Facilitators, Barriers, and Outcomes of Timely Treatment in Golden Hours for Patients with Myocardial Infarction at Selected Hospitals, Chennai

HIGHLIGHTS

A descriptive correlational study to assess the facilitators, barriers, and outcomes of timely treatment in golden hours for patients with myocardial infarction (MI) at selected hospitals, Chennai, Tamil Nadu, India.

INTRODUCTION

Myocardial infarction is a serious health crisis that demands immediate management. Its early recognition followed by prompt emergency care, improves the patients’ outcomes. Delay in seeking medical aid, after the onset of symptoms might impact the prognosis.¹ The necessity of an early diagnosis among those presenting with chest discomfort is becoming more widely recognized. Prehospital delay is the main obstacle to early reperfusion treatment, which is essential for preserving “at-risk” myocardial and lowering unfavorable cardiovascular events.^2,3 Only a small percentage of patients reach the hospital within the first hour of symptom onset, despite the fact that this window of time increases the patient’s chances of survival. Prehospital delay is the main factor contributing to an increase in both early and late mortality in MI by increasing heart damage and decreasing the chances of survival.⁴ Identifying the facilitators and barriers in seeking timely treatment among MI victims paves the pathway to formulation and regulation of policies of health care services in India to reduce the mortality rate due to delay in treatment among them. Evidence is limited on the facilitators and barriers of timely treatment in golden hours for patients with MI. Hence this study was aimed to assess the facilitators, barriers, and outcome of timely treatment in golden hours for patients with MI.

OBJECTIVES

• To assess the facilitators and barriers of timely treatment in golden hours for patients with MI.

• To assess the outcome of timely treatment in golden hours among patients with MI.

• To find out the association between selected background variables and timely treatment in golden hours for patients with MI.

• To determine the association between the timely treatment and outcome of patients with MI.

MATERIALS AND METHODS

This descriptive correlational study was carried out for four weeks in August 2020, among patients admitted due to MI in the cardiac intensive care unit of the selected tertiary care center in Chennai. The institutional ethical committee clearance and permission from the concerned authorities were obtained. An extensive review of the literature laid the foundation for the development of study instruments such as background variables pro forma, checklist to assess facilitators, barriers, and outcomes of timely treatment in golden hours for patients with MI. The content validity of the tools was obtained from the experts. The reliability was obtained by inter-rater observation method for the checklists to assess the facilitators (r = 0.75), the barriers (r = 0.81), and the outcome (r = 0.82) of timely treatment in golden hours for MI patients. The pilot study was conducted to determine the feasibility and measurability of the tools. A total of 100 patients with MI after being shifted from the emergency ward or cardiac catheterization laboratory were selected by consecutive sampling technique. The study included individuals, who were at least 20 years old, had acute myocardial infarction (AMI) as determined by cardiac markers or an electrocardiogram (ECG), were completely cognizant and coherent (able to explain their symptoms), hemodynamically stable, and had not had chest pain for at least 48 hours. The patients with further severe physical or mental problems were excluded. The researcher briefly explained about the research to the selected patients and the consent was obtained from them and the data was collected two to five days after their admission. The data regarding background characteristics were collected and whether they received timely treatment or not were identified. Those who received timely treatment were interviewed by the facilitators and those who have not received timely treatment were assessed for the barriers using the predetermined tools and their outcomes were assessed. The collected data were analyzed using descriptive (frequency and percentage distribution) and inferential statistics (Chi-square).

RESULTS AND DISCUSSION

The background variables distribution reveals that the majority of the patients were aged above 65 years (65%), males (79%), married (99%), living in urban areas (96%), and had no health insurance coverage (91%). About 32% had a higher secondary level of education, nearly half of them were retired (42%), sedentary workers (45%) with a monthly family income of above ₹50,000 (55%) and 34% of them received information regarding MI through mass media. The results project that gender played a significant role in the delay of treatment since females prolonged the decision-making process due to the presence of atypical symptoms compared with males.⁵ There was a delay in seeking medical help among single/widowed/divorced patients rather than married patients. Figure 1 projects that only 64% of the patients received and 36% of them did not receive timely treatment in golden hours.

