Research paperNurses' recognition and response to clinical deterioration in the cardiac catheterisation laboratory
Introduction
In patients experiencing an unstable acute coronary syndrome (ACS), primary percutaneous coronary intervention (PCI) is the gold standard in reducing mortality and morbidity through timely reperfusion of the affected coronary artery.[1], [2] Timely reperfusion is a class Ia recommendation for all patients experiencing unstable ACS where ischaemic symptoms have been present for less than 12 h, and ST-segment elevation persists on electrocardiography.[3], [4] A worldwide strategy to minimise time to reperfusion therapy has been the implementation of systems of care, expediting patient transfer to the cardiac catheter laboratory (CCL).[3], [4], [5] Patients with unstable ACS are at risk of clinical deterioration6 and timely recognition, and response to clinical deterioration is a key strategy to reduce mortality and morbidity in patients with unstable ACS.7 However, the recognition of clinical deterioration is potentially difficult as compensatory mechanisms for acidosis have already triggered changes in the heart rate, respiratory rate, and blood pressure.8
As systems of care for patients with unstable ACS have evolved, time to patient transfer from the emergency department (ED) to the CCL has decreased dramatically, and, in some instances, patients are transferred to the CCL by prehospital care providers, bypassing the ED. A consequence of rapid transfer to the CCL is the brevity of patient assessment before commencement of primary PCI.5 As a consequence, there may be a lack of recognition of the early signs of clinical deterioration in patients with unstable ACS or the assumption that early signs of clinical deterioration will be corrected with reperfusion.
During primary PCI, haemodynamic support and the ability to anticipate, recognise, and respond to complications is a core nursing role and vital to support the technical execution and procedural success of PCI.9 Accurate assessment and interpretation of physiological cues to inform nurses' recognition of clinical deterioration is well described in the literature in ward settings as research related to rapid response systems (RRSs) has gained momentum.[7], [10], [11], [12], [13] More recently, studies on recognition and response to clinical deterioration in areas not traditionally serviced by hospital rapid response systems, such as EDs, have emerged.[14], [15] The CCL is also an area of the hospital that tends to manage deteriorating patients within their own resources. Despite nurses being vital to patient safety in the CCL, little is known about the physiological cues used by interventional cardiac nurses to recognise clinical deterioration in patients undergoing primary PCI for unstable ACS and how nurses in CCL respond to clinical deterioration once it is identified.
Understanding how nurses use physiological cues in the CCL setting will provide valuable insights into how nurses recognise and respond to clinical deterioration in patients at high risk of deterioration in a highly specialised area of practice.
Section snippets
Objectives
The objective of this study was to explore how nurses in the CCL setting recognise and respond to clinical deterioration in patients with unstable ACS undergoing primary PCI.
The specific research questions were the following:
- i)
What were the physiological cues used by CCL nurses to recognise clinical deterioration?
- ii)
What were CCL nurses' preferred responses once clinical deterioration had been identified?
Design and setting
A prospective exploratory descriptive design was used to conduct the study. A survey of CCL
Results
Thirty interventional cardiovascular nurses participated in the study. The majority (93.4%) of participants were employed in Australian CCLs (Table 1). Participants had a median of 15-year experience as registered nurses (IQR 7.3, 22.3), with a median of 9-year experience as CCL nurses (IQR 4.3, 15.0). Participants held a number of different positions within CCLs with the largest cohorts being registered nurses (36.6%) and clinical nurse specialists (33.3%; Table 1). Most participants held a
Discussion
This study had two major findings. First, CCL nurses were inconsistent in their recognition of clinical deterioration and relied heavily on hypotension, the presence of pain, and the presence of changes in heart rhythm to recognise clinical deterioration. Hypotension, pain, and changes in the heart rhythm were preferenced over tachypnoea, tachycardia, and conscious-state changes. Second, CCL nurses preferred to initiate nursing responses to clinical deterioration. This preference occurred even
Conclusions
Clinical deterioration of patients with ACS is a likely clinical event, but there is scant understanding of nurses' practices of recognising and responding to these events in CCLs. Using case scenarios based on literature and expert panel evaluation, this study found that nurses most commonly use hypotension and the presence of pain to recognise clinical deterioration in patients presenting to the CCL with an unstable ACS. Hypotension and presence of pain were preferenced over earlier and more
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Cited by (1)
Assessment framework for recognizing clinical deterioration in patients with acs undergoing pci
2021, Critical Care NurseCitation Excerpt :For this patient cohort, however, both are included in the circulation element because this approach is logical, ensures that physiological cues are collected in order of clinical importance, and still gives priority to respiratory rate and oxygenation status. Hypotension, heart rate and rhythm abnormalities, skin pallor, diaphoresis, and chest pain are physiological indicators used to identify clinical deterioration.8 However, these indicators have limitations for distinguishing clinical deterioration in patients with unstable ACS because tachypnea and tachycardia are the primary physiological compensation mechanisms for low cardiac output and resultant acidosis in patients with ACS.16