Acute coronary syndrome (ACS) is a situation whereby the coronary arterial blood supply to the heart is suddenly reduced or blocked. Therefore, the major symptom patients with ACS exhibit is chest pain (Katz et al., 2017, p. 967). A considerable number of patients with the suspected ACS make up a relatively large percentage of emergency department (ED) cases in hospitals. As a result, overcrowding in the ED becomes a significant problem in the effectiveness of treatment; thus, the door-to-diagnosis time is relatively long putting the patient’s life at risk. It could also lead to misdiagnosis of the patient due to the vast extension of symptoms related to ACS (Katz et al., 2017, p. 968). Reducing the door-to-diagnosis time allows for timely intervention by physicians and also minimizes the risk on the patient’s life. The reflective or meditative approach concept in Watson’s theory of caring inspires this outcome in the realization of ways to help tackle this problem.
There have been studies done to determine ways of timely detection and accurate diagnosis of ACS. One of these ways is the use of resting echocardiography in CPU patients before the onset of changes in the ischemic ECG or elevated troponin-T levels (Body et al., 2011, p. 1332). The CPU aims to ensure that there are very few or no cases of misdiagnosis of ACS. According to Vito Maurizio et. al, misdiagnosis cases occur in 2%-8% of these patients and often leads to an increase in mortality. Identification of chest pain in the CPU is made by physical examination, history, serial ECG and cardiac enzymes. These parameters, however, have certain restrictions for detection of ACS since they are unable to detect the left ventricle wall motion abnormalities, an accurate predictor of ACS. Resting echocardiography can discover brief hypokinesia or akinesia in parts of the left ventricle wall during ischemia, and the normal wall motion after ischemia is resolved (Body et al., 2011, p. 1334). Ischemia refers to the reduced blood flow into the heart as a result of arterial damage causing heart muscle injury (Myocardial infarction).
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Several factors could lead to the presence of WMAs after coronary occlusions. These include the duration of the obstruction or occlusion, size of the risk ischemic region and the parallel blood flow. As the region of ischemic risk decreases, so does the echocardiography sensitivity for the detection of an ACS (Katz et al., 2017, p. 971). The appearance of WMAs can be seconds after the myocardial ischemia onset and can also be identified before the start of ECG changes and medical symptoms. Echocardiography can detect these WMAs enable it to be an accurate diagnostic tool for diagnosis of myocardial infarction. In addition to this, echocardiography has greater sensitivity compared to ECG and offers more diagnostic information.
Kontos MC evaluated the incremental value provided by echocardiography and revealed that it could prove to be a useful tool in the identification of patients with myocardial infarction and ischemia. He concluded that early echocardiography in triaging patients could be used to distinguish patients initially thought to be at low risk into two groups; those with normal echocardiograms and could be subject to early discharge and those with abnormal echocardiograms who need to be admitted into the intensive care unit. In comparison to ECG monitoring and serial measurement of troponin-T, serial rest echo-monitoring of WMAs had the shortest time to diagnosis from CPU admission (Reichlin et al., 2012, p. 1211). Thus, resting echocardiography possesses both accuracy and timely diagnosis advantages because it can detect left ventricle wall motions earlier than ECG or elevation of cardiac markers like troponin-T.
Another way of diagnosis of ACS is the use of a single high sensitivity troponin to enable identification of low-risk patients suitable for discharge taken at the ED (Rubini Giménez et al., 2013, p. 3897). Current stipulated protocol requires two tests of non-high-sensitivity troponin between 6h and 12h after checking into the ED. Most of the patients take a long time before being cleared to go home yet only a handful have a final diagnosis on ACS (Rubini Giménez et al., 2013, p. 3899). Many reports suggest that high-sensitivity troponin tests could be used to reduce discharge time by using several testings over 3-6h. The TRUST study attempted to compare the diagnostic accuracy of ADP using initial undetectable high sensitivity troponin (hs-cTn) levels (Reichlin et al., 2012, p. 1211).
This study determines whether a novel ADP for unconfirmed ACS could confidently identify low-risk patient suitable for discharge after a single hs-cTn taken on arrival at the ED. The TRUST ADP approach has immense clinical utility and has high diagnostic accuracy (Thokala et al., 2012, p. 1499). It translates into precision when identifying those who require immediate revascularization. Assimilation of this procedure would decongest ED, reduce hospital admission rates and optimize resources. A diagnostic strategy that reduces staff time and increases in health accuracy significantly improves the healthcare service.
