reflection paper
‘1.   What were your primary concerns related to patient care? What were you primary concerns as a senior nursing student preparing for your final simulation?
–   My primary concern about this patient is that he has chest pain related to acute coronary syndrome, and the pain is unstable. If we don’t intervene, he might go into cardiac arrest.
–   As a senior nursing student, I’m anticipated what could be the worse situation that can happen to my patient in simulation. I try to gather more information as I could to figure out what was the caused that brought the patient to the hospital, and how can I alleviate his symptoms so that he can get better and not worse.
2.   Did you miss anything in getting report on these patients? If so why? Were you distracted? Did you receive too little information? Did you receive not enough or incomplete information? Were there environmental distractors?? What actions could you have taken to improve your patient report? What systems are in place that would assist you? (SBAR, etc.) Describe them.
– During report with the last shift’s nurse, I was pretty thorough and asked what I need to know about my patient. I was focus and listen to what the two nurses have to say. The information I receive was good but it wasn’t enough tell me much about the patient and especially his current condition. We were inside the patient’s room while doing our turn over report. If I was to utilize the PASSMESAFELY report, it could have been better.
3.   Did you have the required clinical knowledge and skills to manage the patient illness? If not, what concepts were you missing? Support your reflection with an evidence based reference from a peer reviewed journal (not greater than 5 years old). This information needs to be relevant to your patient, the clinical scenario and your knowledge deficit.
–   I have the skills and clinical knowledge to manage this patient and prevent him from dropping blood pressure and going into heart attack. Treatment such as: …………(article) and I can based of hospital protocol and call ask the doctor.
4.   How did you prioritize the patient information/data? On what did you base choice of intervention?
– I prioritize the information/data based on the severity of his illness and the present symptoms. The patient has chest pain, but no shortness of breath, crackles on the bilateral lungs, hypotensive, tachycardia, unstable O2 saturation. Airway, breathing, circulation are my top priorities. The patient airway wasn’t compromised, his breathing is normal (24 breath per minute). His circulation is diminished due to low blood pressure.
– So I called the doctor to report about my patient dropping blood pressure and ask him for some treatment orders. The doctor ordered bolus normal saline (NS), and dopamine running at 5mcg/kg/min, maximum 20mcg/kg/min. Titrate it to keep the systolic blood pressure above 90.
5.   What were your strengths during the clinical scenario? What areas do you think you could improve upon? How did you utilize the nursing process to enhance your clinical reasoning?
–   My strength during simulation was teamwork, assessment skill, recognize the severity of symptoms/condition, pick up on the necessary information from the patient and follow orders from the doctor’s chart.
–   I still need to work on my communication skills including verifying the doctor order by repeat or verbalize what the doctor just order to make sure I got the verbal orders correctly. My medication calculation was taken a long time before I decided to ask for help. I took a long time on setting up the pump to run the dopamine after I got the calculation. I didn’t check the monitor and set the 15 minutes cycle for vital signs to be taken. I was solely depend on what the monitor to tell me what happen to my patient. No wonder his condition didn’t get better. I assess my patient before I administered the dopamine drip but I didn’t reassess him 15 minutes after to see if his condition improve.
6.   How would you approach this clinical scenario if you had to do it over again? Which objectives were you unable to achieve?
–   I will have to practice on my pump setting skill, drug calculation for drip, and re-verbalize the doctor order when I communicate so that if I have to do it again, I won’t make the same mistake like I did in simulation.
–   I didn’t:
o   Incorporate assessment and critical/clinical reasoning skills, to create priority interventions for patients who have complex multi-system health care needs
o   Utilize effective communication skills in providing care to diverse patient populations and in collaborating with the interprofessional team.
o   Integrate patient care technologies, information systems, and communication devices that support nursing practice.
7.   How would you summarize this experience?
– My experience in simulation allow me to begin to think critically overall the big picture about my patient.
Australian Critical Care 27 (2014) 111–118
Contents lists available at
ScienceDirect
Australian Critical Care
journal homepage:
www.elsevier.com/locate/aucc
Timely treatment for acute myocardial infarction and health
outcomes: An integrative review of the literature
Lorelle Martin RN, MNSc
a
,
b
,
*
,
Maria Murphy PhD
b
,
a
,
Andrew Scanlon DNP
b
,
c
,
Carolyn Naismith MN
a
,
David Clark MBBS (Hons), FRACP
a
,
Omar Farouque MBBS (Hons), PhD, FRACP
a
a
Department of Cardiology, Austin Health, Australia
b
LaTrobe University School of Nursing, Australia
c
Department of Neurosurgery, Austin Health, Australia
article information
Article history:
Received 28 August 2012
Received in revised form
24 November 2013
Accepted 26 November 2013
Keywords:
Myocardial infarction
Time factors
Percutaneous coronary intervention
Door to balloon time
abstract
Background:
Coronary heart disease is the most common condition affecting Australians. The time sen-
sitive nature of treating ST-segment elevation myocardial infarction (STEMI) has been the subject of
extensive research for several years. Despite important advances in strategies to reduce time to treat-
ment, time continues to represent a major determinant of mortality and morbidity. Door to balloon time
(DTBT) is a key indicator of quality of care for STEMI. Nurses play a pivotal role in streamlining the care
processes to influence timely management of STEMI.
