This article aims to investigate the management of acute instances of Coronary Heart Disease within the North West pre-hospital environment. The clinical audit approach of addressing quality issues of care will be specifically examined, focussing on how the framework attempts to improve practice. During this analysis, the importance of pain relief in the treatment of acute coronary syndrome will be explored before evaluating effectiveness within practice. This will be achieved by reviewing the topic of coronary heart disease and examining national and local policies which aim to tackle the condition in the North West.
Coronary heart disease
Ischemic heart disease is a condition characterised by inadequate myocardial perfusion caused by reduced blood supply, increased myocardial oxygen demand, or both (Falk et al. 2011). Coronary heart disease is characterised by compromising the supply of blood to the heart and is the most common cause of myocardial ischemia which is also known as coronary vascular disease (Falk et al. 2011). The British Heart Foundation (2010) claim the underlying cause for coronary heart disease is a gradual build up of fatty deposits in the walls of the coronary arteries, causing them to narrow which is known as atherosclerosis.
Coronary heart disease can manifest as a range of chronic or acute coronary syndromes which can be defined as a range of myocardial ischaemic states (Grech and Ramsdale, 2003).
Acute coronary syndrome
The term acute coronary syndrome encompasses the conditions of unstable angina, non-ST segment elevation myocardial infarction and ST segment elevation myocardial infarction (Healthcare Quality Improvement Partnership, 2010). The pathogenesis of the term begins with disruption or rupture of the atheromatous plaque which exposes the core constituents of lipids, smooth muscle, and foam cells. The local immune response generates thrombin and produces fibrin to combat the rupture. Platelet aggregation occurs at the rupture site and adhesion produces the formation of an intra-coronary thrombus. Blood flow to the heart is consequently decreased or completely obstructed causing ischemic hypoxia of coronary muscle and symptomatic pain (Grech and Ramsdale, 2003).
National effect of coronary heart disease
The national impact of coronary heart disease is huge, accounting for almost two-thirds of premature deaths in the country ( UK National Statistics, 2011). Cardiovascular disease affects an additional 1.8 % of the population each year with 0.8 % attributable to coronary heart disease (Capewell et al, 2008). The annual incidence of myocardial infarction in those aged 30–69 is around 600 per 100000 for men and 200 per 100000 for women with an estimated 268000 cases a year within the UK (Rothwell et al, 2005). It is recorded that 35 patients will suddenly die every day from the effects of coronary heart disease which labels the condition as the largest cause of death in the UK (The Health Foundation, 2011).
‘...every ambulance trust should offer complete and correct packages of audited, effective interventions to all patients suffering from acute coronary syndrome.’
Predictions suggest incidence figures are set to increase following demographic changes and lifestyle decisions if unaddressed. Various studies have proven the population is living longer and in turn suffering from more chronic conditions, such as coronary heart disease, for longer which is challenging NHS resources (Stewart et al, 2003; Rothwell et al, 2004; Leal et al, 2006).
The condition constitutes a major cost to the UK economy amounting to £8.5 billion per year (Liu et al, 2002). Overall 60 % of this figure relates to healthcare costs, with the remaining being spent on personal nursing, community care or productivity losses and disability benefits (Leal et al, 2006). As a result, cardiovascular diseases are a priority for pre-hospital research, quality improvement and government reform (DH, 1999).
Government initiatives
Our Healthier Nation, (DH, 1999) was one of the first government initiatives to acknowledge coronary vascular disease as a major burden for health. The document pledged to reduce coronary heart disease related disorders by 40 % in people aged below 75 by the year 2010. This initiative was driven by research suggesting rates of sickness were affecting the national economy. It was found that 20 million working days were lost due to illness and welfare costs for supporting chronically ill patients were spiralling (DH, 1999). In response, the National Service Framework for Coronary Heart Disease (DH, 2000) was implemented to reduce the death rate from heart disease and related illnesses in those aged under 75 by two-fifths by 2010.
The framework had massive implications for Ambulance services, suggesting recommendations to be implemented over a two year period to obtain results within ten years. The strategy consisted of 12 standards which were aimed toward the whole of the National Health Service however, pre-hospital care was identified as an evolutionary field which could be modified to achieve this target. The framework cited that every ambulance trust should offer complete and correct packages of audited, effective interventions to all patients suffering from acute coronary syndrome. This should be demonstrated by clinical audit data no more than 12 months old and achieved by implementing models of clinical governance and audit.
Clinical governance
The National Institute for Clinical Excellence (NICE) (2008), define clinical audit as a quality improvement process that aims to improve patient care by carrying out a systematic review against explicit criteria and the implementation of change (NICE, 2008).
