Julie Shardlow

Matron Cardiology Services

Bradford Royal Infirmary

e-mail

22-3@bradfordhospitals.nhs.uk

Nurse Initiated Thrombolysis

♦ Why ♦ What ♦ How♦ Results♦ One year later♦ Lessons learned

Why

♦ 1997 - 25% of eligible patients received thrombolyisis within 60 minutes of arrival at hospital

♦ 1998 – 50% of eligible patients received thrombolyis within 60 minutes of arrival at hospital

♦ 2000 – No patients received thrombolysis within 30 minutes of arrival at hospital

Why

♦ Improve care

♦ Improve patient outcome

♦ Meet NSF targets

How

♦ No money

♦ No extra resources

♦ Lots of enthusiasm and support

Who

♦ E grades and above in CCU

♦ F Grades and above in A/E dept

Who

♦ Chief Nurse♦ Ward staff♦ Senior nurses♦ Cardiologists – Lead Clinician♦ Pharmacist♦ Nurse manager♦ Practice development♦ Professional development♦ Trust advisory group (Advancing Practice Group)

Patient Group Direction

“ specific written instruction for the supply or administration of named medicines in an identified clinical situation. It is drawn up locally by doctors, pharmacists and the appropriate professionals and approved by the employer. It applies to groups of patients or other service users who may not be individually identified before presentation..”

(Crown report 1988)

Principles of PGD

♦ PGD to be used where it provides an advantage to patient care without compromising safety

♦ All disciplines affected by the PGD to be involved in the development

♦ Regular formal review dates

♦ Changes to PGD to be submitted through formal process

When

♦ First course February 2001

♦ Courses scheduled throughout each year

according to demand

Results:

♦ 24hour cover by nurses on CCU.♦ Senior nurses in A/E and CCU trained♦ All patients thrombolysed by nurses safely

and effectively.♦ Improvement in door needle times

Results% Thrombolysed in 30 minutes or less 2001-2002

0

20

40

60

80

100

120

Jan Feb Mar AprMay

June July AugSept Oct Nov

Dec

Perce

ntag

e

% in 30 mins or less in year2001% in 30 mins in year 2002

ResultsMedian Door To needle Times 2001 and 2002

0

10

20

30

40

50

60

70

Jan

Feb

March Apr

MayJu

neJu

lyAug

Sept

Oct NovDec

Tim

e in

min

utes

Median Time in Year 2001

Median Time in Year 2002

ResultsThrombolysis 2002

0

20

40

60

80

100

120

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Per

cent

age

% in 20 mins

% in 30 mins

Direct admission to + NITs CCU

Problems……….

♦ Bed availability on CCU♦ Majority of patients were thrombolysed in

A/E♦ Senior staff trained to thrombolyse in A/E

were often busy with other things♦ Thrombolysis in A/E much slower

One Year Later

♦ Secured extra funding from PCTs ( Two E grades)

♦ Thrombolysis link sister in A/E

♦ Nurses in CCU bleeped to attend Chest pains in A/E to support thrombolysis

(July 03)

Results2003 Door to Needle Times

0

10

20

30

40

50

60

70

80

90

100

Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

% Thrombolysed<30 mins

% Thrombolysed< 20 mins

Results

Call to Needle Times 2003

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1 2 3 4 5 6 7 8 9 10 11 12

%<60 mins

Lessons learned

♦ Solve one problem find another one ♦ Continuous monitoring and review ♦ Everyone's problem♦ Team approach is essential ♦ Communication and Education is on going♦ Relationships matter

Lessons learned

♦ Continuous feedback is essential ♦ Accurate documentation/audit systems♦ Requires multidisciplinary approach♦ Eliminate interdepartmental barriers♦ Develops Staff (confidence and

communication and team work) ♦ Solutions don’t always depend on extra

funding

Lessons Learned

♦ NITs course evaluated very well

♦ Survey of A/E staff show NITs perceived to be extremely beneficial

♦ To extend it to E grade staff in A/E

Lessons Learned

New ways of working