The findings of this study revealed that the source of information and history of hypertension were significantly associated with timely treatment (p < 0.05) among patients with MI. The reported facilitators seeking timely treatment in golden hours (Table 1) were the presence of bystander/family members when the symptom first appeared (88%) and family members’ insistence (83%). The family members and mass media are crucial in seeking timely treatment. Since the symptoms occurred during day time (67%), the hospital was within 5 km, quickly recognized as cardiac-related symptoms (69%) they sought prompt medical attention (78%) and sought timely treatment. Considering that they understood the value of prompt treatment due to the perceived seriousness of their symptoms (56%) and preferred attending the emergency department (53%) overseeing a general physician, the majority of patients (61%) either had a supporting person accompany them or managed to get themselves to the hospital. The study concluded that recognition of signs and symptoms of AMI is a decisive factor for the seeking of a specialized service.^5,6 Perkins–Porras et al.⁷ also reported that patients whose symptoms started in the presence of a bystander rather than being alone were more likely to have a short decision time (p = 0.006). Patients who were away from home when their symptoms started had shorter decision times than those who were at home (p = 0.05).

Regarding the barriers to receiving prompt medical attention (Table 2), these include failing to recognize the symptoms as cardiac related (78%), being unwilling to bother people (70%), perceiving the symptoms as being less severe (62%), and being alone themselves when they occurred (61%). More than half of them assumed their symptoms would subside (56%) were unaware that they posed a health risk (52%), concerned about the cost of therapy (42%), and took care of themselves (48%). About 30% of people claimed the hospital was far from where they lived, and 25% said they prioritized their jobs over going to the hospital. According to George et al.,⁸ symptom progression and attempts at home on symptom treatment were found to be major determinants in patients’ decision delays. Prior consultation at the study center, site of symptom onset, symptom interpretation, and method of conveyance were all substantially (p = 0.05) correlated with prehospital delays. Krishnan et al. reported that patients monthly family income and distance to health care facility increased the chance of delayed arrival to health care facility.⁹ The outcome of patients with MI shows that their survival rate was high (98.44 and 86.11%), required only medical management (15.6 and 2.7%), percutaneous transluminal coronary angioplasty (PTCA) (81.25 and 52.78%), 3 days of hospitalization (93.75 and 30.55%), thrombolysis (4.69–5.55%), emergency coronary artery bypass graft (CABG) (1.56–38.9%) and intra-aortic balloon pump (IABP) support (3.12% – 25%) among those who received timely treatment and delayed treatment respectively. There was incidence of complications such as cardiac arrest (1.56–30.55%), embolism (1.56–5.55%), and dysrhythmias (4.69–50%) among those who received timely treatment and delayed treatment, respectively.

There was a significant association between timely treatment and source of information and history of hypertension (p < 0.05), as in Table 3. The family members and mass media play important roles in seeking timely treatment. There was no significant association between the timely treatment and other background variables. Similarly, Farshidi et al.¹⁰ mentioned that a high level of education (p = 0.0492) and a family history of coronary artery disease (p = 0.01) had a positive impact in causing less delay in arriving at the hospital. Patients claimed that self-medication (34.3%) and ignorance of CAD (38.8%) constituted the most frequently cited causes for arrival delays. Direct hospital presentation was found to be independently predicted by smoking, the history of CAD, and the absence of diabetes.² These study findings illustrate that increasing awareness of patients about cardiovascular symptoms and their risk factors could be helpful in patient’s decision in seeking medical help. So general education via media and primary and middle schools could be helpful.

