Nurse initiated thrombolysis in the accident and emergency department: Safe, accurate, and faster than fast track

Abstract

Objective: To reduce the time between arrival at hospital of a patient with acute myocardial infarction and administration of thrombolytic therapy (door to needle time) by the introduction of nurse initiated thrombolysis in the accident and emergency department. Methods: Two acute chest pain nurse specialists (ACPNS) based in A & E for 62.5 hours of the week were responsible for initiating thrombolysis in the A & E department. The service reverts to a "fast track" system outside of these hours, with the on call medical team prescribing thrombolysis on the coronary care unit. Prospectively gathered data were analysed for a nine month period and a head to head comparison made between the mean and median door to needle times for both systems of thrombolysis delivery. Results: Data from 91 patients were analysed; 43 (47%) were thrombolysed in A & E by the ACPNS and 48 (53%) were thrombolysed in the coronary care unit by the on call medical team. The ACPNS achieved a median door to needle time of 23 minutes (IQR=17 to 32) compared with 56 minutes (IQR=34 to 79.5) for the fast track. The proportion of patients thrombolysed in 30 minutes by the ACPNS and fast track system was 72% (31 of 43) and 21% (10 of 48) respectively (difference=51%, 95% confidence intervals 34% to 69%, p<0.05). Conclusion: Diagnosis of acute myocardial infarction and administration of thrombolysis by experienced cardiology nurses in A & E is a safe and effective strategy for reducing door to needle times, even when compared with a conventional fast track system.