Since you asked!
I have not sorted these, and it was a very quick search. I am pretty certain
that there is a paper from Hong Kong as well knocking about. Some
interesting observations though. The first one is interesting, concluding
that thrombolysis should be at point of entry. that makes sense. What never
makes sense to me is seeing a patient with an MI in one place and then
moving them to another (though having said that someone is going to bring up
prehospital thrombolysis (again) - I just know it :-) ).
Simon
Simon Carley
SpR in Emergency Medicine
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Evidence based emergency medicine
http://www.bestbets.org
Citation 1.
Unique Identifier
11357731
Medline Identifier
21257395
Authors
Bryant M. Kelly AM.
Institution
Western Hospital, Footscray, Victoria.
Title
"Point of entry" treatment gives best time to thrombolysis for acute
myocardial infarction.
Source
Australian Health Review. 24(1):157-60, 2001.
Abstract
The aim was to compare time to thrombolysis for patients treated via three
treatment pathways: thrombolysis in the emergency department (ED),
thrombolysis following direct admission by ambulance officers to coronary
care (CCU) and thrombolysis after transfer from ED to CCU. We used a
retrospective study of time to thrombolysis for all patients receiving
thrombolysis for acute myocardial infarction (AMI) at Western Hospital
during 1999. The median time to thrombolysis in the ED group was 30 minutes
(mean 40 minutes), compared with 60 minutes for the CCU group (mean 63
minutes) and 40 minutes (mean 43 minutes) for the direct CCU admission
group. Eighty-five percent of patients treated in ED received thrombolysis
in less than 60 minutes compared with 21% of those transferred from the ED
for treatment in CCU and 52% of those directly admitted to CCU. We conclude
that point of entry thrombolysis, be it in ED or in CCU after direct
admission, gives shorter times to thrombolysis than processes that require
transfer of patients between departments.
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Citation 2.
Unique Identifier
10505910
Medline Identifier
99433729
Authors
Edhouse JA. Sakr M. Wardrope J. Morris FP.
Institution
Accident and Emergency Department, Northern General Hospital, Sheffield.
[log in to unmask]
Title
Thrombolysis in acute myocardial infarction: the safety and efficiency of
treatment in the accident and emergency department.
Source
Journal of Accident & Emergency Medicine. 16(5):325-30, 1999 Sep.
Abstract
OBJECTIVES: To assess the safety and efficiency with which the accident
and emergency (A&E) department provides thrombolytic treatment for patients
with acute myocardial infarction (AMI). METHODS: A prospective observational
study based in a teaching hospital for one year. All patients who presented
with the clinical and electrocardiographic indications for thrombolytic
treatment were studied. Patients were grouped according to route of
admission. After logarithmic transformation, the "door to needle times" of
the groups were compared using a two tailed Student's t test. Arrhythmias
and complications after thrombolytic treatment were noted. The
appropriateness of the treatment was assessed retrospectively by review of
the clinical records and electrocardiograms, judged against locally agreed
eligibility criteria. RESULTS: Data from 153 patients were analysed; 138/153
(90%) patients were admitted via the A&E department. The shortest door to
needle times were seen in those patients thrombolysed by A&E staff within
the A&E department (mean 43.8 minutes). The transfer of A&E patients to the
coronary care unit (CCU) was associated with a significant increase in the
door to needle time (mean 58.8 minutes, p = 0.004). Only one malignant
arrhythmia occurred during the administration of thrombolysis in the A&E
department, and this was managed effectively. No arrhythmias occurred during
transfer of thrombolysed patients to the CCU. In every case, the decision to
administer thrombolysis was retrospectively judged to have been appropriate.
CONCLUSIONS: The A&E department provides appropriate, safe, and timely
thrombolytic treatment for patients with AMI. Transferring A&E patients to
the CCU before thrombolysis is associated with an unnecessary treatment
delay.
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Citation 3.
Unique Identifier
9827830
Medline Identifier
99043532
Authors
Berglin Blohm M. Nilsson G. Karlsson T. Herlitz J.
