Effect of Implementing Clinical Pathway Guidelines on Patients' Clinical Outcomes with Acute Coronary Syndrome
Acute coronary syndrome refers to a range of potentially life-threatening conditions that affect the coronary artery blood supply to the heart. It is associated with increased patient mortality, length of hospital stay and health care costs. Clinical pathways are now one of the main tools that used to manage the quality in healthcare concerning the standardization of care processes. Hence, the aim of this study is to evaluate the effect of implementing a clinical pathway guideline on the clinical outcomes of patients with acute coronary syndrome. A quasi experimental research design was utilized in this study and it was conducted on 60 adult patients at the Cardiac Intensive Care Unit of Tanta University Hospital. The patients were divided into two groups (control and study group) 30 patients in each. The control group: non-clinical pathway group involved patients receiving the routine management regimen while the study group: clinical pathway group (CP group) involved patients who received management according to the clinical pathway guidelines. The findings of this study revealed that a significant changes among control and study group from admission to discharge regarding mean scores of body temperature, Pulse and respiration rate where P<0.05. There was significant increased mean score of central venous pressure among control group compared to study group on admission, after 2 hrs and on 2nd day of admission with P=0.013, 0.007 and 0.001, respectively. The present study showed that low percentages (20.0 %) of control group had cardiogenic shock compared to none patient in the study group with a significant difference between two groups, where P=0.012. Insignificant difference was observed between control and study group regarding duration of stay in ICU and status of patients on discharge with P=0.075 and 0.206. Also it was noticed that the level of reduction of the mean of Hamilton Anxiety Score in the study group was higher than its level in the control group on discharge. It can be concluded that the established pathway achieved its goal of, improving physiological parameters and decreasing patient's complications, length of stay, and anxiety levels. Based on the findings of this study, the following recommendations are suggested; clinical pathway should be implemented routinely for patients with acute coronary syndrome. Integrating ACS clinical pathway into plan of care to replace the traditional nursing care plan.
Safaa Eid Sayed Ahmed,
Nagwaa Ibrahim Abbas,
Sameh Samir Khalil,
Effect of Implementing Clinical Pathway Guidelines on Patients' Clinical Outcomes with Acute Coronary Syndrome, American Journal of Nursing Science.
Vol. 6, No. 5,
2017, pp. 401-417.
Wasserfallen J, Berger A, Eckert P, and Yersin B. Impact of medical practice guidelines on the assessment of patients with acute coronary syndrome without persistent ST segment elevation. International Journal for Quality in Health Care, 2004; 16(5): 1-7.
Fox KA, Goodman SG and Klein W. Management of acute coronary syndromes. Variations in practice and outcome. Findings from the Global Registry of Acute Coronary Events. Eur Heart J, 2002; 23: 1177–89.
Jarvis S and Saman S. Diagnosis, management and nursing care in acute coronary syndrome. Nursing Times, 2017; 113(3): 31-35.
Go AS, Mozaffarian D, Roger VL. Heart disease and stroke statistics—2013 update: A report from the American Heart Association. Circulation 2013; 127(6):245-250.
Gomar F, QuilisC, Leischik R, Lucia1A. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl Med, 2016; 4(13):256-270.
Youssef G, Kassem H, Ameen O, Al Taaban H and Rizk H. Pre-hospital and hospital delay in patients with non-ST elevation acute coronary syndromes in tertiary care. The Egyptian Heart Journal, 2017; 69(3):177-181.
Andrikopoulos G, Tzeis S, Mantas I, et al. Epidemiological characteristics and in-hospital management of acute coronary syndrome patients in Greece: results from the TARGET study. Hellenic J Cardiol. 2012;53(1):33–40.
Tawfeek H, Nour M, Bary A, Fattah A. Contemporary retrospective analysis of acute coronary syndrome. An Egyptian study. The Egyptian Journal of Critical Care Medicine, 2016; 4(1):79–84.
Sadaka M, El-Sharkawy E, Sobhy M and Hammad B. Long-term prognostic implication of coronary plaque characterization as detected by 64-multidetector computed tomography in Egyptian population. The Egyptian Heart Journal. 2017; 69:63–70.
Abdel Rahman H, Ghany M and Youssef A. Correlation of fragmented QRS complexes with the severity of CAD (using Syntax score) in patients with non-ST elevation acute coronary syndromes. The Egyptian Heart Journal. 2016; 68(2): 125–29.
Smith J, Negrelli J, Megha B, Hawes E, Pharm D and Anthony J. Diagnosis and Management of Acute Coronary Syndrome: An Evidence-Based Update. Diagnosis and Management of Acute Coronary Syndrome. American Board Family Medicine J, 2015; 28(2): 283–93.
Ferry C, Fitzpatrick M, Long P, Levi C and Bishop R. Towards a Safer Culture: clinical pathways in acute coronary syndromes and stroke. Medical J of Australia, 2004; 180: 92–96.
Herck P, Vanhaecht K and W Sermeus. Effects of clinical pathways: do they work? Journal of integrated clinical pathways, 2004; 8(1): 95-105.