Rickards and Cunningham (1999) debate the value of the process following a number of high profile failures which was claimed to decrease confidence in the auditing process. Following investigation, it was found that not all of the issues surrounding the collection of data, analysis and interpretation of results had been solved before the auditing process had been initiated (Rickards and Cunningham, 1999). Analysis and evaluation revealed early audit data was often of poor quality and inaccessible. Administrative convenience was commonly prioritised above reliability or value during data collection (NICE, 2008) causing fundamental flaw and belittling the process (Rickards and Cunningham, 1999).
Addressing these issues allowed practitioners to clearly examine their performance (Birkhead et al. 1999) and provided a compelling evidence base which yielded positive results (de Bono and Hopkins; Weston et al. 1994). In turn, confidence surrounding the process grew which stimulated the NICE and the Commission for Health Improvement to adopt and utilise the method for use in clinical governance (Scally and Donaldson, 1998).
Coronary heart disease and clinical governance
In response to the National Service Framework, the Myocardial Ischaemia National Audit Project (MINAP) was commissioned by the Health Care Quality Improvement Partnership (HQIP). MINAP is one of several national audit projects managed by the National Institute for Cardiovascular Research (NICOR) which focus on the management of acute coronary syndrome in the pre-hospital setting. The project was overseen by a steering group that represented key stakeholders including professional bodies, government representatives, patient representatives and the British Cardio Vascular Society.
MINAP data is collated from each participating Trust against best practice guidelines which in turn suggests how well each service is performing. Evidence of best pre hospital clinical practice for acute coronary syndrome is defined in the National Service Framework (NSF) for coronary heart disease and translated into guidance for Paramedics and other pre–hospital clinicians in national clinical guidelines ( Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2006).
Clinical performance indicators
These guidelines have been widely adopted across English ambulance services and translated into clinical performance indicators following guidance from the National Ambulance Services Clinical Quality Group. This was suggested following evidence that previous performance criteria were unreliable and dated (Siriwardena et al. 2010). It was found that the success of each service was based on response time rather than validated clinical measures of effective care. Although regarded as important, response times could not fully assess the range and quality of care provided to patients by front line ambulance staff (Pons et al, 2005). It was implied that large variations in performance were present along with limited evidence of quality clinical care across services. Performance standards had been set within most trusts however these were used for monitoring and quality assurance rather than supporting quality improvement. Comparisons between trusts were not viable using these standards due to differences in criteria.
To meet NSF recommendations, a set of meaningful, validated national clinical performance indicators were required, through which ambulance trusts could compare the quality of patient care with each other. This would promote sharing of good practice, quality improvement and deliver equitable standards of care across the country. Using these recommendations, it was approved that six indicators would be created; using best practice guidelines and agreed by national stakeholders who consisted of the National Ambulance Services Clinical Quality Group, audit leads and ambulance Trust representatives (National Ambulance Service Clinical Quality Group, 2010).
Locally, the North West Ambulance Service (NWAS) adopted a standardised approach to acute coronary syndrome treatment in 2007 and introduced the North West Ambulance Service Pre Hospital Management of Cardiac Related Chest Pain Policy (2011). Using performance indicators, the Trust measured clinical effectiveness using a care bundle which assesses the complete treatment package against a recognised benchmark (JRCALC, 2006). The trust defines a care bundle as a group of interventions related to the treatment of acute coronary syndrome that results in better outcomes than if delivered individually (NWAS, 2010).
‘Performance standards had been set within most trusts however these were used for monitoring and quality assurance rather than supporting quality improvement.’
Physiology of pain
After reviewing the evidence supporting performance indicators, it was suggested that one of the most important facets of acute coronary syndrome treatment is pain management (NSF, 2000; JRCALC, 2006). This view is reinforced by the North West Ambulance Service Pre-Hospital Management of Cardiac Related Chest Pain Policy (NWAS, 2011) which demonstrates over 20 % of indicators being dedicated to the management of pain. JRCALC (2006) cites the control of pain is important not only for humanitarian reasons but also because it may prevent deterioration of the patient and allow better assessment. Furthermore, it is accepted that pain can threaten homeostasis which Macintyre and Ready (2001) understood to be detrimental when experiencing a substantial cardiac event. To fully understand the importance of pain management, Middleton (2003) suggests a firm knowledge is required in the process of pain which will be explored further.
