Thrombolysis in the Pre-Hospital Setting
Thrombolysis in the Pre-Hospital Setting
Pre-hospital thrombolysis has proven clinical benefits in the management of acute myocardial infarction (MI). If the targets for administering thrombolysis, in particular call-to-needle time, are to be met, then it seems likely that its use will be more widespread. With appropriate training and support, paramedics can competently perform 12-lead electrocardiograms (ECGs) and administer thrombolysis. Cardiologists should be prepared to undertake paramedic training and play a central role in the development of protocols and pathways for the administration of pre-hospital thrombolytic therapy.
Recent articles in the journal have reviewed published evidence for the clinical benefits of pre-hospital thrombolysis in acute myocardial infarction and have also discussed unpublished experiences of early thrombolysis in the UK and elsewhere. In this article, consultant cardiologist Paul Kelly takes the discussion a stage further; he reviews last autumn's guidance of the National Institute for Clinical Excellence and looks at the likely implications of pre-hospital thrombolysis for hospital cardiology teams.
Thrombolytic treatment for acute MI is of greatest benefit reducing mortality by 2050% if it is administered within the first hour of symptom onset. The National Service Framework (NSF) for Coronary Heart Disease established as its first target that healthcare professionals should aim to initiate thrombolysis in 75% of eligible patients within 30 minutes of hospital arrival. This target was being met by less than one half of hospitals in 2002/2003. A recent MINAP report, however, says that 76% of eligible people with MI are now being treated within 30 minutes of hospital arrival.
It also stated that pre-hospital thrombolysis should be considered where local 'call-to-hospital' times are likely to exceed 30 minutes so that a 'call-to-needle' target time of less than 60 minutes could be achieved. NSF targets are now even tougher and expect emergency care professionals to reduce door-to-needle times further to a new target of 20 minutes.
A recent meta-analysis of randomised, controlled trials of pre-hospital thrombolysis (delivered by paramedics, general practitioners or mobile ICUs) showed that pre-hospital thrombolysis can reduce the relative risk of short-term, all-cause hospital mortality by 17% compared with in-hospital thrombolysis. Based on such evidence, the NHS Plan in England (2000) gave a commitment to a three-year programme to train and equip ambulance paramedics to provide thrombolysis, estimating that "on average, patients will get thrombolysis an hour earlier than if they were taken to hospital first, saving up to 3,000 lives a year once fully implemented".
These aspirations were backed by government funding in May last year when the Department of Health announced the provision of £14 million to equip all front-line ambulances with 12-lead ECG machines, to provide communications equipment for telemetry of ECG diagnosis data from the ambulance to the hospital, to supply thrombolytic drugs to ambulance trusts, and to train paramedics in MI diagnosis and administration of thrombolysis.
Pre-hospital thrombolysis has proven clinical benefits in the management of acute myocardial infarction (MI). If the targets for administering thrombolysis, in particular call-to-needle time, are to be met, then it seems likely that its use will be more widespread. With appropriate training and support, paramedics can competently perform 12-lead electrocardiograms (ECGs) and administer thrombolysis. Cardiologists should be prepared to undertake paramedic training and play a central role in the development of protocols and pathways for the administration of pre-hospital thrombolytic therapy.
Recent articles in the journal have reviewed published evidence for the clinical benefits of pre-hospital thrombolysis in acute myocardial infarction and have also discussed unpublished experiences of early thrombolysis in the UK and elsewhere. In this article, consultant cardiologist Paul Kelly takes the discussion a stage further; he reviews last autumn's guidance of the National Institute for Clinical Excellence and looks at the likely implications of pre-hospital thrombolysis for hospital cardiology teams.
Thrombolytic treatment for acute MI is of greatest benefit reducing mortality by 2050% if it is administered within the first hour of symptom onset. The National Service Framework (NSF) for Coronary Heart Disease established as its first target that healthcare professionals should aim to initiate thrombolysis in 75% of eligible patients within 30 minutes of hospital arrival. This target was being met by less than one half of hospitals in 2002/2003. A recent MINAP report, however, says that 76% of eligible people with MI are now being treated within 30 minutes of hospital arrival.
It also stated that pre-hospital thrombolysis should be considered where local 'call-to-hospital' times are likely to exceed 30 minutes so that a 'call-to-needle' target time of less than 60 minutes could be achieved. NSF targets are now even tougher and expect emergency care professionals to reduce door-to-needle times further to a new target of 20 minutes.
A recent meta-analysis of randomised, controlled trials of pre-hospital thrombolysis (delivered by paramedics, general practitioners or mobile ICUs) showed that pre-hospital thrombolysis can reduce the relative risk of short-term, all-cause hospital mortality by 17% compared with in-hospital thrombolysis. Based on such evidence, the NHS Plan in England (2000) gave a commitment to a three-year programme to train and equip ambulance paramedics to provide thrombolysis, estimating that "on average, patients will get thrombolysis an hour earlier than if they were taken to hospital first, saving up to 3,000 lives a year once fully implemented".
These aspirations were backed by government funding in May last year when the Department of Health announced the provision of £14 million to equip all front-line ambulances with 12-lead ECG machines, to provide communications equipment for telemetry of ECG diagnosis data from the ambulance to the hospital, to supply thrombolytic drugs to ambulance trusts, and to train paramedics in MI diagnosis and administration of thrombolysis.
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