Li1 W, Liu1 K, Yang1 H and Yu2 C. Integrated clinical pathway management for medical quality improvement – based on a semiotically inspired systems architecture. European Journal of Information Systems, 2014; 23, 400–417.
Cheah J. Clinical Pathways – An Evaluation of its Impact on the Quality of Care in an Acute Care General Hospital in Singapore. Singapore Med J, 2000; 41(7): 335-346.
Rotter T, Kinsman L, James EL, Machotta A, Gothe H, Willis J, Snow P and Kugler J. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Collaboration and published in The Cochrane Library. Published by John Wiley & Sons, Ltd. 2010, Issue 7.
Shields A. Pathways to Improving Patient Safety and Reduced Cost: The Implementation of Clinical Effectiveness Guidelines for Congenital Cardiac Anomalies, Critical Care Nurse J, 2013; 33( 4,):79-82.
Abd-Elwanees A, El-Soussi A, Othman S, Ali R. Effect of Implementing Clinical Pathway on the Clinical Outcomes of Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease. International Journal of Nursing Science,2014; 4(1): 1-10.
Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol,1959; 32:50–55.
Maier W, Buller R, Philipp M, & Heuser I. The Hamilton Anxiety Scale: Reliability, Validity and Sensitivity to Change in Anxiety and Depressive Disorders, J Affect Disorder, 1988; 14(1) 61-8.
Obaya M, Yehia M, Hamed L and Fattah A. Comparative study between elderly and younger patients with acute coronary syndrome, The Egyptian Journal of Critical Care Medicine,2015; 3(1):69–75
Sadaka M, El-Sharkawy E, Sobhy M and Hammad B. Long-term prognostic implication of coronary plaque characterization as detected by 64-multidetector computed tomography in Egyptian population. The Egyptian Heart Journal, 2017; 699(1): 63–70.
Keddeas V, Swelim S and Selim G. Role of 2D speckle tracking echocardiography in predicting acute coronary occlusion in patients with non ST-segment elevation myocardial infarction, The Egyptian Heart Journal, 2017;69(2): 103-110.
Hadi AR, Ahmed H, Wael A, Jawad A, and Jassem A. Marital Status and Outcome of Patients Presenting with Acute Coronary Syndrome: An Observational Report. Clin. Cardiol J, 2011; 35(12):741-8.
Bi Y, Gao R, Patel A, Su S, Gao W, Hu D, Huang D, Kong L, Qi W, Wu Y, Yang Y and Turnbull F. Evidence-based medication use among Chinese patients with acute coronary syndromes at the time of hospital discharge and 1 year after hospitalization: Results from the Clinical Pathways for Acute Coronary Syndromes in China (CPACS) study. Am Heart J, 2009;157(3):509-16.
Abdelmoneim H, Ali H and Abdulkader S. Demographics of Acute Coronary Syndrome (ACS) Egyptian patients admitted to Assiut University Hospital: Validation of TIMI and GRACE scores. The Egyptian Journal of Critical Care Medicine, 2014;2(1):3-11.
Shaheen S, Magdi A, Esmat I, Mohannad A, and EL Kilany W. National Heart Institute Acute Coronary Syndrome Registry. Med. J. Cairo Univ, 2012; 80( 2): 141-149.
Kumar A, Sathian B. The clinical utility of lipid profile and positive troponin in predicting future cardiac events. Asian Pac J Trop Dis, 2012;2(1):66–69.
Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK. update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American college cardiology/American heart association task force on practice guidelines. Am Coll Cardiol, 2008;51(1):210–47.
Kumar A and Sathian B. Correlation between lipid profile and troponin I test results in patients with chest pain in Nepal, Asian Pac J Trop Biomed, 2013; 3(6): 487–491.
Peppes V, Rammos G, Manios E, Koroboki E, Rokas S, and Zakopoulos N. Correlation between myocardial enzyme serum levels and markers of inflammation with severity of coronary artery disease and Gensini score: A hospital-based, prospective study in Greek patients. Clin Interv Aging J. 2008; 3(4): 699–710.
Apple S. High-sensitivity cardiac troponin assays: what analytical and clinical issues need to be addressed before introduction into clinical practice. Clin Chem J,2010; 56(6):886–91.
Sekiyama H, Nagoshi T, Komukai K, Matsushima M and Katoh D. Transient decrease in serum potassium level during ischemic attack of acute coronary syndrome: Paradoxical contribution of plasma glucose level and glycohemoglobin. Cardiovasc Diabetol J. 2013; 12(1): 4.
Madias JE, Shah B, Chintalapally G, Chalavarya G and Madias NE. Admission serum potassium in patients with acute myocardial infarction: its correlates and value as a determinant of in-hospital outcome. Chest J. 2000;118(4):904–913.
Foo K, Sekhri N, Deaner A, Knight C, Suliman A, Ranjadayalan K and Timmis AD. Effect of diabetes on serum potassium concentrations in acute coronary syndromes. Heart J. 2003;89(1):31–35.