Institution
Division of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden.
Title
The possibility of influencing components of hospital delay time within
emergency departments among patients with ST-elevation in the initial
electrocardiogram.
Source
European Journal of Emergency Medicine. 5(3):289-96, 1998 Sep.
Abstract
The aim of this study was to describe the possibility of influencing
components of hospital delay time within the emergency department (ED) among
patients with ST-elevation on the initial electrocardiogram (ECG). Nurses
recorded seven patient time points: (1) ED admission; (2) ECG recording; (3)
decision by nurse/ED physician; (4) cardiologist ED arrival; (5) decision of
coronary care unit (CCU) admission; (6) ED departure; (7) CCU arrival. After
special training in ECG, nurses in the ED were subsequently delegated to
send patients directly to the CCU if showing ST-elevation on the admission
ECG without contacting either the physician in ED or the cardiologist on
call (intervention). Delay times between hospital admission and admission to
the CCU were evaluated during the 9 months prior to and during the 6 months
after the start of this intervention. Fifty patients (66% men) participated
in the first study during 3 months (prior to intervention). Patients with
suspected or confirmed acute myocardial infarction (AMI) in the ED had a
median delay time from ED arrival to CCU arrival of 55.5 minutes (34.5
minutes for patients with confirmed AMI; ST elevation on admission). Time
interval from decision to admit to CCU and ED departure was an average of
31% of the total delay. A mean of 21% of total delay occurred between ED
decision to cardiologist arrival, and 19% during the time interval from
cardiologist ED arrival until decision to CCU admission. Among patients
receiving thrombolysis, the median delay time from hospital admission to CCU
admission was reduced from 40 minutes during the 9 months prior to start of
the intervention (nurses sending patients directly to the CCU) to 22 minutes
during the 6 months thereafter (p = 0.02). The largest proportion of
hospital delay components for acute coronary syndrome patients occurred
between the cardiologist's decision to admit to the CCU and departure from
the ED, and the interval following the decision by the nurse or physician to
the cardiologist ED arrival. When nurses were delegated to transfer patients
with ST-elevation on admission directly to the CCU without contacting a
physician, the delay time from ED admission to CCU admission was reduced by
nearly 50%.
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Citation 4.
Unique Identifier
9627162
Medline Identifier
98288851
Authors
Berglin Blohm M. Hartford M. Karlsson T. Herlitz J.
Institution
Division of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden.
Title
Factors associated with pre-hospital and in-hospital delay time in acute
myocardial infarction: a 6-year experience.
Source
Journal of Internal Medicine. 243(3):243-50, 1998 Mar.
Abstract
OBJECTIVES: To explore factors associated with delay time prior to
hospital admission and in hospital amongst acute myocardial infarction (AMI)
patients with particular emphasis on the delay time to the administration of
thrombolytic therapy. METHODS: During a 6-year period we prospectively
computerized pre-hospital and in-hospital time intervals for AMI patients
admitted to the coronary care unit (CCU) direct from the emergency
department (ED) or via paramedics, at Sahlgrenska Hospital, Goteborg,
Sweden. RESULTS: Pre-hospital delay: independent predictors of a prolonged
delay were increased age (P = 0.0007), female sex (P = 0.02) and a history
of hypertension (P = 0.03). For AMI patients who received thrombolytic
treatment and the only independent predictor of a prolonged delay was
increased age (P = 0.005). In-hospital delay: for all AMI patients
independent predictors of a prolonged delay were prolonged pre-hospital
delay (P < 0.0001), increased age (P = 0.03) and a history of angina (P =
0.002), hypertension (P = 0.01) and diabetes (P = 0.01). For thrombolytic
treated AMI patients independent predictors of a prolonged delay were
prolonged pre-hospital delay (P < 0.0001), female sex (P = 0.02) and a
history of diabetes (P = 0.02). CONCLUSION: Risk factors for both
pre-hospital and hospital delay time could in AMI be defined although
slightly different. Two factors appeared for both, i.e. increasing age and a
history of hypertension.
