Frances O’Brien

A randomized controlled trial to reduce prehospital delay time in patients with acute coronary syndrome (ACS).

BACKGROUND The literature suggests that people delay too long prior to attending emergency departments with acute coronary syndrome (ACS) symptoms. This delay is referred to as prehospital delay. Patient decision delay contributes most significantly to prehospital delay. OBJECTIVES Using a randomized controlled trial, we tested an educational intervention to reduce patient prehospital delay in ACS and promote appropriate responses to symptoms. METHODS Eligible patients who were admitted across five emergency departments (EDs) in Dublin were recruited to the study (n = 1944; control: 972, intervention: 972). RESULTS Median baseline prehospital delay times did not differ significantly between the groups at baseline (Mann-Whitney U, p = 0.34) (CONTROL: 4.28 h, 25(th) percentile = 1.71, 75(th) percentile = 17.37; Intervention 3.96 h, 25(th) percentile = 1.53, 75(th) percentile = 18.51). Both groups received usual in-hospital care. In addition, patients randomized to the intervention group received a 40-min individualized education session using motivational techniques. This was reinforced 1 month later by telephone. Of the 1944, 314 (16.2%) were readmitted with ACS symptoms: 177 (18.2%) and 137 (14.1%) of the intervention and control groups, respectively. Prehospital delay times were again measured. Median delay time was significantly lower in the intervention compared to the control group (1.7 h vs. 7.1 h; p ≤ 0.001). Appropriately, those in the intervention group reported their symptoms more promptly to another person (p = 0.01) and fewer consulted a general practitioner (p = 0.02). There was no significant difference in ambulance use (p = 0.51) or nitrate use (p = 0.06) between the groups. CONCLUSION It is possible to reduce prehospital delay time in ACS, but the need for renewed emphasis on ambulance use is important.

Mature students’ experiences of undergraduate nurse education programmes: The Irish experience

In recent years mature students have been encouraged into nurse education for the valuable qualities they are known to possess, along with their ability to assist in providing a sustainable solution to the current health care crisis. Unfortunately corresponding resources and support structures have not accompanied this widening of access and mature students are expected to fit into structures that already exist, structures that were formulated with eighteen year olds in mind. This qualitative study explores the experiences of mature students in nurse education. Three discipline specific focus group interviews were used as a means of gathering data from 28 mature students. Data were analysed using thematic content analysis as described by Burnard [Burnard, P., 1991. A method of analysing interview transcripts in qualitative research. Nurse Education Today 11, 461-466]. Findings revealed that students continue to struggle with the academic component of the course. They also found it difficult to balance the home and university divide. Greater challenges were identified by female participants as they maintained their previous roles. Males on the other hand were provided with greater freedom to pursue their studies. There is a need for curricular changes to be implemented in order to provide a greater flexibility and supportive experience for mature students. Further research is advocated in this area.

Cardiac rehabilitation after myocardial infarction: What influences patients’ intentions to attend?

Background: Cardiac rehabilitation (CR) programmes have increased their availability and expanded their eligibility criteria. This study sought to identify current predictors and reasons influencing myocardial infarction patients’ pre-discharge intentions to attend CR. Methods: Patients in this longitudinal, prospective, five site study completed questionnaires that surveyed their intentions to attend, attendance and main reasons for non-attendance at CR. Results: 84% of the 1172 patients indicated that they intended to attend CR. Multivariate analyses revealed that age, employment and earlier history of myocardial infarction were significant predictors of intention to attend CR, yet contributed to only a small proportion of the variance. The main reasons given for not intending to attend CR were lack of interest and perception that the programme would not be beneficial. Other obstacles included work, transport or time. A total of 708 (60%) patients responded at 12 months, and of these, 44% who did not intend to attend CR had attended. Conclusion: Patient sociodemographic and clinical profile, although significant, are not major predictors of intention to attend CR. Lack of interest and misconceptions regarding CR are cited as key barriers. Some of these seem to have been addressed post discharge as a good proportion of patients who had not intended to attend CR did change their minds and attended. Motivation of patients to participate in CR, including the identification of barriers and the provision of comprehensive information about the purpose and varied formats of CR programmes, could be used to help further address barriers to attendance.

