Nurses' recognition and response to clinical deterioration in the cardiac catheterisation laboratory

Abstract

Background

Patients presenting to the cardiac catheter laboratory for treatment of unstable acute coronary syndromes (ACS) experience a mismatch in myocardial oxygen supply and demand, causing vital sign abnormalities prior to neurological, cardiac and respiratory deterioration. Delays in detecting clinical deterioration and escalating care increases risk of adverse events, unplanned intensive care (ICU) admission, cardiac arrest, and in-hospital mortality.

Objectives

The objective of the study was to explore how nurses in the cardiac catheter laboratory (CCL) recognise and respond to clinical deterioration in patients with unstable ACS undergoing primary percutaneous coronary intervention (PCI).

Methods

A prospective exploratory descriptive design was used with 30 participants completing 10 written clinical scenarios. Participants scored their level of concern for each physiological cue and then then ranked their preferred immediate response based on the deterioration identified.

Results

Hypotension and the presence of pain were the physiological cues of highest concern. The most common responses to clinical deterioration were to increase vital sign assessment to 5-minutely intervals, administer pain relief or provide reassurance. Despite the presence of clinical deterioration fulfilling organisational escalation of care criteria, calling cardiac arrest or rapid response team (RRT) were not commonly selected responses.

Conclusion

Nurses most commonly use hypotension and the presence of pain to recognise clinical deterioration in patients presenting to the CCL with an unstable ACS. Once clinical deterioration is identified, interventional cardiac nurses delay the escalation of care to the RRT or cardiac arrest team, preferring to implement local nurse initiated interventions.

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.