Nursing Leadership and Management Field Experience: Reducing Door to Balloon Time in STEMI - Essay Example

Reducing Door to Balloon Time in STEMI Affiliation Problem definition Door- to – balloon time is the duration taken for a patient with myocardial infarction to receive the appropriate care as per to the American heart association. From national cardiac registries, it indicates that over one and half of the STEMI patients do not go through reperfusion or electro cardiogram in a timely fashion within the first 90 minutes (Amruthlal Jain et al. 2012). At the same time, there were over 30 percent of legible patients who never went through any treatment at all (Cheskes et al. 2011).Mortality rate is definitely likely to increase with untimely intervention on the patients with elevated myocardial infarction. Much worse is the fact that many patients are missed out of diagnosis that will follow the emergency care of these patients (Attard Biancardi, 2013). The American cardiology college, American heart association and the European society of cardiology, jointly recommended the minimum time of intervention on ST elevated myocardial infarction patient as 90 minutes from the time of medical contact (Brodie, et al. 2010). They went further to make it a policy used to predetermine the quality performance on patients with myocardial infarction by hospitals. The findings on the hospital performance are recorded in the registry hence used to assess the performance of the respective hospitals. However, from records obtained from hospitals participating in the national registry of myocardial infarction, there is a small percentage of compliance to the guidelines. For instance in the year 2009, there was 35 percent of patients with ST elevated myocardial infarction attended to within the first 90 minutes and less than 15 percent of the participating hospitals had a median of 90 minutes in the time taken to attend to the these patients as Correia, et al.(2013) observed . Willson et al. (2010) established that there are different subgroups of patients that are more susceptible to delays than others are. For example, most patients that are brought in during the off hours (weekends and during the night) experience more delays than those brought in during the day and the week. Second are the patients referred forms other facilities of acute care, since there is a problem in coordinating the two facilities on the emergency basis. According to the observations made by Cheskes et al. (2011), every minute of delay in patient with STEMI affects one-year mortality. In fact, the 1-year mortality rate is elevated by over 7.5 percent for every 30 minutes delay as observed by Pitta, et al. (2010). Explanation to the above mentioned findings are as established in animal models, infarct size is affected significantly by the period of coronary occlusion. Thus, late reperfusion is deemed for poor results with less myocardial salvage and higher rate of mortality than as evidenced in early reperfusion even with application of optimal mechanical reperfusion. Holding up this data is the finding by Willson, et al (2010) whereby, pre-procedural Thrombolysis in myocardial infarction is an independent forecaster of the patients’ mortality rate. From the studies conducted on the effect of door to balloon time significance of patients’ prognosis after the ST elevated myocardial infarction, indicate negative implication on delayed intervention. Hence, efforts should be geared towards reduction of the ischemic time for both thrombolytic therapy and primary angioplasty. Causes of long door to balloon time There are several causes of delayed door to balloon time in various institutions classified as either systemic or non-systemic. First, patients that have cardiac arrest and need intubation before the initiation of PCI, experienced large portions of delays with a morality rate of over 30 percent (Fitchett, et al 2011). The process intubation consumes the time that could have been used to manage the patients expeditiously. Secondly, according to Willson, et al (2010) 8.4 percent of STEMI patients, have experienced delays of the DBT as a result of difficult in accessing the vasculature and 18.8 percent were delayed for difficulty on crossing the culprit lesion. Thirdly, consent provision delays, have a great challenge in complying with the 90 minutes as stipulated by the American heart association. The mortality rate of patients with this kind of delay according to Pitta, et al. (2010) is about 9.4 percent. Timely consenting process can provide a substantial reduction in delays, thus reducing the D2B time. Therefore, increased awareness on the importance to seek medical care and sign the consent among patients will go a long way in mitigating the mortality rate among the ST elevated myocardial infarction patients who fail to sign the consent timely. Stakeholders in care of patients ST elevated myocardial infarction care involves a group of people that have to collaborate for better outcome of the patients. Concisely, cohesion between the stakeholders is paramount in the bid to improving the quality of care, which is wholesomely determined by the time taken before the patient is attended to. This duration is reflective of the overall patient outcome because the ischemic period is an independent factor in death rate of these patients. Each department needs to move swiftly to save the patients’ life’s for the fact that the mortality rate is increased by each minute lost. The requisite stakeholders are very important in bringing about a revolutionary change in the patients care. Each party has a role that it plays which is very crucial in caring for the patients. First on the list of stakeholders, are the patients themselves and the family members. Initial