Pain process
On initial contact with a stressor, the sympathetic nervous system will initiate a reflex response which could allow the patient to escape the environment which could potentially be life saving (Curtis and O’Keefe, 2002). This is called the flight or fight response, however, it is only of life saving-value if the stressor is an environmental factor (Marieb, 2006). The analgesic process is a good example of this method, where naturally occurring endogenous opioids called encephalins and endorphins are released in response to stressful stimuli. These substances prevent the release of neurotransmitters such as substance P by binding onto opioid receptor sites. In turn they inhibit the transmission of pain impulses, causing an analgesic effect. Although this process works effectively, the endogenous opioid are very short acting due to fast degradation which is why they are not considered useful analgesics (Pasero et al. 1999) and further pain management is required.
‘Though accepted as a lifesaving process, prolonged activation of the sympathetic nervous system can induce a number of physiological changes...’
Though accepted as a lifesaving process, prolonged activation of the sympathetic nervous system can induce a number of physiological changes which can be detrimental and potentially life-threatening (Middleton, 2003; Marieb, 2006). This risk is enhanced further when demonstrated by a patient suffering from the symptoms of coronary heart disease (Macintyre and Ready, 2001). Middleton cites that physiological changes produced in response to pain have impact on the cardiovascular, gastrointestinal, respiratory, genitourinary, musculoskeletal and immune systems. Taking the process of acute coronary syndrome into consideration, increased sympathetic activity will induce a number of detrimental processes. Heart rate, blood pressure and peripheral vascular resistance will rise to facilitate the elevated demands of oxygen and other nutrients to vital organs (Curtis and O’ Keefe, 2002). Enhanced workload and stress of the heart induces greater oxygen consumption of the myocardium. When the level of consumption is greater than supply, further myocardial ischaemia will occur, exacerbating levels of pain and enhancing cardiac damage (Macintyre and Ready, 2001).
Taking the process above into consideration, it is apparent that pain management is a priority in providing quality treatment of acute coronary syndrome (Middleton, 2003) and recorded in the NSF for coronary heart disease (2000).
Pain management
Taking the importance of pain into consideration, it is interesting to note that numerous authors suggest pain management is inadequate in the pre-hospital setting (Fullerton-Gleason et al, 2002; Jones and Machen, 2003). Lord and Parsell (2005) suggest the problem stems from poor education whereas Hennes et al (2005) believe the issue is due to poor assessment techniques. Fullerton-Gleason et al (2002) conclude that the problem is multifaceted with improvements required in all fields. Fullerton-Gleason et al (2002) expand by suggesting that effective pain management requires formal protocols supported by effective analgesic therapies along with education which addresses attitudes that may inhibit pain assessment or management by paramedics.This should be reinforced by regular audits that form part of clinical quality assurance programs that assess analgesic practice. Such audits must have access to data obtained from patient self-reporting of pain using a valid and reliable pain measurement tool. Joint Royal Colleges Ambulance Liaison Committee guidelines (2006) support this view and advises practitioners to resist estimating the patient’s pain. McCaffery and Pasero (1999) believe pain is whatever the patient perceives at any time and failure to accept this will result in poor pain management.
Pre-hospital guidelines suggest effective pain management should adopt a multifaceted approach with clinicians considering the underlying condition, psychological support and physical methods before pursuing pharmacological avenues. Evidence of best practice suggests that analgesia should be introduced in an incremental format considering timeliness, effectiveness and potential adverse effects. Pharmacological methods of pain relief used by ambulance services can be divided into three groups consisting of inhalational, oral and parenteral/enteral analgesia. Pain relief specific to the treatment of acute coronary syndrome suggested by the NSF (2000) includes entonox and morphine.
Entonox is an inhalational analgesic which has sedative, analgesic and anxiolytic properties however as it is a weak anaesthetic agent, when it is mixed with 50 % oxygen. It rarely produces loss of consciousness (Vater and Hessel, 2000). Although entonox has been used for many years, the mechanism of action has not yet been fully understood (Wee, 2005). It has been suggested that it’s affects are due to the nitrous oxide component which causes the release of biochemical substances, such as endorphins and serotonin. It is understood that nitrous oxide takes effect within the brain, as well as in the spinal cord, inhibiting pain impulses by stimulating various receptors and altering pain pathways. Furthermore, due to its low fat solubility, entonox does not accumulate within the body to any great extent and is rapidly eliminated via the lungs when inhalation ceases (Vater and Hessel, 2000). Parbrook and Rees (1964) suggest Nitrous oxide can possess a profound analgesic effect and claim an inhaled concentration of 25 % nitrous oxide and oxygen can be compared favourably with a standard dose of morphine. Chambers and Guly (1993) disagree by suggesting the analgesic effect of entonox does not offer complete pain relief and patient compliance at times is poor (Chambers and Guly, 1993). It is due to these characteristics that ambulance guidelines suggest using entonox as the first analgesic whilst other methods are instituted ( JRCALC, 2006).
