AMI education cuts LOS, complications
AMI education cuts LOS, complications
NHLBI recommends educational strategies
A new report from the National Heart, Lung, and Blood Institute (NHLBI) in Bethesda, MD, concludes that poor education of patients at high risk for acute myocardial infarction (AMI) can translate into longer lengths of stay and a greater number of complications when these patients do have heart attacks.
Although designed to help cardiac specialists and primary care physicians identify patients likely to delay treatment, it's also useful for hospital-based discharge planners, says Marian Kratage, a spokeswoman at NHLBI's information center. "It can help case managers in pre par ing for discharge and giving patients counseling on what to look for, as well as what to be attentive to in their own behavior," Kratage says. "It's for anyone in a patient education role or who finds themselves in a situation where they can counsel."
According to the report, published by NHLBI's National Heart Attack Alert Program, the most common reason for delay in the treatment of AMI is patients not seeking care promptly. In fact, the median time delay between appearance of symptoms and treatment ranges from 2 hours to 6.4 hours, with few patients being treated within the first 60 to 90 minutes. That holds true even for patients who've already had a heart attack.
In order to help identify patients at high risk for AMI, the NHLBI lists the following factors found to contribute to prehospital delay:
· older age;
· female gender;
· African-American race;
· low socioeconomic status;
· low emotional or somatic awareness;
· history of angina, diabetes, or both;
· consulting a spouse or other relative;
· consulting a physician;
· self-treatment.
Interestingly, the study found that calling a physician when symptoms occurred can actually contribute to a significant delay in treatment because physicians or other health care providers may not be readily available at the time of the call. "Office staff or telephone services try to reach them or give advice and assurance, thereby increasing the delay," the report says.
Physicians also indirectly contribute to treatment delays by failing to provide much heart attack education for their high-risk patients, says John Clinton Bradley, MS, a support contractor at R.O.W. Sciences of Rockville, MD, which contributed to the NHLBI report. "A lot of them really don't have any kind of paradigm for what to say to the patient, what kinds of information needs to be relayed to them," he says.
Another barrier to providing rapid care for AMI patients is managed care's use of the gatekeeper model of care to decrease inappropriate uses of medical resources. To solve that problem, it's important to educate patients about what constitutes an emergency and when it's appropriate to call 911 instead of their primary care physician, Bradley says. "If they even suspect that they are having a heart attack, they should feel that they have permission from their insurer to access the 911 system and seek care without having to worry about whether it's going to be reimbursed or not."
According to the report, clinicians should focus their educational efforts on patients with established clinical atherosclerotic disease of the aorta, arteries to the limbs, or the carotid arteries. These include patients with "definite clinical or laboratory evidence of MI," ischemia, or a history of coronary artery bypass surgery, coronary angioplasty, or related procedures.
Educational messages targeted at these high-risk patients should include the following three components:
· Information about typical symptoms of AMI and actions to take if symptoms occur.
Although symptoms can vary from patient to patient, they most typically include the following:
- chest pain, discomfort, or pressure;
- left arm pain or discomfort;
- pain radiating to the neck or jaw;
- shortness of breath;
- sweating;
- upset stomach;
- discomfort in the area between the breastbone and navel;
- a sense of dread.
Because many patients believe that a heart attack involves sudden, crushing chest pain and unconsciousness, they should be told that symptoms may build gradually. Also, patients who have already experienced a heart attack should be told that symptoms could present differently during a second attack.
In addition to educating patients about symptoms, clinicians also should tell them what actions they should take once symptoms occur. These include taking one 325 mg tablet of uncoated adult aspirin, taking nitroglycerine (if already prescribed), and calling 911 if symptoms continue for more than 15 minutes. (See sample patient advisory form, p. 122.)
· Emotional issues.
According to the report, recent research "suggests a significant amount of delay is related to patients' beliefs that the symptoms are not serious and attributing them to a noncardiac cause."
Part of combating denial on the part of patients involves finding out whether they or members of their family have had negative experiences related to seeking care for a potentially serious health problem, especially one that was heart-related.
To balance patients' fears about the serious nature of an AMI, it's important to tell them about the efficacy of pharmacologic thrombolysis and other interventions for AMI. The benefits of receiving early treatment, before irreversible heart damage occurs, also should be emphasized.
· Social factors.
Because most patients consult a family member or their spouse about their symptoms before taking action, it's necessary to include close relatives in your education efforts - particularly concerning the nature of AMI symptoms and the importance of calling emergency medical services quickly when symptoms develop. Family members also can be referred to classes on cardiopulmonary resuscitation.
According to the report, one-on-one instruction is the most effective method for delivering educational messages to patients, provided that all health care providers caring for the patient are consistent in the messages they relate. In addition, written material about symptom recognition, appropriate steps to take, and the location of the nearest emergency department should accompany the verbal instruction to reinforce the message. Patient education materials should be written at no higher than a sixth-grade reading level.
For a copy of the report Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction, contact the National Heart, Lung, and Blood Institute Information Center, P.O. Box 30105, Bethesda, MD 20824. Telephone: (301) 251-1222. The report's publication number is 97-3787.
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