Knowledge and Practices of Nurses about Streptokinase Injection Administration and Monitoring among Myocardial Infarction in Emergency Room

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Cardiovascular diseases (CVD) are the number one cause of death globally. An estimated 17.9 million people died from cardiovascular diseases in 2016, representing 31% of all global deaths. Pakistan is there in the list of developing countries of the world and the contribution cardiovascular disease (CVD) of developing countries to the global weight of CVD is more than 80 %. Myocardial infarction (MI) is the most prominent cause behind all these mortalities (World Health Organization, 2018). Myocardial infarction is caused by complete blockage of the coronary artery due to a thrombus attach to a rapture plaque. They may have some modifiable and non-modifiable risk factors. Patient may present in emergency department with severe chest pain, dysrhythmias, shortness of breath, and sweating. Due to occlusion of blood supply, cardiac muscle damaging started. Most of the death are due to ventricular fibrillation after ischemia. Myocardial infarction is an emergency situation which requiring immediate diagnosis and treatment. It should be recognized immediately to avoid the consequences. In developing countries, due to different issues including poverty, socioeconomic status, and lack of facilities it’s difficult to identify the proper diagnose. Knowledge regarding myocardial infarction, their signs and symptoms, risk factors provides beneficiary sources in proper identification and treatment. All health care professionals have a good knowledge regarding the patients of cardiovascular diseases. First goal for being a health care professionals in management of myocardial infarction is to diagnoses the condition in very rapid manner. The research topic “What is nurses’ knowledge and practices about streptokinase administration and monitoring among myocardial infarction emergency room (ER)?” was selected.

Aims of the study:

The aims of the study are to assess:

What is the knowledge and practices of nurses about streptokinase injection administration and monitoring among myocardial infarction in the emergency room (ER)?
What is different protocol used for administration of streptokinase in emergency room (ER)?

Background /significance of the research topic:

The reasons behind for selection of this topic are: As working as a charge nurse in ER patient census for usage of streptokinase was huge, due to which medication errors occurred. I have observed different incidences while administrating streptokinase (SK) to myocardial infarction patients i.e. nurses did not follow the protocol streptokinase. It was seen that Foleys Cather inserted after administration of streptokinase and patient started severe bleeding. Another incident was observed that patient was shifted to cardiac care unit (CCU) without proper instruction after SK administration and patient came out of bed and went to washroom due to which he got Cerebrovascular Accident (CVA). Once misinterpretation of electrocardiogram (ECG) also created a big problem. These incidents were different causes, but 80% of these were due to gap in knowledge and practices of nurses. Furthermore, due to overcrowding nurses were not able to give proper attention to the patient. These all incidences have directly effected on patients, which lead to mortality or increased the stay of patients. Most of the time it was seen that patient came with a single problem i.e. myocardial infarction but a single mistake created a lots of problem for him. Therefore I am keen to interest to study the knowledge and practices of nurses regarding streptokinase form myocardial infarction patient in ER.

Tools for measurement of knowledge level of nurses for SK:

Searching from different publications, which given different tools in form of questionnaire, I also want to develop self-development tools will be uses for data collection from participants. The tools will be consist on questionnaires regarding knowledge, attitude and practices of nurses for administration and monitoring of streptokinase drug in emergency rooms. The study design will be quantitative study.

The purpose of the literature review are: identify the gap and inconsistences in the body of knowledge, select proper theoretical frame work and guided propped study. Its helps to refines not only research questions but also selecting suitable design. Furthermore the intervention are developed and refined based of literature review (Polit & Beck, 2013).

Search strategy:

For searching different publications, different search engines i.e. PubMed, Google Scholar, Wiley online library, Journal of Cardiovascular Nursing were searched. Different keywords were used: streptokinase, Nurses knowledge, monitoring and administration, myocardial infarction. The Boolean operator “AND” and “OR” were mostly used for getting significant hits and relevant publications. The Boolean operator “AND” gave condensed and relevant publications regarding the topic and. All publication condensed by Boolean operator “OR” tried to discuss comparison instead of relationship between keywords. An inclusion criteria was kept for the systemic literature search from different databases .articles publication from 2010 to 2019, publication written in English language and participant should be nurses. Although, some publication were out of range according to date of publication criteria but there were a lot of significant literature review regarding the topic and helpful in study. Most of the publication retrieved from different databases were descriptive studies designs and none of publication was available in Pakistani context (See appendix B).

After conducting the literature review from different search engine, 12 relevant publications were selected for review.