steps to reducing the time taken before care is initiated, is a majorly predetermined by the patients and the family, these is so for the fact that the initial step is consenting which has to be done by the patient or the relatives. Therefore delayed consenting, will ultimately lead to poor care and devastating outcome on the patients prognosis. Secondly, physicians play a very crucial role too in the patient care. They are the main players of the patient care. In essence, competence of these physicians is key in seeing the patients go through this ordeal swiftly (Cheskes, et al. 2011). These are so because the physicians are responsible for the timely diagnosis of a heart attack and start the care, which is aimed at reperfusion the ischemic heart muscles immediately. They double up in the consenting process for they are responsible for providing the relevant information necessary for the patient to make that informed decision on the care they are going to receive. It is important that the patients make the informed decision since the outcome of the patient is not definite and the mortality rate is quite high depending on the door to balloon time. Third is the emergency medical systems management team. ST elevated myocardial infarction is and emergency that needs timely care for positive prognosis. Therefore, the emergency team has to be prepared to handle these cases timely by having in place the right resources. With adequate resources, the process is expedited and hence positive outcome of the patients ultimately. The process of catheter acquisition and the location of the vascular form the study form part of the delaying factors as indicated by Willson et al (2010). The closest healthy facilities the patients rush into on feeling sick is the community hospitals. Most of the time these facilities, may not have the capabilities to handle such kind of patients because of the complex process of accessing the heart vessels needs a cardiologist as a team leader. However, these centers can play a critical role by timely diagnosis and swift referral and communication system to the better-equipped facilities. Efficient and timely diagnosis will play a critical role in management of these patients. The tertiary hospitals that are sophisticated in handling these kinds of patients have to device mechanisms and communication system to collaborate with the community hospitals in order to initiate timely care (Pitta, et al. 2010). The time lost in referral system and collaborating with the referring facilities can be reduced by revamping the systems in the referral hospitals. Medical care on patient with ST elevated myocardial infarction need sophisticated professionals with sophisticated facilities. Therefore, the patients have to pay large amounts of money in order to receive these services. The insurance companies are stakeholders in caring for these patients since they are involved in catering for the patient’s bills. They should cater for the medical needs of their clients to ensure timely care of the patients. Lastly, is a team of experts that determines the gaps of care from the ideal care and figure out the weaknesses in order to improve on them. All the hospitals have that team of experts that determine the quality of care and look at the factors that are affecting level of patient care. A team that is proactive and determined to achieving its goals and objectives will be of importance in determining the patient outcome. This is because they are likely to improve the level of services provided to the patients with time as they evaluate the outcome of care with their preceding patients in the facility. Consequently, each of the stakeholders has a hand in improving the door to balloon time in one way or another. By each group performing its tasks as stipulated by the guiding principles and policies, there will be definitely reduced time taken before the patient receives that care that they dearly need. Since the project is aimed at reducing the door to balloon time, it has to utilize all this stakeholders’ by ensuring they revamp their areas of specialization to see better services to the patients. Each group has an equal and vital role they play in ensuring patient safety. Essentially, none of the groups is to be underestimated in carrying out the change that is geared towards improving the quality of patient care wholesomely. Purpose of the project and the proposed solution for your project The proposal is aimed at reducing the time taken to get patient to the ballooning stage. It is significant for the fact that patients with ST elevated myocardial infarction depend on the time they take to be attended to. Therefore, swift action is likely to save the patient’s life and at the same time increase the quality of life thereafter. According to Hutchison, et al. (2009) delayed time of care leads to further compromised patient performance by the fact that the heart muscles die off due to prolonged ischemia of the body muscles. The main goal is to increase the swiftness in action that is geared towards increasing the patient outcome. The numbers of barriers that have presented in the past have to be tackled in order to reduce the time taken. As observed earlier, the main causes of delayed action on the patients were vasculature access, catheterization, and delayed process of intubation among others. In some area where there has been phenomenal performance on patient care, they have been characterized by various factors. One is increased support by the management, innovation of working protocols with maximum flexibility of the protocols to allow for refining them to meet the standards. The management will have to play a great role in facilitating the change. For instance, for better performance in the community