Knowledge, attitudes, and beliefs about acute coronary syndrome in patients diagnosed with ACS: an Irish cross-sectional study:

Background: To reduce mortality and morbidity associated with acute coronary syndrome (ACS), individuals who experience ACS symptoms should seek treatment promptly. However, for this to be possible, they must adopt appropriate attitudes and beliefs about ACS symptoms and have the prerequisite knowledge to respond to those symptoms. Aim: This paper details the results of a cross-sectional Irish study that measured knowledge, attitudes, and beliefs about ACS in patients diagnosed with ACS. Methods: A total of 1947 patients were enrolled in the study. Recruitment took place across five academic teaching hospitals in Dublin, Ireland. Knowledge, attitudes, and beliefs about ACS were measured using the ACS Response Index questionnaire. Results: Almost half the patients (n=49.5%) demonstrated high knowledge levels (i.e. >70% of correct answers) about ACS symptoms. The majority recognized chest pain/pressure (98.9%) and left arm pain (90.2%) as symptoms. Many failed to associate jaw pain, heartburn and/or indigestion (44.7%), nausea and vomiting (47.6%), and neck pain (42.5%) with a heart attack. Higher knowledge levels were independently associated with higher levels of education (p=0.007), a history of angina (p=0.001), and attitudes (p=<0.001) and beliefs (p=<0.001) that are consistent with positively decisive responses to ACS symptoms. Conclusion: Despite having experienced an ACS event, overall knowledge levels were poor. Higher knowledge levels were associated with better attitudes and beliefs, indicating the inextricable relationship between all three components. Educational programmes should incorporate all three components so that prompt behaviour can be initiated when symptoms arise.

Gendered symptom presentation in acute coronary syndrome: A cross sectional analysis

BACKGROUND The international literature suggests that the symptom presentation of acute coronary syndrome may be different for men and women, yet no definitive conclusion about the existence of gendered presentation in ACS has been provided. OBJECTIVE This study examines whether gendered symptom presentation exists in a well-defined sample of men and women with ACS. DESIGN AND SETTING A cross-sectional analysis of baseline data pertaining to symptom experience and medical profiles were recorded for all ACS patients who participated in a multi-centered randomized control trial, in 5 hospitals, in Dublin, Ireland. PARTICIPANTS : Patients were deemed eligible if they were admitted through the Emergency Department (ED) with a diagnosis of ACS, if they were at least 21 years of age and able to read and converse in English. Patients were excluded if they had serious co-morbidities, cognitive, hearing or vision impairment. METHODS Patients were interviewed 2-4 days following their ACS event and data was gathered using the ACS response to symptom index. RESULTS The study included 1947 patients of whom 28% (n=545) were women. Chest pain was the most commonly experienced symptom in men and women, reported by 71% of patients. Using logistic regression and adjusting for clinical and demographic variables, women had greater odds of experiencing shortness of breath (50% vs 43%; odds ratio [OR]=1.32; 95% CI=1.08-1.62; p=.006) palpitations (5.5% vs 2.8%; OR=2.17; CI=1.31-3.62; p=.003) left arm pain (34% vs 30.5%; OR=1.27; CI=1.02-1.58; p=.03) back pain (7.5% vs 4.8%; OR=1.56; CI=1.03-2.37; p=.034) neck or jaw pain (21.5% vs 13.8%; OR=1.84; CI=1.41-2.40; p=.001) nausea (28% vs 24%; OR=1.30; CI=1.03-1.65; p=.024) a sense of dread (13.4% vs 10.5%; OR=1.47; CI=1.08-2.00; p=.014) and fatigue (29% vs 21.5%; OR=1.64; CI=1.29-2.07; p=.001) than their male counterparts. CONCLUSIONS Although chest pain is the most commonly experienced symptom by men and women, other ACS symptomology may differ significantly between genders.

Improving knowledge, attitudes and beliefs about acute coronary syndrome through an individualized educational intervention: A randomized controlled trial

OBJECTIVE To test the effectiveness of an individualized educational intervention on knowledge, attitudes and beliefs about acute coronary syndrome (ACS). METHODS This multi-site, randomized controlled trial was conducted on 1947 patients with a diagnosis of ACS. Both groups received usual in-hospital education. Participants randomized to the intervention group received a 40-min one to one individualized education session, delivered using motivational interviewing techniques. The intervention was reinforced 1 month and 6 months later. Knowledge, attitudes and beliefs were measured using the ACS Response Index. A total of 1136 patients (control, n=551; intervention, n=585) completed the questionnaire at baseline, 3 and 12 months. Data were analyzed using repeated measures analysis of variance. Ethical approval was obtained. RESULTS There was a significant effect of the intervention on mean knowledge (p<0.001), attitude (p=0.003) and belief (p<0.001) scores at 3 and 12 months. CONCLUSION Ensuring patients retain information post education has always been difficult to attain. This study demonstrated that patient education using motivational interviewing techniques and an individualized approach has the potential to alter knowledge, attitudes and beliefs about ACS among a high risk population. PRACTICE IMPLICATIONS This relatively short, simple and effective educational intervention could be delivered by nurses in multiple settings.