Literature Review and synthesis:

In 17th century the idea about angina and chest pain, their risk factors, pathophysiology were known, but there were no proper treatments for it. Till 1950, the treatments for myocardial infarction (MI) were palliative rather than curative. After that the drugs that show effect for treatments off MI were anticoagulants. Furthermore, after 1947 different clinical trials were started on the streptokinase (anticoagulant). Until 1979, the direct administration of streptokinase into the coronary arteries was not tried and it was performed by a small group of patients. The risk intracoronary streptokinase (SK) administration can be classified as cardiac and extra cardiac (Sikri, & Bardia, 2007).An common practice, in all over the world when patients present with chest pain enter to emergency room, nursing staff should have a suspicious of cardiac pain. After taking history and 12 leads Electrocardiogram (ECG) the initial therapy for restoration of perfusion to prevent further damage to the second layer of heart myocardium is given. The initial therapy such as Morphine, Oxygen, Nitroglycerin and Aspirin (MONA) are used for stabilizing the patient’s conditions. While streptokinase therapy is used to dissolve a clot and reopen the arteries or veins, but it cannot be used in all conditions. The administration of streptokinase depend upon the specific criteria and protocol. Nurses who working in emergency rooms, are expected to be knowledgeable about the characteristics of the therapy and able to make decision for administration of streptokinase (Mustafa & Elfaki, 2017). The American Heart Association (AHA) and the World Health Organization (WHO) recognized the key role that nurses and other team members play in supporting the goal to reduce cardiovascular diseases and disability by 25 % in 2025. Nurse’s knowledge is a significant role in proper management and prevention of early morbidity and mortality due to myocardial Infarction. For determination of nurses knowledge about drugs used during emergency management of acute myocardial infarction, Mustafa and Elfaki (2017) conducted a study and reported that most level of knowledge among trained nurses about streptokinase and regard their complication were poor and there were inverse correlation. As streptokinase used for the reopening of arteries and veins, sometime it can lead to undesirable effects. So nurses must be a good observer to master these problems. Nurses should aware about the window periods of streptokinase. Streptokinase prepared, administered, and monitored by nursing staff, that they had an experienced working in emergency department. One of the adverse effect of streptokinase is dysrhythmias, can lead to ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT), which required prompt defibrillation. A study conducted by Mustafa and Elfaki in 2016, regarding the attitude of nurses to defibrillate a rhythmic patient and was found low, shows that 82% of nurses did not fibrillate the patient until the doctor attended. Nurses think that defibrillation is the doctor responsibility. Furthermore, delay in defibrillation could lead to brain death, so patient needs quick interventions and should not be wait for doctor. Being a nurse, it’s our responsibility to know that brain death can occur less than four minutes if blood supply is interrupted (Mustafa & Elfaki, 2016). One of the aspect related to the competency and knowledge of nurses is to, quickly identify the adverse reaction. As streptokinase should be administer through intravenous infusion of 1.5 million units is given over 30 to 60 minutes. Their rapid infusion can lead to hypotension (Aylward, 1996). Sometime, streptokinase causes transient blood pressure loss in many patients and in some of them would also create allergic reactions including rash, fever, and bronchospasm. Another rare complication is cerebral hemorrhage (Zad, 2014). Before deciding for antiplatelet therapy, the identification of different risk factory is necessary. Although the therapy can decrease the risk of ischemic but it can increase the risk of moderate or severe bleeding. Therefore, it is important to carefully select the candidate for extended dual antiplatelet therapy. Selection should be performed on the basis of certain guidelines, while the risk between the ischemic events and risk of bleeding should be balanced. Bobadilla (2018) identified different bleeding risks calculators such as TIMI and CRUSADE, they are designed for the acute setting. Other calculators, HAS-BLED and HEMORR2HAGES are also used. According to Umanath (2012), “A thrombolytic therapy will be considered successful if there was no documented infiltration of the AV access or extravasation of thrombolytic agent”. According to American college of Cardiology (ACC) and American Heart Association (AHA) guidelines emphasize implementing reperfusion as soon as possible after the patient enter the medical system as the most important feature of managing ST Elevation Myocardial Infarction (STEMI). Furthermore, it seems that the chances of mortality is decreasing when fibroblastic therapy is started in initial three hours after symptoms onset. Streptokinase therapy is the sample option to manage STEMI du to its general accessibility, lack of requirement of specialized skills, and ability to rapidly reinstate perfusion when administered in a timely manner (Spinler, 2006). Spinler (2006) identified different causes which can delay to reperfusion and effective treatment are: hesitation of patient to contact health personal, delays due to patients transport issues are common, delays in effective STEMI management may occur in emergency rooms due to overcrowding , lack of proper communication among departmental staff or lack of proper protocol of STEMI patients.

Conclusion:

Although in all developing countries as well as in some develop countries the administration of streptokinase for myocardial infarction is still in high level, but different studies discussed in literature review, identified gap in knowledge, attitude and practices of nurses regarding administration of streptokinase in myocardial infarction. It seems that nurses have experiences of Critical Care Unit (CCU), Emergency Room (ER) ranging from different years but they don’t have knowledge regarding streptokinase and their administration. They just follow the colleagues without any logical reasoning. Nurses working in Emergency Rooms (ER), will be certified for advanced cardiac life support (ACLs) and Basic life support (BLS). Nurses should be aware about the window period, main adverse effects, pre and post teaching of the streptokinase.

In last it is concluded, that the competency in term of knowledge, attitude and practices of nurses directly affect patient with myocardial infarction and receiving streptokinase.

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