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Citation 5.
Unique Identifier
9507439
Medline Identifier
98168282
Authors
Banerjee S. Rhoden WE.
Institution
Department of Cardiology, Barnsley District General Hospital.
Title
Fast-tracking of myocardial infarction by paramedics. [see comments.].
Comments
Comment in: J R Coll Physicians Lond. 1998 Mar-Apr;32(2):176 ; 9597638
Source
Journal of the Royal College of Physicians of London. 32(1):36-8, 1998
Jan-Feb.
Abstract
OBJECTIVE: To study the effectiveness of a fast-track method of admitting
patients with myocardial infarction directly to the coronary care unit
(CCU). STUDY DESIGN: Ambulance paramedic staff were trained and provided
with a Life Pak XI Monitor/Defibrillator which can obtain a 12-lead
electrocardiogram. When a diagnosis of acute myocardial infarction was made
by the paramedics, the CCU was informed and the patient was directly
transferred to the CCU, bypassing the accident and emergency (A&E)
department. The appropriateness of admission to the CCU was assessed against
set criteria. The time from call for help to the administration of
thrombolytic therapy (thrombolysis time) in patients directly admitted to
the CCU was compared with that in another group of patients with definite
myocardial infarction who were admitted through the A&E department over the
same period of time. RESULTS: Twenty-five patients were fast-tracked to the
CCU. Diagnosis of myocardial infarction was confirmed on admission in 14.
Thirteen were treated with thrombolysis as there were no contra-indications;
of the other 11 patients, seven were diagnosed as angina, one had complete
heart block, one had haemodynamically significant atrial fibrillation and
two had non-cardiac chest pain. The average time from call for help to
thrombolysis in this group was 82 +/- 32 minutes. This was significantly
shorter (p < 0.02) than in the patients who were admitted through A&E, in
whom the average time from call for help to thrombolysis was 112 +/- 35
minutes. Twenty-one of 25 fast-tracked patients fulfilled the criteria for
CCU admission. CONCLUSION: The majority of fast-trackings are appropriate
and will result in quicker administration of thrombolysis in hospitals where
the facility for thrombolysis does not exist in the A&E department.
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Citation 6.
Unique Identifier
9484327
Medline Identifier
98145321
Authors
Palmer DJ. Cox KL. Dear K. Leitch JW.
Institution
Department of Cardiology and Emergency Medicine, John Hunter Hospital,
Newcastle, NSW.
Title
Factors associated with delay in giving thrombolytic therapy after arrival
at hospital. [see comments.].
Comments
Comment in: Med J Aust. 1998 Feb 2;168(3):101-2 ; 9484323, Comment in: Med
J Aust. 1998 Jul 6;169(1):57-8; discussion 58-9 ; 9695704, Comment in: Med J
Aust. 1998 Jul 6;169(1):58; discussion 58-9 ; 9695705
Source
Medical Journal of Australia. 168(3):111-4, 1998 Feb 2.
Abstract
OBJECTIVE: To identify factors associated with delay in administration of
thrombolytic therapy for acute myocardial infarction. DESIGN: Retrospective
case note review of a six-month period in 1995. Data were obtained on age,
sex, hospital arrival time, triage priority, assessment process in the
emergency department, grade of emergency doctor, patient history, timing of
and findings on electrocardiogram (ECG), type of infarct, timing and site of
administration of thrombolytic therapy, and type of thrombolysis given.
SETTING: Tertiary referral hospital in Newcastle, New South Wales.
