Community coronary units: strategies to promote pre-hospital thrombolysis

Early diagnosis and the early delivery of pre-hospital thrombolysis in cases of acute myocardial infarction (AMI) have been shown to decrease mortality. Despite strong evidence of its benefits, pre-hospital thrombolysis rates are still worryingly low. The challenge is to empower community practitioners to deliver thrombolysis. In the Grampian region there is a network of community hospitals which have been equipped with both videoconferencing and remote telemetry equipment. This allows realtime consultation with the local accident and emergency department and coronary care unit. Early trials of the system show that clinical information can be viewed in realtime, with transfer of a 12-lead electrocardiogram at 60 s intervals. This will give general practitioners unprecedented access to specialist advice. Our aim is to use a combination of teaching and decision support technology to ensure that all patients with AMI have the opportunity to access timely and appropriate prehospital thrombolysis.     

Prophylactic treatment after myocardial infarction in primary care: how far can we go?

BACKGROUND: Despite best practice, it may not be achievable in some patients to reach the optimal goals of secondary prevention recommendations for various reasons, such as co-morbidity, contraindications for some drugs or side effects. OBJECTIVE: Our aim was to estimate the achievable standards for audit purposes in primary care for prophylactic treatment of secondary prevention of myocardial infarction. METHODS: We conducted a survey of consecutive patients with a hospital diagnosis of first acute myocardial infarction during 1997 who were identified from discharge books from four hospitals and interviewed at their primary health centre 2 years after admission. The achievable standard for a prophylactic drug was then defined as the proportion of patients that could benefit from the treatment excluding those that for one justified reason or another were off medication. RESULTS: Three hundred and sixty-nine patients were interviewed in the follow-up. Aspirin or another antiplatelet regimen was prescribed in 86.9 patients, beta-blockers in 50.2%, angiotensin-converting enzyme (ACE) inhibitors in 32.5% and lipid-lowering drugs in 52%. The estimated achievable standards for those prescribed drugs were 94.5, 71,8, 50.5 and 69.8%, respectively. CONCLUSIONS: There is an underuse of prophylactic drug therapies after myocardial infarction. The standards established in this study for secondary preventive drug treatment might be achieved through a reasonable effort by GPs working in primary care committed to improving the quality of care.     

Centenary of tele-electrocardiography and telephonocardiography - where are we today?

Telecardiology applications can be categorized as pre-hospital, in-hospital and post-hospital. The major purpose of pre-hospital 12-lead electrocardiographic diagnosis is the early detection of acute myocardial infarction with ST-segment elevation and the communication of that information to the receiving emergency physician before the arrival of the patient. In-hospital telecardiology is used between small hospitals in rural regions and main hospitals. Telemedicine here has the potential to improve access to echocardiography diagnoses in the intensive care unit, emergency room and newborn nursery. In some centres, urgent echocardiography is performed during weekends, evenings and overnight to assess ventricular function, ischaemia, pericardial effusion, valvular disease and heart donor status. Post-hospital applications include teleconsulting between GPs and specialists, home telenursing for chronic cardiac diseases and the diagnosis of arrhythmias. Telecardiology is one of the fastest-growing fields in telemedicine. There is already a significant quantity of published clinical data, with some randomized multi-centre trials to answer the most important questions definitively. Telecardiology in some fields such as emergency and chronic care undoubtedly improves the quality of health care and helps to contain rising costs. Telecardiology has yet to reach maturity, but the evidence to date indicates that it has made a good start.     

