce medication-related deterioration and refine RRS medication use and management.     

Emergency Department Chest Pain Patients With or Without Ongoing Pain: Characteristics,Outcome, and Diagnostic Value of the Electrocardiogram

BackgroundIn emergency department (ED) chest pain patients, it is believed that the diagnostic accuracy of the electrocardiogram (ECG) for acute coronary syndrome (ACS) is higher during ongoing than abated chest pain.ObjectivesWe compared patient characteristics and the diagnostic performance of the ECG in ED patients presenting with ongoing, vs. abated, chest pain.MethodsIn total, 1132 unselected ED chest pain patients were analyzed. The patient characteristics and diagnostic accuracy for index visit ACS of the emergency physicians’ interpretation of the ECG was compared in patients with and without ongoing chest pain. Logistic regression analysis was performed to control for possible confounders.ResultsPatients with abated chest pain (n = 508) were older, had more comorbidities, and had double the risk of index visit ACS (15%) and major adverse cardiac events (MACE) at 30 days (15.6%) compared with patients with ongoing pain (n = 631; ACS 7.3%, 30-day MACE 7.4%). Sensitivity of the ECG for ACS was 24% in patients with ongoing pain and 35% in those without, specificity was 97% in both groups, negative predictive value was 94% and 89%, respectively, and positive likelihood ratio 10.6 and 7.8, respectively. When the diagnostic performance was controlled for confounders, there was no significant difference between the groups.ConclusionOur results indicate that ED chest pain patients with ongoing pain at arrival are younger, healthier, and have less ACS and 30-day MACE than patients with abated pain, but that there is no difference in the diagnostic accuracy of the ECG for ACS between the two groups.