PARTICIPANTS: Eighty-five patients given thrombolytic therapy for acute
myocardial infarction. OUTCOME MEASURE: Time between hospital arrival and
initiation of thrombolytic therapy. RESULTS: The median time from hospital
arrival to administration of thrombolytic therapy was 80 minutes
(interquartile range [IR], 50-133). Only 26% of patients were triaged to
Priority 1 or 2 (to be seen by a doctor within 10 minutes). Patients
initially assessed by a specialist emergency physician received thrombolytic
therapy a median of 38 (IR, 33-50) minutes after hospital arrival, compared
with 65 (IR, 50-107) minutes if initially assessed by a medical registrar,
and 148 (IR, 89-185) and 160 (IR, 95-163) minutes, respectively, if
initially assessed by an intern or a resident medical officer (P < 0.001).
Factors associated with increased delay in receiving thrombolytic therapy
(after adjustment for possible confounders) were low triage priority,
initial assessment by a junior doctor, atypical presenting history of
myocardial infarction, and lesser degrees of ST-segment elevation on the
presenting ECG (all P < or = 0.01). CONCLUSIONS: Delay in administration of
thrombolytic therapy in hospital results from a combination of hospital and
patient factors. Changes in emergency department protocol may reduce these
delays in some patients.
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Citation 7.
Unique Identifier
8821229
Medline Identifier
96418444
Authors
Kendall JM. McCabe SE.
Institution
Accident and Emergency Department, Gloucester Royal Hospital.
Title
The use of audit to set up a thrombolysis programme in the accident and
emergency department.
Source
Journal of Accident & Emergency Medicine. 13(1):49-53, 1996 Jan.
Abstract
OBJECTIVE: To improve the thrombolysis service offered by Gloucester Royal
Hospital, by reducing the "door to needle time" (DTN) to 30 min (from a
median of 110 min), and increasing the proportion of patients with acute
myocardial infarctions receiving thrombolysis to 70% (from 58%). This would
be achieved by moving the thrombolysis programme from the coronary care unit
(CCU) to the accident and emergency (A&E) department. DESIGN: The process of
audit was used to identify an area of poor performance, set standards,
acquire funding, demonstrate achievement, and subsequently secure recurrent
funding. SETTING: Gloucester Royal Hospital. SUBJECTS: 946 patients
presenting consecutively to the A&E department with non-traumatic chest pain
between August 1993 and March 1994. MAIN OUTCOME MEASURES: DTN, overall
delay time, and acute myocardial infarction thrombolysis rate. RESULTS: 946
patients were assessed over the eight month period, of whom 266 (28%) had
suffered an acute myocardial infarction; 182 (68%) received thrombolysis
(compared to 58% previously P < 0.05). Median DTN was reduced to 38 min (v
110 min previously, P < 0.0006). 127 (70%) patients received thrombolysis in
the A&E department, and 55 (30%) in the CCU. Median overall delay time
between onset of pain and thrombolysis was 3 h 35 min; 70% of patients
received thrombolysis within 6 h of onset of symptoms and 90% within 12 h.
Re-audit has subsequently shown maintenance of improvement. CONCLUSIONS: An
in-house A&E based thrombolysis programme works in the District General
Hospital setting; the process of audit can be used to acquire, and
subsequently secure, funding for the project. The key to successful
implementation of change is sensible resource allocation into adequate
staffing and appropriate education.
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Citation 8.
Unique Identifier
10136256
Medline Identifier
94373065
Authors
Nee PA. Gray AJ. Martin MA.
Institution
Stockport Infirmary, UK.
Title
Audit of thrombolysis initiated in an accident and emergency department.
Source
Quality in Health Care. 3(1):29-33, 1994 Mar.
Abstract
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.
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Citation 9.
Unique Identifier
2152463
Medline Identifier
93191810
Authors
Saetta JP. Quinton D. Dacruz D. Barnes M.
Institution
Accident and Emergency Department, Leicester Royal Infirmary, U.K.
Title
Delay in thrombolytic treatment in acute myocardial infarction: the role
of the accident and emergency department. [see comments.].
Comments
Comment in: Arch Emerg Med. 1992 Mar;9(1):70 ; 1567535
Source
Archives of Emergency Medicine. 7(3):206-11, 1990 Sep.
