Canadian Medical Association Journal 1996; 154: 509-511
Delays in treatment that occur before the patient reaches hospital can be considerable. Between 29% and 42% of patients wait more than 4 hours before seeking medical help,[2-4] and numerous factors contribute to patients' delays in responding to symptoms.[3,5] Aggressive and sustained educational initiatives by physicians and community organizations are needed to improve public awareness of the symptoms of myocardial ischemia and the advantages of rapid treatment.
Although many patients come to hospital on their own, many others access community emergency medical services. Unfortunately, transport by ambulance is not without its own delays: a study conducted in eight American cities showed that an average of 46 minutes passed between the time patients dialled 911 and their arrival at hospital.[6]
The recommendations relating to care in hospital address a frustrating reality: unnecessary delays in treatment by emergency physicians, nurses and medical consultants are now the most common avoidable cause of death in patients with AMI. As part of the Thrombolysis in Myocardial Infarction II trial, Sharkey and associates[7] investigated the delays that preceded treatment of 236 consecutive patients with intravenous tissue plasminogen activator. Delays in hospital accounted for 59% of the time that elapsed from the onset of ischemic symptoms to the initiation of thrombolytic therapy. This finding suggests that reducing in-hospital delays would be the single most important factor in shortening the time to the initiation of thrombolytic therapy and achieving coronary artery reperfusion.
Even though thrombolytic therapy has clearly become the standard of care in AMI, its delivery in Canada continues to be extremely variable. A survey of metropolitan Toronto hospitals carried out in 1994 revealed that thrombolytic therapy was being initiated in the emergency department 100% of the time in only 12 of 21 hospitals (E.L. and Dr. Bjug Borgundvaag, Mount Sinai Hospital, Toronto: unpublished data, 1994). In another six hospitals, thrombolytic therapy was sometimes initiated in the emergency department, and in three hospitals it was never initiated in the emergency department. The survey also revealed that emergency physicians initiated thromobolytic therapy themselves in only 12 hospitals, and did so on average only 30% of the time. In nine hospitals the thrombolytic therapy given was never initiated by the emergency physician. Instead, the decision was made by on-call internists or consultant house staff.
These data mirror practice patterns in the rest of the country. We conducted a pre-course survey of thrombolytic therapy practice patterns among registrants for a 1-day workshop on the recognition and treatment of AMI, held in 12 cities on behalf of the Canadian Association of Emergency Physicians. Of 289 emergency physicians surveyed only 68% worked in hospitals where thrombolytic therapy was always initiated in the emergency department, and 14% worked in hospitals where thrombolytic therapy was never initiated in the emergency department (unpublished data). This is regrettable. Numerous studies have demonstrated that delaying thrombolytic therapy until patients get to an intensive care or coronary care unit adds between 50 to 60 minutes to the time before therapy is initiated.[8,9] Furthermore, only 25% of respondents said they initiated thrombolytic therapy without obtaining a consultation with a cardiologist or internist. Routine consultation of a second physician necessarily adds delays.
Clearly, significant and avoidable delays in the provision of thrombolytic therapy continue to occur in many Canadian hospitals. The goal of treatment for AMI in emergency departments should be for all eligible patients to receive thrombolytic therapy within 30 minutes of their arrival. Therefore, thrombolytic therapy must be initiated in emergency departments, and it should be instituted by the first physician capable of making the diagnosis and of determining the patient's eligibility for this treatment. In the overwhelming majority of cases, this could and should be the emergency physician rather than the attending internist or on-call cardiologist. Established guidelines for selecting the best agent to use in different clinical cases, protocols for preparing and administering medications, and ready access to thrombolytic agents in the emergency department are a few of the other essential components of a system that will allow for faster initiation of therapy.
We urge emergency physicians to accept responsibility for the use of thrombolytic agents in AMI and to become familiar with all aspects of their use: indications, contraindications, available preparations, dosages and the management of complications. We urge internists and cardiologists who assume responsibility for the subsequent care of patients with AMI to cooperate in establishing policies and protocols that will facilitate the rapid and secure administration of thrombolytic agents in the emergency department. Old habits and "turf wars" serve only to detract from optimal patient care.
Great strides have been made in the past 10 years in the treatment of AMI, specifically with respect to thrombolytic and adjunctive therapy. The goal for emergency service providers and hospital personnel is to get patients with apparent ischemic pain to hospital quicker, to identify patients who are eligible for thrombolytic therapy sooner and to start thrombolytic therapy earlier in the emergency department. These measures are essential if we are to reduce morbidity and mortality further among patients with AMI.