Purpose:
The aim of this paper is to review the evidence on the time to treat STEMI, the associated factors
impacting upon health outcomes and explore systems of care that reduce time to treatment, using an
integrative review approach.
Method:
Established databases were searched from 2000 to 2012. The search terms ‘myocardial
infarction’, ‘emergency medicine’, ‘angioplasty balloon’, ‘time factors’, ‘treatment outcome’, ‘mortality’,
‘prognosis’, ‘female’, ‘age factors’, and ‘readmission’, were used in various combinations. Research studies
that addressed the aims of this paper were examined.
Findings:
Twenty-nine papers were included in this integrative review. The literature demonstrates a
strong relationship between shorter DTBT and reduced in-hospital mortality. Factors such as age, gen-
der, time of presentation and co-morbid condition were associated with increased in-hospital mortality.
There is sparse literature examining the effect timely reperfusion has on longer-term mortality and other
longer-term outcomes such as readmission rates and occurrence of heart failure. Additionally, strategies
that effectively reduced DTBT were identified, yet little has been reported on the impact reduced DTBT
has had upon health outcomes and whether these improvements were sustained.
Conclusion:
Whilst the importance of timely reperfusion is now well recognised, additional efforts to
streamline the process of care and demonstrate sustained improvement for STEMI patients is required.
Nurses in the areas of emergency medicine and cardiac care, play an essential role in facilitating this.
Crown Copyright © 2013 Published by Elsevier Australia (a division of Reed International Books
Australia Pty Ltd) on behalf of Australian College of Critical Care Nurses Ltd. All rights reserved.
*
Corresponding author at: Department of Cardiology, Austin Health, Australia.
Tel.: +61 0421106296.
E-mail addresses:
lorellemartin@yahoo.com.au
,
lorelle.martin@austin.org.au
(L. Martin),
Maria.Murphy@latrobe.edu.au
(M. Murphy),
A.Scanlon@latrobe.edu.au
(A. Scanlon),
carolyn.naismith@austin.org.au
(C. Naismith),
clarkdavidj@hotmail.com
(D. Clark),
omar.farouque@austin.org.au
(O. Farouque).
Introduction
Cardiovascular disease (CVD) refers to all diseases of the heart
and blood vessels.
1
Coronary heart disease (CHD) is the largest
subset of CVD accounting for 14.6% of all deaths in Australia in
2011.
2
In terms of burden of disease, CVD was responsible for
18% of the total burden of disease and injury in Australia in 2003,
second only to cancer.
1,3
The Australian expenditure on CVD for
2004–2005 was recorded as $5.94 billion, more than any other
1036-7314/$ – see front matter. Crown Copyright © 2013 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on b
ehalf of Australian College of Critical Care Nurses Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.aucc.2013.11.005
112
L. Martin et al. / Australian Critical Care 27 (2014) 111–118
disease group, and accounted for 11% of the total health care
expenditure.
4,5
Whilst mortality from CHD is decreasing, it remains the single
largest cause of mortality in Australia for both men and women.
Further, almost half of these deaths were attributed to acute
myocardialinfarction(AMI).
2
CHDspansthespectrumfromclinical
presentations with stable coronary disease to acute coronary syn-
dromes (ACS). The focus of this paper will have particular emphasis
on the subset of ACS known as ST-segment elevation myocardial
infarction (STEMI).
It is recognised that gender and age are contributing factors to a
presentation to hospital with STEMI. In Australia during 2007 there
were 55,997 hospitalisations for STEMI; two thirds were male, with
40% aged 55–74 years and an additional 40% aged 75 and over.
5
The
prevalence of STEMI and costs attributed are likely to increase due
to the ageing demographic of Australia.
It is clear that advancing treatments for CHD are having a direct
impactonmortalityrates;inparticularforpatientspresentingwith
STEMI. In 2009 63% of people who suffered a STEMI survived, com-
paredwith47%in1997.
3
Promptreperfusionoftheculpritcoronary
lesion using primary percutaneous coronary intervention (PPCI) is
the preferred treatment, with national and international guide-
lines for STEMI management suggesting a timeframe of
=
90min
from presentation to first balloon inflation or door to balloon time
(DTBT).
6–8
The importance of time has become a key measure of
quality of care. The past decade has seen an intense focus on sys-
tems of care that best deliver these treatments in a timely manner.