Abstract
During a 6-week period, 248 patients presenting with chest pain presumed
to be cardiac in origin, were recruited in a time and motion study in the
Accident and Emergency Department of the Leicester Royal Infirmary. The
study considered the ambulance-response and transfer times from the scene to
the hospital, as well as the duration of the patients stay in the
Department. While Ambulance Time from the scene of the incident to the
hospital averaged 28 min, the time spent in the Accident and Emergency
Department prior to admission averaged 76.5 min. This study was conducted in
the light of growing concern expressed at the delay in administering
thrombolytic agents to those patients with acute myocardial infarction
(AMI). The authors propose possible ways of reducing such delays.
----- Original Message -----
From: "Dunn Matthew Dr. (RJC) ACCIDENT & EMERGENCY - SwarkHosp-TR"
<[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, June 06, 2002 9:24 AM
Subject: Re: Chest Pain Units
> > The evidence in the BMJ showed that if you have a rubbish
> > system before (stop off in ED, do nothing, then transfer) it
> > does not take much to improve things. I thought their
> > original system went out with the ark, but apparently not.
> > there was no mention of the expansive literature that shows
> > that ED thrombolysis is quicker than CCU thrombolysis.
>
> I haven't actually seen much saying that ED thrombolysis was quicker than
> CCU thrombolysis with direct admission. DO you have the references to
hand?
> (I'm not disagreeing with you here- I hope and believe you are right; just
I
> haven't seen the papers).
>
> >
> > There is a proposal in our hospital to have patients
> > presenting acutely with chest pain directed to a chest pain
> > unit. This will be geographically separated from the Accident
> > and Emergency Department and run by Cardiologists who would
> > supervise Chest Pain Nurse Practitioners. It will essentially
> > take all cardiological cases not requiring resuscitation.
> > Does anyone have any experience with such a unit, not just in
> > the context of thrombolysis for AMI but also with regard to
> > the impact on the provision of the wider emergency service? I
> > would be very grateful for any experienced insight.
>
> When I started here, not only were chest pains admitted direct to CCU but
> asthmatics went straight to the chest ward and haematemesis went straight
to
> the GI ward. For chest pain, the figures look pretty good if you just look
> at door to needle time, but thrombolysis was effectively nurse initiated
in
> CCU (and of course, CCU has more nurses than A and E). The problems arose
> with physiologically unstable patients (rather than just simple
arrythmias)-
> out of hours it took a long time for the medical SHO to see the patient
and
> out of hours treatment was very much SHO based. The other problem specific
> to thromobolysis was that CCU could not take all chest pains (sometimes
> full)- they tended to cherry pick a bit, so A and E got the less obvious
> ones and the overspill when CCU was full. Result was your dodgier cases
> being seen by A and E staff who didn't see enough MIs to be thinking along
> the lines of an MI (we have fewer MIs here than anywhere else I've worked
in
> any case) so A and E thrombolysis times were long (indeed when I started
> thrombolysis was always initiated in CCU). Since we moved to A and E
> thrombolysis, overall door to needle times have dropped. There might be
> another change with ambulance ECGs (?/ thrombolysis)- CCU is wanting to be
> faxed the ECGs so they can take the patients with ECG changes. My biggest
> worry about this is the effect on A and E staff experience of patients
with
> MI.
> Personal feeling is all sick patients should come through A and E. There
is
> a good case to be made for having a small coronary care unit within and
> under the care of A and E. I understand (quite possibly erroneously) this
to
> be part of the plan for Walsgrave hospital.
>
> There's a reasonable amount of literature on chest pain units in the last
> couple of years (we're considering one ourselves- possibly as part of a
> general 'clinical decisions unit'). General gist seems to be that they are
> sometimes cost effective and sometimes not.
> It might be worth looking at expanding to a general clinical decisions
unit-
> elderly collapsed patients could get their Holter monitor and echo there;
> patients with headache get their LP or CT etc. This sort of thing has been
> discussed on the list before.
>
> Matt Dunn
> Warwick
>
>
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