The second option available to the paramedic to treat acute coronary syndrome symptomatic pain is morphine. It is classed as the gold standard of pain relief carried by ambulance services and can be given intravenously or orally. Morphine is an opioid which is defined as a chemical that works by binding onto specific receptors found in the nervous system (Iverson, 1996). The toxicity of opioid analgesics stem from the extensive effect upon the central nervous system (CNS). Opioid interact with stereospecific saturable binding sites located in the CNS. Interaction with the opioid receptors mimics the actions of endogenous encephalin and endorphins naturally generated by the body. Morphine is a pure opiate agonist and exerts its activity primarily on the µ receptor. Activity also appears to involve an alteration in the release of neurotransmitters, such as the inhibition of acetylcholine, norepinepherine, and dopamine. These actions result in the therapeutic effects of analgesia, sedation and euphoria (Hiotis, 2005).
Clinical audit in practice
The value of effective pain relief in acute coronary syndrome management is evident and the National Ambulance Service Clinical Performance Indicator project to audit clinical performance concluded in March 2010. The first cycle of published results was deemed inconclusive due to the method of data collection adopted. As it was the initial cycle in the process, the aim of the figures was to act as a comparative marker for further cycles. To obtain the data, the agreed sampling method adopted was to search through databases of clinical records (electronically or manually), and estimate the number of condition specific clinical presentations per month. The group acknowledged a level of unreliability with this method however claimed that initial baseline figures were required to initiate the auditing process.
‘More patients suffering from symptoms of acute coronary syndrome received some form of analgesia within the care package and in turn, received a better standard of care.’
For the second, third and fourth cycles of audit, each trust agreed to examine the first 300 records of the clinical condition before sending the data for analysis. Records had to strictly adhere to the given time period and conform to the agreed inclusion/exclusion criteria. Unique templates were specifically developed for clinical performance indicator input and sent for investigation.
The results of the project were striking. Taking pain management into consideration, it was estimated that 43.9 % of national acute coronary syndrome patients would receive analgesia however in practice it was found that 54 % was a more accurate figure (NASCQG, 2010). By the end of the project this increased to 66 %, demonstrating a national improvement of nearly 12 % (NASCQG, 2010) due to interventions after audit alone.
Upon closer analysis, it was found that the performance of every ambulance trust improved throughout the cycles of the scheme. More patients suffering from symptoms of acute coronary syndrome received some form of analgesia within the care package and in turn received a better standard of care. Upon conclusion of the project, each trust accepted the benefit of clinical performance indicators and the audit process in the pursuit of quality practice.
However, taking the 2010 results into consideration, 33.6 % of acute coronary syndrome patients were not receiving any form of pre-hospital pain relief (NASCQG, 2010).
It was identified that nearly half of all patients presenting with the condition were missing vital components of the care bundle which may have enhanced levels of risk.
Local statistics
Local evidence confirmed national findings with NWAS demonstrating a 43 % care bundle performance rate in the treatment of acute coronary syndrome (NWAS, 2010). The trust accepted that quality enhancements were required and developed a quality improvement plan using guidance from the Ambulance Services Cardiovascular Quality Initiative group. Proposals suggested the implementation of a Quality Improvement Team (QIT) who aimed to improve patient care and encourage others of the benefits that could be achieved from clinical governance methods and interventions.
Results following QIT implementation have been impressive with each group identifying barriers to change and suggesting methods to overcome the identified hindrances. It was acknowledged that clinicians should be encouraged to engage with the project early which was supported by empirical studies conducted by Hulscher et al (2001) and as well as Prior et al (2008).
Statistically, the team has achieved the aimed objective with figures suggesting an improvement of over 17 % in the management of pain alone. Holistically, the auditing process has enabled a 25 % increase in the quality of practice in just one year which proves the validity of the process (NWAS, 2010).
Conclusions
To conclude, it is evident that the treatment of coronary heart disease will shape how resources are used within the NHS. Progress has been made following recommendations provided by the NSF, however the condition still affects more people in the UK than any other. The DH have a number of provisions which aim to address the disease, however evidence suggests that the governance process is the most valuable.
Ambulance services are at the forefront of NHS access and play a pivotal role in treating the effects of the condition. The aim of the clinical performance indicator programme was to provide ambulance services with useful data to allow continuous quality monitoring and improvement of care delivery. Project implementation was successful, however focus must remain on addressing the service inadequacies identified. This may prove problematic in an era where cost effectiveness takes priority, however effective pain management is one area of practice which needs enhancing for the pursuit of best practice. Resources need to be allocated to the attainment of this goal if the potential benefits to the patient population are to be realised.