急性心肌梗死的院前急救与护理

目的探讨急性心肌梗死患者院前急救护理的意义。方法选用2010年1月～2012年5月140例急性心肌梗死患者,观察组72例采取院前急救护理,对照组68例未实施院前急救护理,比较两组抢救成功、死亡率。结果观察组66例患者安全送回医院,死亡6例,抢救成功率91.67%,死亡率为8.33%;对照组患者送院后成功抢救53例患者,死亡15例,抢救成功率77.94%,死亡率为22.06%。观察组抢救成功率提高13.73%,死亡率降低13.73%。结论对急性心肌梗死患者在院前给予正确的指引,实施相应的院前急救护理措施、加强监护,、安全转运、正确交接班是提高急性心肌梗死患者急救成功率、降低死亡率的有效措施。     

Home care before and after hospitalization for acute myocardial infarction in Alberta, Canada

Home care services are provided to about 10% of those admitted to hospital for acute myocardial infarction and about 20% of those discharged from hospital. The use of home care in patients with an acute myocardial infarction is growing in Alberta over the brief time span of this four year study. Those that received home care prior to a hospitalization for acute myocardial infarction were "old and frail" with a high mortality rate during and after hospitalization. The provision of home care after hospitalization selected those patients that stay in hospital longer and required more hospital care. BACKGROUND: The use of home care before and after hospitalization for acute myocardial infarction is described. METHODS: Hospital discharge abstracts were used to identify patients hospitalized in alberta, canada for acute myocardial infarction which were then linked to home care administrative data. RESULTS: There were 12,648 patients with acute myocardial infarction from April 1, 1995 until March 31, 1999. Home care within 60 days prior to hospitalization was provided for 8.7% of patients with acute myocardial infarctions (n = 1097) which significantly (p = 0.023) increased from 7.6% in the fiscal year 1995/6 to 9.5% in the fiscal year 1998/9. Home care within 60 days after hospitalization was provided to 16.4% of patients with acute myocardial infarctions (n = 2076) which significantly (p < 0.000) increased from 14.1% in the fiscal year 1995/6 to 18.1% in fiscal year 1998/9. Recipients of home care were significantly older, had more comorbidities, and greater severity of illness, but were less likely to undergo coronary artery revascularization during hospitalization. After multivariate adjustment, length of hospital stay, 60 day re-admissions, and mortality were higher in those receiving home care post hospitalization. Nearly half of those receiving home care prior to hospitalization died within one year. 80% of those receiving home care prior to admission also received home care services after hospitalization. CONCLUSION: Those patients who received home care prior to a hospitalization for acute myocardial infarction were "old and frail" with a high mortality rate during and after hospitalization. The provision of home care after hospitalization selected those patients that stay in hospital longer and required more hospital care.     

Factors affecting practice nurse involvement in follow-up care of patients following myocardial infarction

BACKGROUND: Preventive care can reduce the morbidity and mortality of patients following myocardial infarction. Recent evidence has shown that such care is not being provided effectively. The involvement of practice nurses has been proposed as a means of improving the completeness of follow-up and the quality of preventive care. OBJECTIVES: We aimed to determine the extent to which follow-up care for people discharged from hospital after a myocardial infarction is currently being undertaken by practice nurses and to assess the factors influencing the provision of such care and the nurses' attitudes towards this extended role. METHOD: Postal questionnaires were sent to 183 practice nurses working in general practices in the Southampton and South-West Hampshire Health District; 121 nurses responded (66%), representing 58 out of 64 practices surveyed (91%). RESULTS: The majority of responding practice nurses (55%, 95% CI 47-64%) had hospital experience of caring for patients with ischaemic heart disease, and most (83%, 95% CI 76-89%) believed that they played a key role in follow-up care of patients following myocardial infarction. In the absence of external support from a cardiac liaison nurse, few nurses (26%, 95% CI 16-41%) provide such care at present and only 21% work in practices with a register of myocardial infarction patients. Factors predicting the provision of follow-up care are having adequate time (odds ratio 4.59, 95% CI 1.66-12.7), the support of a cardiac liaison nurse (odds ratio 3.07, 95% CI 1.28-7.34) and GP colleagues (odds ratio 3.38, 95% CI 1.38-8.23), training in consultation skills (odds ratio 7.25, 95% CI 2.08-25.3), fundholding (odds ratio 3.11, 95% CI 1.26-7.69) and the confidence and knowledge of the practice nurse (odds ratios and 95% CIs respectively: 2.84, 1.18-6.83 and 2.80, 1.13- 6.89). CONCLUSION: Most practice nurses are enthusiastic and have some of the necessary experience to provide follow-up care for patients who have experienced a myocardial infarction. Yet few currently provide it. The most important organizational incentives for providing such care are further training and the support of GPs and the cardiac liaison nurse.      