Ambulance use in acute coronary syndrome in Ireland: A cross-sectional study

Background: As myocardial salvage is time dependent, prompt emergency department attendance is imperative in the presence of unresolved acute coronary syndrome symptoms. Although ambulance use is the recommended mode of transport during an acute coronary syndrome event, people regularly have misperceptions about its role. Consequently, many fail to use this service when warranted. Aim: To evaluate factors associated with ambulance usage among patients admitted to emergency departments with acute coronary syndrome symptoms in Ireland. Methods: Patients (N=1947) diagnosed with acute coronary syndrome were recruited across five hospitals. The ACS Response Index was used to identify mode of transport to access the emergency department, symptom context and experience and the rationale for non-ambulance use. Using logistic regression, predictors of ambulance use were identified. Results: Only 40.1% of the sample used an ambulance. The primary reason for non-ambulance use was the perception that it was unwarranted (31%). A further 23.8% thought another mode of transportation would be faster. Independent predictors of ambulance usage differed among the three sub-diagnoses of acute coronary syndrome. For each group, visiting the general practitioner with symptoms was associated with a greater likelihood of not using an ambulance. Conclusion: The use of ambulance services is not positively embraced by the public. Furthermore, it appears that general practitioners may not always promote its use, particularly in the early stages of acute coronary syndrome symptom onset. The findings from our study suggest that a public education drive is necessary to promote ambulance usage during an acute coronary syndrome event.

The clinical experiences of mature mental health nursing students in Ireland

Mental health nursing has traditionally attracted a high level of mature applicants and this trend has not altered since the introduction of the Bachelor in Science in Nursing programme. The literature suggests that for many mature students, entering into nurse education is the fulfillment of a lifelong ambition. However, in reality they face many challenges not always shared by their younger classmates. The aim of this paper is to explore the clinical experiences of mature students in the field of mental health nursing. A qualitative descriptive method was utilised to guide the research with a focus group being the method of data collection. Current mental health mature nursing students in one urban university were invited to participate. Data were analysed using content analysis. Findings revealed that overall the students in this study found their clinical experiences invaluable. However, sometimes mature students were given roles and responsibilities beyond their scope of practice because of their age and apparent experience. This often conflicted with their supernumerary status and compounded the differences between them and their traditional counterparts. This was not perceived as negative by the students themselves as it contributed to a wider range of learning experiences.

A cluster and inferential analysis of myocardial infarction symptom presentation by age

Background: Pre-hospital delay time in myocardial infarction is usually longer in older than in younger patients, with symptom presentation known to be a contributing factor. Aim: The aim of this article is to examine symptom presentation differences, by age, in patients with myocardial infarction. Methods: This is a cross-sectional study using secondary analysis of a multi-site randomised controlled trial on pre-hospital delay time. Data were analysed using logistic regression and factor analysis. Results: Post-myocardial infarction patients were recruited prior to discharge (n=1211), 54% were ≥65 years and 80% male. The average number of symptoms was three, with the ≥65 years age group reporting significantly less symptoms. Logistic regression controlling for gender, diabetes and diagnosis with 11 symptoms (χ2=52.09, p<0.001) was significant. Those ≥65 years had less chest symptoms, sweating, stomach upset and left arm pain, in addition to longer pre-hospital delay time. This group also had less symptom clustering and fewer symptoms within atypical clusters. Non-chest clusters occurred in 22% and 18% of the older and younger group respectively. Of note, two clusters ‘atypical’ (upset stomach/sweating) and ‘typical arm’ (right and left arm pain symptoms), accounted for 14% and 5% of myocardial infarction presentations in the ≥65 years group, within which 25% and 24% had no chest symptoms. Conclusions: The results of this study indicate that myocardial infarction symptom presentation in older patients is likely to be less recognisable and more complex. Increased awareness of the presentation profile of older patients could expedite their triage, diagnosis and, consequently, their prognosis.

A cohort study examining the factors influencing changes in physical activity levels following an acute coronary syndrome event

Background: Low physical activity has long been identified as a risk factor for coronary heart disease. Aims: The aim of this study was to determine the factors that influence changes in the physical activity of patients following an acute coronary syndrome event. Methods: The prospective, inferential cohort design recruited patients admitted to hospital following an acute coronary syndrome event across five research sites. Physical activity was assessed using the short form international physical activity questionnaire. Results: Data were collected at baseline and 3 months on 380 patients. The sample profile was: 21% women; body mass index 28 ± 4.6; unstable angina 36%; ST-segment elevation myocardial infarction 25%; non-ST-segment elevation myocardial infarction 39% and a mean age of 63 ± 11.8. There was a significant improvement in physical activity at 3 months (n=380, t=−3.704, P≤0.001). All regression models, baseline, 3 months and change in physical activity were significant (p≤0.001). Low physical activity was associated with: at baseline not having health insurance, older age and depression; at 3 months not having health insurance, not in employment and low baseline physical activity; and improvement in physical activity was associated with low physical activity at baseline and not being in employment. Conclusions: While physical activity improved significantly, 45% did not reach guideline recommendation levels at 3 months post-event. Physical activity change was little influenced by sociodemographic, clinical, psychological and behavioural factors, suggesting the need to look elsewhere such as behavioural change and improved processes across the care divide to improve physical activity in this at-risk population.