However systems of care that reduce DTBT require first and fore-
most, institutional drive with active participation and leadership
across multiple disciplines. Given the delicate balance of providing
thistimelymanagement,adeeperunderstandingofthefactorsthat
influencetimetotreatmentandtheirassociatedclinicalhealthout-
comes,alongwithstrategiesthatreduceDTBTareworthyoffurther
examination.
Aim
The aim of this paper is to review the literature that demon-
strates the impact time to treatment has on determining health
outcomes for STEMI patients, examine the associated factors that
influence these clinical health outcomes and delivery of timely
treatment, and outline the systems of care that can be applied in
the clinical setting to reduce DTBT.
Methods
An integrative review was used to synthesise the literature
identified. An integrative review uses a broad review method
that incorporates simultaneous inclusion of experimental and
non-experimental research in order to understand the area of
concern.
9
A multi-database search was carried out using Ovid Med-
line, CINAHL and Cochrane databases using the terms ‘myocardial
infarction’, ‘emergency medicine’, ‘angioplasty balloon’, ‘time fac-
tors’, ‘treatment outcome’, ‘mortality’, ‘prognosis’, ‘female’, ‘age
factors’ and ‘patient readmission’. The inclusion criteria for this
review were (1) articles published in English between 2000 and
2012, (2) studies that examined the impact time to treatment in
STEMI had on mortality and other health outcomes, (3) studies
that explored the associated factors that influenced health out-
comes and delivery of timely management of STEMI, (4) studies
that explored system based strategies that reduced time to treat-
ment in STEMI. Exclusion criteria included (1) discussion papers
and book chapters, and (2) small studies with fewer than 450 par-
ticipants. These aforementioned search terms were used in various
combinations using AND.
The electronic search strategy produced 624 potential studies.
This list was read by title and abstract to confirm alignment of con-
tenttothepurposeofthismanuscriptusingtheinclusion/exclusion
criteria.Amanualsearchofreferencetextsandotherresourcesheld
in the university library was also undertaken, some of which fell
outside the restriction of 2000–2012. The final number of relevant
publications included in this review was 29 articles (refer to
Fig. 1
for the study selection process).
Results
The synthesised literature was grouped into three themes: the
impact time to treatment has on mortality and morbidity in STEMI,
associated factors that influence mortality and timely treatment,
and strategies to reduce DTBT. The primary research included in
this review comprised both experimental and non-experimental
studies (see
Table 1
).
The impact time to treatment has on mortality and morbidity
The time sensitive nature of achieving reperfusion of coronary
vessels is well recognised and precedes the introduction of PPCI
as front line treatment. A PPCI involves the urgent opening of the
infarct related epicardial coronary artery with balloon angioplasty
and/or insertion of a metal stent to maintain patency, restore blood
flow and reduce the size of the infarct.
10
A great deal of the initial evidence linking delay to treatment
to higher mortality was generated prior to the wide spread accep-
tance of PPCI when thrombolytic therapy was considered the ‘gold
standard’ in treatment.
11
This research gave credence to the con-
cept of the ‘golden hour’ in offsetting damage from an acute
myocardial infarction. The adage ‘time is muscle’ became a famil-
iar axiom, drawing attention to the importance of expedited care,
along with routine measurement of the time from Emergency
Department presentation to the commencement of thrombolytic
therapy referred to as the door-to-needle time.
Two landmark quantitative reviews contributed to a major shift
in thinking on the best reperfusion strategy for STEMI patients.
12,13
These reviews compared thrombolysis to PPCI and concluded that
PPCI was better than thrombolytic therapy at reducing short-term
major adverse cardiac events, resulting in an absolute decrease of
approximately 2% risk of in-hospital and 30 day death with PPCI
12
and PPCI being associated with a 37% relative risk reduction in 30-
day mortality.
13
A plethora of literature followed the shift in reperfusion therapy
strategy to PPCI, along with extensive examination of the rela-
tionship between time to reperfusion and patient mortality. De
Luca and colleagues were able to show the risk of one-year mor-
tality increased by 7.5% for every 30min of delay to treatment.
14
McNamara and colleagues also concluded that in-hospital mortal-
ity increased significantly with a longer DTBT, but went further
breaking it down into timeframe categories. The in-hospital mor-
tality was 3.0% for DTBT
=
90min as compared to 7.4% for a
DTBT
=
150min.
15
McNamara et al., also found each 15-min reduc-
tion in DTBT from 150min to less than 90min was associated
with 6.3 fewer deaths per 1000 patients; this was seen regard-
less of the length of time from onset of symptoms. More recently
a study by Rathore and colleagues concurred with previous stud-
ies, highlighting the independent association between a delay to
the commencement of treatment and higher mortality.
16
Results
demonstrated a decrease in mortality of 0.8% with a reduction of
DTBT from 90min to 60min, and a further decrease in mortality of
0.5% with a reduction of DTBT from 60min to 30min.
16
Examples in the literature of mortality follow up outside
the acute setting are few. Brodie and colleagues followed 2322