Prehospital thrombolysis--calculated health benefit for catchment population of one hospital

The health benefit of thrombolysis in acute myocardial infarction is greatest when patients are treated soon after onset of symptoms. One approach to reducing treatment delay is to give thrombolysis before the patient reaches hospital. When an ambulance trust proposed a prehospital thrombolysis service, local commissioners requested an estimate of its possible health impact. Clinical audit and ambulance trust data were obtained for 165 patients who received thrombolysis for acute myocardial infarction in the coronary care unit of a local hospital in one year. This information was then used to estimate the health impact of prehospital thrombolysis in the local population in a mathematical model derived from the results of trials comparing prehospital and hospital thrombolysis. The best predicted local health benefit from the proposed prehospital thrombolysis service is that, if 45 minutes can be cut off the call-to-needle time, 61 cases of acute myocardial infarction need to be treated to save one additional life at 35 days. By use of published research data, the health benefits of prehospital thrombolysis can be estimated for a local population. Variables in the treatment population and ambulance service will influence the size of the health benefit that can be achieved.     

The continuing care guidelines and primary and community health services

The confirmation of NHS responsibilities for continuing health care has important implications for primary and community health services. In early 1996, during the period of consultation on draft local policies and eligibility criteria, exploratory interviews were carried out with general practitioners (GPs), community nursing managers, primary care development officers and social services purchasers in three health authority areas. The interviews indicated that few GPs had responded to local consultation and were only slowly becoming aware of the implications for the provision and purchasing of primary and community health services. Moreover, local continuing care policies had apparently not addressed two issues which GPs and community nursing staff indicated were currently highly problematic: their responsibilities in relation to independent sector residential and nursing home patients; and the consequences for primary health and community nursing services of hospital discharge decisions. The need for purchasers and commissioners of health services, whether health authorities or GPs, to begin collecting information on patients' potential needs for continuing care services was widely recognised as an urgent priority.     

A systematic review of the literature exploring the role of primary care in genetic services.

BACKGROUND: In response to growing demands on genetics departments and advances in genetic medicine, it has been proposed that primary care should provide a frontline service in clinical genetics. However, there are concerns that primary care may be unwilling or ill prepared to take on this new role. OBJECTIVES: This study aimed to review systematically the literature exploring the role of primary care in delivering genetic services, and define potential methods of supporting primary care in the provision of genetics services. METHODS: Seven electronic databases were searched. This was complemented by contacting experts in the field and handsearching reference lists. In total, 230 papers were identified, including traditional reviews, of which 96 were examined in detail. Fifty-one papers are included in this review. On account of the heterogeneity of papers identified, we conducted a qualitative synthesis of the results, focusing on five key questions. RESULTS: GPs accept that they have an increasing role to play in genetics, but lack confidence in their ability to do so because of limited knowledge of clinical genetics. Evidence from pilot studies of cystic fibrosis screening provides the strongest evidence for the feasibility of providing genetic services in primary care. CONCLUSIONS: Although genetic issues currently constitute a relatively small part of the overall workload in primary care, this will almost certainly change in the light of new genetic discoveries. Educational programmes and referral guidelines, computer decision support and genetic nurse specialist outreach clinics may provide useful methods of supporting GPs in the new field of primary care genetics.     

