Guideline implementation fails to improve thrombolytic administration

Abstract

International randomised controlled trials conducted over the last two decades have consistently demonstrated improved mortality and morbidity resulting from thrombolytic therapy for patients with acute myocardial infarction (AMI). Subsequently, evidence-based guidelines have been designed and implemented to optimize thrombolytic delivery. The effect of evidence-based clinical guidelines on clinical practice is heavily influenced by strategies used to develop, disseminate and implement those guidelines. This study evaluated the impact of a collaborative, multifaceted implementation strategy for AMI management guidelines on thrombolytic usage in the Loddon Mallee Region, Victoria, Australia. The multi-faceted implementation strategy included an inter-disciplinary team representing all treating venues contributing to the content of the "Guidelines for the Early Management of Acute Myocardial Infarction" followed by education sessions that coincided with the dissemination of the guidelines. A retrospective medical records audit 12 weeks before and 12 weeks after the intervention was used to evaluate the impact on proportion of those patients eligible and receiving a thrombolytic and door-to-needle time. Variables of treating venue, age, gender, type of AMI, and type of transport to hospital were also measured to determine their impact on results. A retrospective audit of 170 medical records found that the intervention appeared to have had no impact on the proportion of patients eligible and receiving a thrombolytic (74.2% vs. 62.5%: p=0.275), and door-to-needle time (67.7 min vs. 60.5 min: p=0.759). Venue specific influences produced a variety of patterns in thrombolytic delivery that require further exploration. This suggests that a single solution approach across multiple venues will have limited impact.