hospitals there is need to have them well equipped with facilities and resources necessary to make and manage the issue. By bring up this kind of changes; the prognosis will be handled better. According to Hutchison, et al. (2009), only five percent of the patients are attained to within the stipulated 90 minutes. Most of the barriers to this late action are caused by poor coordination mostly from the referral centers. Further Willson, et al (2010) in their study, established that the number of cardiologists that have to ensure the process of catheterization is initiated are few. Thus during the off hours, there is increased cases of delayed hence making the group of patients brought in at night and weekends to be at a higher risk of delayed door to balloon time. At the same time, the protocols that guide the process are essential in making the process swift. Therefore, formulation of protocols that will guide physicians is key in maintaining the standards of care and reducing the time taken in decision-making. As observed by Willson, et al (2010) there is over 15 percent of delayed instances that has occurred due to the fact there are delayed decision making on the method of care to be used on particular patients. Confusion in decision-making became more prevalent in the error of PCI and fibrinolysis, which are both substantial of essence in caring for the patients in different circumstances (Terkelsen, 2014). Plan of action The process of implementing the change has to take some time. Some of the objectives will be met earlier in the project while others later for they require different levels of concentration to be handled. Action Timeline resources Increased number of workers to reduce the workload during off hours and at the same time increased the already dwindling number of cardiologists. There should be increment of at least fifteen percent of the working force within a year In increasing the workforce, there are quite a number of activities involved. The major resource that is need is money to retain the already dwindling number of workers and at the same time higher more. These can be achieved by the government liaising with the local training schools to get more students and at the same time increase their salaries and benefits to increase rate of retaining workers. Standardizes and flexible protocols. Within six months, A team of experts’ should be created to look at the most appropriate protocols that will be used in handling these patients. Form the studies it is clear that quite a number of patients are lost due to the fact there is delayed decision making. Therefore, the resources needed in ensuring this is archived include the already established cardiologists and the nurses who have vast experience in these conditions. To facilitate these processes, money will be required to ensure the sooth running of the process and corporation of the selected specialists’. The facilities at the community level are not well equipped hence, there is need to equip them to facilitate adequate diagnosis and referral. Sometimes telemedicine can be used to deter patients from losing their lives in most critical conditions. Within six months Within two quarters of the annual budget, resource should be set aside to at least begin with equipping the local health centers as the telemedicine facilities are put in place to handle these patients. Bearing in mind the seriousness and the mortality rate associated with this condition, there is need to ensure that adequate resources are channeled towards curbing the prevalence of the condition. Barriers to implementation The process of implementation of the above-proposed plan is likely to be faced with the shortage of resources supply. For instance, there is much need of money to ensure there are more doctors and nurses hired as well as trained in the medical schools. The already constrained economy will find it hard to squeeze in more resources for developing more cardiac centers bearing in mind the fact that to equip this centers needs a lot of money in the beginning. At the same time, the numbers of health care professionals that are specialized in this area are few (Hutchison, et al. 2009). As much as there may be funds to employ them, there still lies a challenge of getting these employees. However, with better benefits and wages, there is a likely hood of at least bridging the gap a little bit. Conclusion Mortality rate of the ST elevated myocardial infarction patient is independent on the time taken to initiate the care of patients. Therefore, keen look on the door to balloon time is crucial in ensuring the positive outcome of the patients. In the case of a gap in patient care, there should be a vigorous study on the causes to close the gap. The fact that this type of myocardial infarction kills within minutes suffices the fact that there should be increased emphasis on equipping and ensuring the emergency department and facilities is up and running optimally. References Amruthlal Jain, S., Ismail, Y., Shaw, M., David, S., & Alexander, P. (2012). "Register and Roll":A Novel Initiative to Improve First Door-to-Balloon Time in ST Elevation Myocardial Infarction. Cardiology Research & Practice, 1-4. doi:10.1155/2012/616940 Attard Biancardi, M. A. (2013). Door-to-balloon time in primary percutaneous coronary intervention for patients with ST-Segment Elevation Myocardial Infarction An audit from the Accident and Emergency department of Mater Dei Hospital, Malta. Malta Medical Journal, 25(4), 2-9. Bradley, E. H., Curry, L. A., Ramanadhan, S., Rowe, L., Nembhard, I. M., & Krumholz, H. M. (2009). Research in action: using positive deviance to improve quality of health care. Implementation Science, 4(1), 25. Brodie, B. 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