An audit of clinical nurse practitioner led thrombolysis to improve the treatment of acute myocardial infarction

BACKGROUND: The aim of the study was to audit the impact of cardiac nurse practitioner led thrombolysis as a method of reducing call to needle times for acute myocardial infarction (AMI) in a single district hospital. METHODS: This was a prospectively planned, observational study, comparing time delay between arrival at hospital and the administration of thrombolysis ('door to needle' time) in patients presenting with AMI in a district general hospital serving a population of 270000. The 6 months before and 6 months after initiation of the scheme were compared. RESULTS: There were 151 consecutive patients (undergoing 163 thrombolysis episodes). The median door to needle time fell from 60 min (range 42-110 min) to 30 min (range 20-61 min) (p<0.01). In those patients eligible for immediate thrombolysis the number of cases treated within 30 min of arrival rose from 10/58 (17 per cent) to 48/64 (75 per cent) (p<0.01). The proportion of cases where there was an initial delay as a result of non-diagnostic ECG or possible contra-indication to therapy remained constant, 20/78 (25 per cent) cases before and 21/85 (25 per cent) cases after initiation of the scheme. The number of cases of inappropriate thrombolysis fell from 73 per cent to 30 per cent. CONCLUSION: The provision of i.v. thrombolysis by cardiac nurse practitioners is safe and should be considered as a method for achieving acceptable door to needle times in the management of acute myocardial infarction.     

谈基层医院急性心肌梗死诊治

了解基层医院对于急性心肌梗死的诊治情况以及诊后治疗情况。方法：选取80例患有心肌梗死病症的患者,分析这80例患者的首次诊断以及溶栓治疗等情况。重点分析心肌梗死溶检再通患者和溶栓未通以及未溶栓患者在病死率和心源性休克的差异。结果：诊断率为95．47％,误诊率为4．53％,溶栓再通过率为67．39％。溶栓再通患者比溶栓未通及未溶栓患者的治疗效果明显要好。结论：通过研究发现,基层医院加强对心肌梗死患者的诊治和治疗手段,可以大幅提高心肌梗死患者的治好率以及生存率。     

Process for improving the integration of care across the primary and acute care settings in rural South Australia: asthma as a case study

OBJECTIVE: To develop a process for improving the integration of care across the rural acute and primary care settings using asthma as a case study. METHODS: Development of the process on the analysis of case note audit, survey, interviews and a workshop. SETTING: A rural region of South Australia. RESULTS: A work plan for improving general practitioner (GP)-hospital integration was developed that resulted from analysis of the defined problem, GPs and stakeholder involvement, communication between all stakeholders, provision of an incentive to bring all the stakeholders together, and identification of evidence-based solutions. CONCLUSIONS: Managing chronic disease in a community requires the integration of care across the primary and acute care setting. To be successful, GP-hospital integration initiatives require stakeholder involvement, locally developed solutions, engagement of GPs, communication and a well-developed plan. This project provides a process for achieving this.     

Diffusion of thrombolysis for acute myocardial infarction from 1981 to 2000 in England: trend analysis and comparison with need

OBJECTIVES: To describe the adoption and take up of thrombolytic agents for acute myocardial infarction since 1980 in England and compare use with the estimated ceiling of need. METHODS: Data on national sales and use of thrombolysis since 1980 (supplied by IMS Health) was used to draw an adoption and diffusion curve. The epidemiological ceiling of acute myocardial infarction, from hospital activity statistics, was modified to an estimated clinical need by accounting for diagnostic difficulty and contraindications using information from published surveys of thrombolysis use in the United Kingdom. RESULTS: There was a rapid uptake of thrombolytic agents in the first 2 years after availability in 1987, then a plateau, followed by a rise to a peak use in 1995. The shortfall in doses resulting from the difference between estimated ceiling of clinical need and doses purchased and provided in the 14 years since availability is estimated as 167,800 (95 percent confidence range 94,000 to 241,700). CONCLUSIONS: Although there was a rapid initial uptake of thrombolysis in England, usage took 8 years to reach the ceiling of clinical need of 65 percent of patients with acute myocardial infarction, with many patients missing the opportunity to benefit. Monitoring of uptake of innovations known to be cost-effective is required to identify those developments that need additional stimulus for change to ensure that patients do not miss out on the opportunity to benefit.     

