Thrombolysis in accident and emergency: The exception not the rule. Are we denying patients lifesaving treatment?

Abstract

A recent report by Hood et al. (1998) that thrombolytic therapy was routinely available in only 35% UK Accident and Emergency (A&E) departments, raises some important issues about the role of A&E staff in the management of patients with acute myocardial infarction. Acute myocardial infarction is a common reason for emergency admission to hospital, and is associated with a considerable mortality. While most fatal events occur in the community, presumably because of fatal arrhythrnia, those patients reaching hospital alive have improved outcome if there is prompt restoration of coronary blood flow, usually through the administration of a thrombolytic agent. Moreover, the early mortality benefit appears to be maintained at 10-year follow-up (Baigent et al. 1998). That thrombolytic therapy is a time dependent intervention, more effective when given within the first 6 hours from symptom onset, and even more effective when administered within the first hour or two (Boersma et al. 1996) is well established. National guidelines recommend that suitable patients should receive treatment within 30 minutes of hospital arrival (the 'door to needle' time) (de Bono & Hopkins 1994), with more recent opinion suggesting that this target could be reduced to 20 minutes in well organized centres (European Society of Cardiology 1996). The lifesaving potential of this treatment is such that patients requiring thrombolytic treatment should probably be afforded the same priority as patients in cardiac arrest. Would A&E nurses accept the transfer of patients in cardiac arrest to the cardiac care unit (CCU) before definitive treatment was commenced? Of course not. That the majority of A&E departments do not provide thrombolysis was met with frank disbelief by an American colleague with whom this author recently discussed the Hood et al. (1998) paper. Many factors delay the administration of thrombolytic therapy, not least the actions of patients, carets and pro-hospital health professionals. Birkhead (1992) reported that the major component of delay in a six-centre survey occurred before the patient reached hospital. The focus of this paper, however, is on those delays occurring once the patient enters the hospital system. These are best described using the '4Ds' model developed in the USA (National Heart Attack Alert Program Co-ordinating Committee 1994) and have been adapted for use in the UK by Quinn & Thompson (1995). The 4Ds represent door (triage), data (time to first ECG recording), decision (to initiate thrombolytic therapy) and drug (the overall 'door to needle' time).