The study findings revealed that timely treatment was significantly associated with the outcome of the patients such as survival, the requirement of CABG, PTCA, increased days of hospital stay, IABP, recurrence of cardiac arrest and dysrhythmia of patients with MI at p < 0.05 (Table 4). It is evident from the study results that when compared to patients who received delayed care, those who received prompt care had a higher survival rate and needed fewer emergency CABGs, PTCAs, and longer hospital stays. Additionally, among individuals who received prompt treatment, the prevalence of sequelae such as cardiac arrest and dysrhythmias decreased. The prompt treatment did not significantly affect other outcomes, such as thrombolysis and embolism. Among patients with AMI, ignorance and symptom denial are important risk factors for prehospital delay. It is recommended that emergency cardiac care in the nation could be improved by raising public knowledge on the advantages of early presentation and by enhancing transportation options.¹¹

CONCLUSION

Nurses play a major role in providing education to people about timely treatment. Many people attempt to get relief from their symptoms by using symptom control management strategies such as taking their own medications, deep breathing exercises, etc. Current AHA guidelines suggest that not obtaining relief from the symptoms within a 5-minute window provides evidence that symptoms may be related to the heart and require immediate attention by a healthcare practitioner. These guidelines need to be more prominent in the general public’s education about MI.

ORCID

Sasikala D https://orcid.org/0000-0001-5324-0743

Manju G https://orcid.org/0000-0002-9566-4912

REFERENCES

1. Ottesen MM, Dixen U, Torp–Pedersen C, Køber L. Prehospital delay in acute coronary syndrome: An analysis of the components of delay. Int J Cardiol 2004;96(1):97–103. DOI: 10.1016/j.ijcard.2003.04.059.

2. Sarı İ, Acar Z, Özer O, Erer B, Tekbaş E, Üçer E, et al. Factors associated with prolonged prehospital delay in patients with acute myocardial infarction. Turk Kardiyol Dern Ars 2008;36(3):156–162. PMID: 18626207.

3. Sudhakar M, Dhakshinamoorthy S, Gnanarani J, Satchi NS. Effectiveness of web quest on high alert medications upon knowledge among nursing students, Chennai. Res J Pharmacol Pharmacod 2023;15(3):99–102. DOI: 10.52711/2321-5836.2023.00018.

4. Wang LJ, Liu Y, Liu XF. Investigating the factors of affecting the treatment delay of AMI patients. Nurs Pract Res 2012;9:8–10.

5. Kereiakes DJ, Weaver WD, Anderson JL, Feldman T, Gibler B, Aufderheide T, et al. Time delays in the diagnosis and treatment of acute myocardial infarction: A tale of eight cities. Report from the Pre-Hospital Study Group and the Cincinnati Heart Project. Am Heart J 1990;120(4):773–780. DOI: 10.1016/0002-8703(90)90192-z.

6. Franco B, Rabelo ER, Goldemeyer S, de Souza EN. Patients with acute myocardial infarction and interfering factors when seeking emergency care: Implications for health education. Revista Latino–Americana de Enfermagem 2008:16(3):414–418. DOI: 10.1590/S0104-11692008000300013.

7. Perkins–Porras L, Whitehead DL, Strike PC, Steptoe A. Pre-hospital delay in patients with acute coronary syndrome: Factors associated with patient decision time and home-to-hospital delay. Eur J Cardiovasc Nurs 2009;8(1):26–33. DOI: 10.1016/j.ejcnurse.2008.05.001.

8. George L, Ramamoorthy L, Satheesh S, Saya RP, Subrahmanyam DKS. Prehospital delay and time to reperfusion therapy in ST elevation myocardial infarction. J Emerg Trauma Shock 2017;10(2):64–69. DOI: 10.4103/0974-2700.201580.

9. Krishnan A, Asadullah M, Kumar R, Amarchand R, Bhatia R, Roy A. Prevalence and determinants of delays in care among premature deaths due to acute cardiac conditions and stroke in residents of a district in India. Lancet Reg Health Southeast Asia 2023;15:100222. DOI: 10.1016/j.lansea.2023.100222.

10. Farshidi H, Rahimi S, Abdi A, Salehi S, Madani A. Factors associated with pre-hospital delay in patients with acute myocardial infarction. Iran Red Crescent Med J 2013;15(4):312–316. DOI: 10.5812/ircmj.2367.

11. Hussain MM, Baharuddin KA, Fauzi MH, Bakar MAA, Ziyan A, Ahmed AZ, et al. Factors associated with prehospital delay in acute myocardial infarction in Maldives. Int J Emerg Med 2023;16(1):31. DOI: 10.1186/s12245-023-00503-2.