院前急救护理干预对急性心肌梗死患者的应用效果

目的探讨院前急救护理干预对急性心肌梗死患者的临床应用效果。方法入选2009年3月至2013年3月我中心急救组分布据点的80例急性心肌梗死患者作为研究对象,根据送院方式分为院前急救护理干预组（观察组,我中心急救车送入医院）40例和对照组（家属直接送入医院）40例,通过对我中心院前急救组分布据点院前急救后预后情况跟踪随访对比两组患者的血管再通率、死亡率、抢救时间和住院时间、护理质量满意度。结果两组患者血管再通率组间差异有统计学意义,P〈0．05;观察组死亡率明显低于对照组。但差异无统计学意义,P〉0．05;对比两组溶栓时间和抢救时间,组间差异有统计学意义,P〈0．05：两组护理质量满意度差异有统计学意义,P〈0．05。结论院前急救护理干预可以明显提高患者的临床疗效及护理质量满意度．有效提高血管再通率,降低死亡率和减少抢救时间,值得临床推广应用。     

Audit of thrombolysis initiated in an accident and emergency department.

Early thrombolytic therapy after acute myocardial infarction is important in reducing mortality. To evaluate a system for reducing in-hospital delays to thrombolysis pain to needle and door to needle times to thrombolysis were audited in a major accident and emergency (A and E) department of a district general hospital and its coronary care unit (CCU), situated about 5 km away. Baseline performance over six months was assessed retrospectively from notes of 43 consecutive patients (group 1) transferred to the CCU before receiving thrombolysis. Subsequently, selected patients (23) were allowed to receive thrombolysis in the A and E department before transfer to the CCU. The agent was administered by medical staff in the department after receiving oral confirmation of myocardial infarction from the admitting medical officer in the CCU on receipt of fax transmission of the electrocardiogram. A second prospective audit during six months from the start of the new procedure established time intervals in 23 patients eligible to receive thrombolysis in the A and E department (group 2b) and 30 ineligible patients who received thrombolysis in the CCU (group 2a). The groups did not differ significantly in case mix, pre-hospital delay, or transfer time to the CCU. In group 2b door to needle time and pain to needle time were reduced significantly (geometric mean 38 min v 121 min (group 2a) and 128 min (group 1); 141 min v 237 min (group 2a) and 242 min (group 1) respectively, both p < 0.0001). The incidence of adverse effects was not significantly different. Nine deaths occurred (six in group 1, three in group 2b), an in-hospital mortality of 9.9%. Thrombolysis can be safely instituted in the A and E department in selected patients, significantly reducing delay to treatment.     

"Opening a can of worms": GP and practice nurse barriers to talking about sexual health in primary care

BACKGROUND: There is evidence that health professionals do not discuss sexually related issues in consultations as often as patients would like. Although primary care has been identified as the preferred place to seek treatment for sexual health concerns, little is known either of the factors that prevent GPs and practice nurses initiating such discussions or of how they feel communication in this area could be improved. OBJECTIVE: The purpose of the present study was to identify barriers perceived by GPs and practice nurses to inhibit discussion of sexual health issues in primary care and explore strategies to improve communication in this area. METHODS: Semi-structured interviews were conducted with 22 GPs and 35 practice nurses recruited from diverse practices throughout Sheffield. RESULTS: The term 'can of worms' summarized participants' beliefs that sexually related issues are highly problematic within primary care because of their sensitivity, complexity and constraints of time and expertise. Particular barriers were identified to discussing sexual health with patients of the opposite gender, patients from Black and ethnic minority groups, middle-aged and older patients, and non-heterosexual patients. Potential strategies to improve communication about sexual health within primary care included training, providing patient information and expanding the role of the practice nurse; however, several limitations to these approaches were identified. CONCLUSION: GPs and practice nurses do not address sexual health issues proactively with patients, and this area warrants further attention if policy recommendations to expand the role of primary care within sexual health management are to be met.     