Biyani S, Lodha R and ZLal R. Study of Serum Electrolytes and Blood Urea Levels with Cardiac Markers in Acute Myocardial Infarction. Sch. J. App. Med. Sci J, 2016; 4(5):1570-1573
Samiullah S, Qasim R, Imran S and Mukhtair J. Frequency of stress hyperglycaemia and its influence on the outcome of patients with spontaneous intracerebral haemorrhage. J Pak Med Assoc, 2010;60(1):660-3.
Eljazwi I, Mohamed R, Masoud H, Tuwati M, and Elbarsha A. Association of Hyperglycemia with In-Hospital Mortality and Morbidity in Libyan Patients with Diabetes and Acute Coronary Syndromes. Oman Med J. 2015; 30(5): 326–30.
Schwartz DS, Bremner RM, Baker CJ. Regional topical hypothermia of the beating heart preservation of function and tissue. Ann thorac surg, 2001;72(1):804-9.
Atibioke O. Nurses Roles in Assessment of Chest Pain in the Emergency Department (ED), Egina Project Medic J,2015; September 27
Kumar A, Anel R and Bunnell E. Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or response to volume infusion in normal subjects. Crit Care Med J,2004;32(3):691-9.
Michard F, Alaya S, Zarka V, Bahloul M, Richard C and Teboul JL. Global end diastolic volume as an indicator of cardiac preload in patients with septic shock. Chest J, 2003; 124(5):1900-8.
Nikolaoua N, Arntz H, Bellouc A, Beygui F, Bossaert L and Cariouf A. on behalf of the Initial management of acute coronary syndromes section Collaborator. European Resuscitation Council Guidelines for Resuscitation 2015 Section. Initial management of acute coronary syndromes. Resuscitation J, 2015;95 (1):264–277.
Patel R, Bushnell DL and Sobotka PA. Implications of an audible third heart sound in evaluating cardiac function. West J Med, 2009;158(6):606-9.
Johnston M, Collins SP, and Storrow AB. The third heart sound for diagnosis of acute heart failure. Curr heart fail Resp J, 2007;4(3):164-8.
Mooe T, Stenfors N. The Prevalence of COPD in Individuals with Acute Coronary Syndrome: A Spirometry-Based Screening Study. US National Library of Medicine National Institutes of Health, 2015; 12(4):453-61.
Gandh A and Akholkar P. Metabolic acidosis in acute myocardial infarction, Int J Adv Med. 2015; 2(3): 260-63.
Nagai T, Anzai T, Kaneko H and Anzai A. Impact of Systemic Acidosis on the Development of Malignant Ventricular Arrhythmias After Reperfusion Therapy for ST-Elevation Myocardial Infarction. Circulation Journal, 2010;74(1):1808-16.
Ban A, Ismail A, Harun R, Abdul Rahman A, Sulung S, and Mohamed A. Impact of clinical pathway on clinical outcomes in the management of COPD exacerbation, BMC Pulm Med J, 2012; 12(1): 1-27.
Wehrens XH and Doevendans PA. Cardiac rupture complicating myocardial infarction. Int J Cardiol, 2004; 95(2-3):285-92.
Hillis GS, Møller JE, Pellikka PA, Bell MR and Verzosa GC. Prognostic significance of echocardiographically defined mitral regurgitation early after acute myocardial infarction. Am Heart J, 2005; 150:1268–1275.
Roberts HC, Pickering RM, Onslow E, Clancy M, Powell J and Roberts A. The effectiveness of implementing a care pathway for femoral neck fracture in older people: a prospective controlled before and after study. Age Ageing J, 2004; 33(2):178–84.
Barbieri A, Vanhaecht K, Herck P, Sermeus W, Faggiano F, Marchisio S and Panella M. Effects of clinical pathways in the joint replacement a meta-analysis, BMC J, 2009; 7(1): 1-8.
Kwan, J. & Sandercock, P. In-hospital care pathways for stroke. Stroke, 2005; 36(1): 1348–49.
Arora D,. Anand M, Katyal V. K., and Anand V. Anxiety and Well-being among Acute Coronary Syndrome Patients: Overtime Academy of Applied Psychology J. 2010; 36(1): 79-88.
Easton K, Coventry P, Lovell K, Carter L and Deaton C, Prevalence and Measurement of Anxiety in Samples of Patients With Heart Failure. J Cardiovasc Nurs,2016; 31(4): 367–379.
Molloy G Stamatakis E, Randall G, and Hamer M. Marital status, gender and cardiovascular mortality: Behavioral, psychological distress and metabolic explanations, Soc Sci Med J, 2009; 69(2): 223–8.
Psychiat E. Anxiety in patients with acute coronary syndromes, European Journal of Psychiatry, 2014; 28(3):1-8.
Cebeci F and Çelik SŞ. Effects of discharge teaching and counselling on anxiety and depression level of CABG patients. Turkish J Thorac Cardiovasc Surg, 2011; 19:170–6.
Astin F, Jones K, Thompson DR. Prevalence and patterns of anxiety and depression in patients undergoing elective percutaneous trans luminal coronary angioplasty. Heart Lung J, 2005; 34: 393–401.