The other way of diagnosis of ACS is the use of different biomarkers besides cardiac troponin. These biomarkers could be used as alternatives or complementary to high sensitivity cardiac troponin useful in early diagnosis of ACS and also monitoring its progression and prognosis assessment (Rubini Giménez et al., 2013, p. 3991). These biomarkers possess potential sensitivity and selectivity that allow for a diagnostic and prognostic view into the tissue-specific injury processes and are used in the ACS risk stratification process. Risk stratification is performed better by combining the history of the patient and the available medical data with ECG evaluation and repeated analysis of blood to check for relevant biomarkers.
Methods and techniques are continually explored to increase lower detection levels hence increasing the sensitivity of measurement. For instance, as part of a recent survey by Yanyan, 47 were identified to be associated with coronary artery disease. On the other hand, there are those that measure only a single biomarker separate from other possible analytes in a given sample thus owing to the selectivity of measurement (Reichlin et al., 2012, p. 1218). Biomarkers should, therefore, be specific for the process disease entity and the stage of the disease being tested which in this case is ACS. It thus lowers the patient’s risk.
Research has given a fresh outlook on more effective ways of reaching out to patients with ACS. Technology in the medical field has evolved hence a routine update from nurses would increase timely intervention in the ED (Rubini Giménez et al., 2013, p. 3901). Adding the number of ECG devices and ensuring a nurse is in charge of performing ECG for each shift would accelerate treatment services to these patients. Embracing the ideologies that are in line with the artistry of caring-healing activities promotes healthy living. Being keen towards listening to a patient's complaints could save their life. Patients coming into the ED with chest pains, whether typical or atypical, should undergo screening using ECG and results interpreted as soon as possible. Another approach to reducing the length of stay in the ED would be to target this group of patients with carefully drafted protocols (Thokala et al., 2012, p. 1502). This would aid in decreasing door to door diagnosis time.
Prior studies have demonstrated a rising need for nurses to engage patients in a discussion about healthier lifestyle choices (McNeely, 2005, p. 292). A patient who has undergone counseling on heart-healthy living is likely to adjust health beliefs. Offering guidance at the CPU would result in changing cardiovascular risk behavior amongst the patients. In addition to this, it would help address misconceptions regarding healthy lifestyle choices. Regular and timely follow up as an outpatient is a way of assessing the patient's progress. Intentionally creating healthy environments through counseling is a fundamental skill (Nahm, Warren, Zhu, An, & Brown, 2012, p. 24). Having a personal touch with the patients as they interact one on one with the nurses brings about positive outcome experiences (Lamke, Catlin, & Mason-Chadd, 2014, p. 280). Nurses ought to consider demographic factors, medical comorbidities as well as general health to better understand the patient's needs. Developing an extensive understanding of a patient's health beliefs and readiness to adjust are key strategies that would help CPU patients. The counseling programs should also focus on binding energy across risk behaviors.
Decongesting the ED would help ease the workflow. It would increase response time and facilitate immediate aid to patients walking in. Grouping patients who have been screened for possible ACS can be done by combining patient's records, available medical data on ECG, and several blood analyses for relevant biomarkers (Sitzman & Watson, 2013, p. 52). Focusing on ideas that incorporate clinical assessment would reduce the number of patients sent home after a missed diagnosis of ACS. The presence the ED personnel and fast response to aid the ailing patients who walk in with chest pain would save lives. Acknowledging and being fully present when needed is an effective plan of caring for others. Critical thinking is a necessary skill that would aid in risk stratification of patients with ACS thus saving on door-to-door diagnosis time (Thokala et al., 2012, p. 1500). This will relate to the Watson’s Caritas process that requires one to creatively use themselves and all ways of knowing as part of the healing and caring process by using the artistry of caring-healing practices as highlighted earlier.
In regard to the core concept Watson’s theory of caring, using the reflective or meditative approach, it can be seen that by employing the methods of treatment discussed, the door-to-diagnosis time is significantly reduced hence resulting to effectiveness of treatment of patients and also gives a better understanding on how to go about management of ACS patients in the ED (Sitzman & Watson, 2013, p. 77). Thus, by understanding the essence of time in relation to the handling of patients in the ED, it is possible to actualize Watson’s Caritas process of using oneself and all possible ways of knowing as part of the caring process for the ACS patients.
References
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Rubini Giménez, M., Hoeller, R., Reichlin, T., Zellweger, C., Twerenbold, R., Reiter, M., … Mueller, C. (2013). Rapid rule out of acute myocardial infarction using undetectable levels of high-sensitivity cardiac troponin. International Journal of Cardiology , 168 (4), 3896-3901. doi:10.1016/j.ijcard.2013.06.049
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