Is the National Service Framework standard for thrombolytic therapy achievable in a rural area?

The National Service Framework (NSF) for coronary heart disease requires that patients with acute myocardial infarction should start thrombolytic therapy within 60 min of the patient making contact with the National Health Service. In an audit of 700 patients with suspected acute myocardial infarction, patients' first contact was most commonly with a general practitioner (GP) (505/700; 72 per cent), who attended on 88 per cent (446/505) of occasions when they were called. In 93 per cent (255/284) of cases where both GP and an ambulance attended, the GP arrived first, by 25 min (median). In the final audit period, median call-to-thrombolysis time was 90 min (26 per cent < or = 60). We conclude that with existing physical and personnel resources in this semi-rural area of Northern Ireland, the NSF standard for thrombolytic treatment is unlikely to be met in a majority of cases unless GPs adopt prehospital thrombolysis.     

A qualitative study of the assessment and treatment of incontinence in primary care

BACKGROUND: Although incontinence is a common condition, previous studies have suggested that access to appropriate treatment is variable. Recent guidelines recommend initial conservative treatment in primary care and this study explores GPs management practices and the feasibility of applying guidelines. OBJECTIVES: To describe the assessment and management practices of incontinence by GPs in primary care. METHODS: Semi-structured interviews were carried out with 32 GPs practicing in South East Wales. Sampling was purposive to include a range of characteristics such as gender, age and size and location of practice. Interviews were audio taped and transcribed and a thematic analysis carried out using a grounded theory approach. RESULTS: The extent to which GPs felt adequately informed to carry out assessment and treatment of incontinence was varied. While most were aware of appropriate assessment and investigation, none felt in a position to undertake conservative treatments such as bladder training or to monitor pelvic floor therapy either due to lack of knowledge or organizational constraints. Access to specialist continence services was also variable across different localities with many GPs being unaware of the remit of specialist nurses. However, there was a high rate of referral to secondary care which will result in high cost to the National Health Service. CONCLUSIONS: There are a number of barriers to provision of first-line treatments in primary care, including variability in training and knowledge of GPs, as well as practical barriers (such as time resource) to carrying out assessments and treatment in routine surgeries. This results in increased likelihood of referral to secondary care.     

院前急救护理路径在急性心肌梗死中的救治效果分析

目的探讨院前急救护理路径在急性心肌梗死救治中的应用效果。方法选取2018-06至2019-10在我院120站救治的136例急性心肌梗死患者资料进行回顾性分析,根据救治流程进行分组,实施常规急救流程的患者设置为对照组(n=61),院前急救护理路径指导下实施急救流程的患者设置为观察组(n=75),对比两组患者院前急救项目时间、救治效果及急救护理满意度。结果 (1)两组出诊反应时间及急救反应时间比较,差异无统计学意义(P>0.05),观察组现场救治时间、急诊室至首次球囊扩张时间及心肌总缺血时间均少于对照组,组间比较差异有统计学意义(P<0.05);(2)观察组院前急救人员到达时及治疗后症状缓解率、转运成功率以及急救成功率均高于对照组,各组间比较差异有统计学意义(P<0.05);(3)观察组心理护理、服务态度及总分高于对照组,各组间比较差异有统计学意义(P<0.05)。结论院前急诊救治急性心肌梗死时应用院前急救护理路径可缩短现场救治时间、急诊室至首次球囊扩张时间及心肌总缺血时间,提高救治效率及患者满意度,是提升院前急救水平的有效方法。通过培训、宣传等模式提高急性心肌梗死患者及家属自行救治水平,为患者心肌梗死争取宝贵的抢救时间十分重要。