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Hospital delays and problems with thrombolytic administration in patients receiving thrombolytic therapy: a
E R Gonzalez1, L A Jones, J P Ornato
1Department of Pharmacy and Pharmaceutics, School of Pharmacy, Virginia Commonwealth University, Richmond.
Insights
Delays in acute myocardial infarction treatment are primarily pre-hospital. Stocking and initiating thrombolytics in the emergency department (ED) by emergency physicians can significantly reduce door-to-needle times.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Services Research
Background:
- Acute myocardial infarction (AMI) treatment requires timely intervention.
- Thrombolytic therapy is a critical treatment for AMI.
- Optimizing the timing of treatment decisions and clinical events is essential for improving patient outcomes.
Purpose of the Study:
- To assess the timing of key decisions and clinical events in the treatment of AMI with thrombolytic therapy.
- To identify factors influencing treatment delays.
Main Methods:
- Prospective study involving patients with presumed AMI receiving thrombolytic therapy in emergency departments (EDs) across 11 urban and two rural hospitals.
- Analysis of time intervals from pain onset to therapy, ED arrival to ECG, decision-making, and drug infusion.
- Statistical analyses included frequency determination, cross-tabulation, and Wilcoxon rank sum tests.
Main Results:
- Median time from pain onset to therapy was 155 minutes, with 67% of delay occurring pre-ED arrival.
- Median door-to-needle time was 50 minutes.
- Shorter delays were observed in urban, teaching, high-volume hospitals, and when thrombolytics were initiated in the ED by emergency physicians.
Conclusions:
- Thrombolytic therapy for AMI should be stocked and initiated within the ED.
- Emergency physicians should lead treatment decisions, adhering to protocols, to minimize delays.
- Streamlining ED processes can improve the timeliness of thrombolytic administration.
Study Objectives:
To assess the timing of key decisions and clinical events in the treatment of acute myocardial infarction with thrombolytic therapy.
Design:
Prospective study of emergency department patients.
Setting:
EDs in 11 urban and two rural hospitals.
Types Of Participants:
Patients with presumed acute myocardial infarction for whom a decision was made in the ED to administer thrombolytic therapy.
Measurements And Main Results:
Statistical analyses included determination of frequency of response, cross tabulation analysis, and Wilcoxon rank sum tests. In 210 thrombolytic-treated patients (mean age, 57 +/- 14.1 years), a median time of 155 minutes elapsed between pain onset and therapy; 67% of the delay was pre-ED arrival. The median time between ED arrival and the initial ECG was six minutes. The median time required for physicians to make a treatment decision was 20 minutes, followed by another median time of 20 minutes for staff to begin drug infusion. The median total hospital (door-to-needle) time was 50 minutes. Significantly shorter delays occurred in urban, teaching, and high-volume hospitals; when thrombolytics were stocked and/or started in the ED; and when emergency physicians treated without involving private attending physicians. Although 95% of patients received tissue plasminogen activator, six patients treated with anisoylated plasminogen-streptokinase activator complex experienced a significantly faster door-to-needle time (P less than .05).
Conclusion:
Thrombolytics should be stocked and started in the ED. Emergency physicians should generally make the decision to administer thrombolytic therapy with reference to accepted protocols without awaiting an ED consultation from either private attendings or cardiologists.