Abstract
BackgroundPeople living in rural Australia are more likely to die in hospital following an acute myocardial infarction than those living in major cities. While several factors, including time taken to access hospital care, contribute to this risk, it is also partially attributable to the lower uptake of evidence-based guidelines for the administration of thrombolytic drugs in rural emergency departments where up to one-third of eligible patients do not receive this life-saving intervention. Clinical pathways have the potential to link evidence to practice by integrating guidelines into local systems, but their impact has been hampered by variable implementation strategies and sub-optimal research designs. The purpose of this study is to determine the impact of a five-step clinical pathways implementation process on the timely and efficient administration of thrombolytic drugs for acute myocardial infarctions managed in rural Australian emergency departments.Methods/DesignThe design is a two-arm, cluster-randomised trial with rural hospital emergency departments that treat and do not routinely transfer acute myocardial infarction patients. Six rural hospitals in the state of Victoria will participate, with three in the intervention group and three in the control group. Intervention hospitals will participate in a five-step clinical pathway implementation process: engagement of clinicians, pathway development according to local resources and systems, reminders, education, and audit and feedback. Hospitals in the control group will each receive a hard copy of Australian national guidelines for chest pain and acute myocardial infarction management. Each group will include 90 cases to give a power of 80% at 5% significance level for the two primary outcome measures: proportion of those eligible for thrombolysis receiving the drug and time to delivery of thrombolytic drug.DiscussionImproved compliance with thrombolytic guidelines via clinical pathways will increase acute myocardial infarction survival rates in rural hospitals and thereby help to reduce rural-urban mortality inequalities. Such knowledge translation has the potential to be adapted for a range of clinical problems in a wide array of settings.Trial registrationAustralia New Zealand Clinical Trials Registry code ACTRN12608000209392.
Highlights
People living in rural Australia are more likely to die in hospital following an acute myocardial infarction than those living in major cities
People living in rural Australia are more likely to die in hospital following an Acute myocardial infarction (AMI) than people in major cities[6]
Whilst there are obvious problems associated with distances people travel to access treatment, there appears to be lower uptake of national guidelines for thrombolytic drugs in rural areas, where up to one-third of eligible patients do not receive this life-saving intervention[7]
Summary
People living in rural Australia are more likely to die in hospital following an acute myocardial infarction than those living in major cities. While several factors, including time taken to access hospital care, contribute to this risk, it is partially attributable to the lower uptake of evidence-based guidelines for the administration of thrombolytic drugs in rural emergency departments where up to onethird of eligible patients do not receive this life-saving intervention. The National Heart Foundation of Australia (NHFA) and the Cardiac Society of Australia and New Zealand (CSANZ) jointly produced clinical guidelines for the management of AMI, including the administration of thrombolytic drugs when percutaneous coronary intervention services are unavailable. These guidelines provide precise recommendations directing which patients should receive a thrombolytic drug based on presenting symptoms, electrocardiographic (ECG) findings and contraindications[5]. Peak Australian bodies, including the NHFA, the Australasian College of Emergency Medicine (ACEM) and the Cardiac Society of Australia and New Zealand (CSANZ) have promoted the development of local systems to improve to uptake of national guidelines [8]
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