An exploratory inquiry into the implementation of prehospital thrombolysis in the treatment of acute myocardial infarction : a case study of a private emergency medical service within South Africa

Abstract

Introduction Patency and the restoration of an occluded artery both during and after ST-segment myocardial infarction or STEMI remains the highest priority in acute coronary care. The gold standard of reperfusion therapy is percutaneous coronary intervention, which represents the internationally recommended practice for STEMI. Although technically a non-surgical procedure, percutaneous coronary intervention constitutes a specialised practice, and therefore remains subjective to the limitations of existing clinical resource capacity. Facilities supporting this procedure require specialised equipment and highly trained medical personnel, both of which are often unavailable in the developing and/or underdeveloped regions of South Africa. Thrombolysis, however, also plays a critical role in the management of STEMI, and is recommended in instances where percutaneous coronary intervention is inaccessible or when time delays are present. In 2009, the Health Professions Council of South Africa (HPCSA) allocated thrombolysis to emergency care practitioners in a move which, it was hoped, would improve patient access to reperfusion therapy for STEMI and, ultimately, the country’s national healthcare profile. Unfortunately, since its approval for use by emergency care practitioners, thrombolysis has yet to be integrated effectively into prehospital practice. The current study aimed to analyse the factors associated with the implementation or lack thereof regarding prehospital thrombolysis, despite the evidence and principles supporting its application. Methodology The research used a case study based on data that was obtained through individual, semi- structured interviews. Participants in various positions in a private emergency medical service were purposefully selected to participate in the study. The requisite data was collected through the interviews with participants, and was grounded in their perspectives, observations, knowledge and experience regarding the implementation of prehospital thrombolysis. Collected data was analysed through both a theoretical and data-driven approach, with the consolidated framework for implementation research conceptualising the data, and thematic analysis facilitating data coding procedures. Findings This study identified four primary themes, eight sub-themes and ultimately a total of 14 discussion points relating to the barriers to prehospital thrombolysis. The primary themes comprised interventional characteristics, inner-organisational settings, outer-organisation settings as well as the characteristics of the individuals involved. Within these primary themes, eight sub-themes recognised barriers relating to cost, complexity, cosmopolitanism, implementation climate, readiness for implementation, leadership engagement, knowledge or beliefs and self-efficacy. The 14 discussion points were focused specifically on these topics and, in a broader sense, also acknowledged the patterns as well as interrelationships between the themes. Conclusions and recommendations Implementation, as a process and science, continues to be underestimated, and within healthcare, affects populations who may have otherwise benefited from new, evidence-based practices, guidelines or policies. Healthcare implementation requires strategic planning, and until key pieces of this process are realised, and implementation gaps filled, the potential to improve outcomes through new practices such as early thrombolytic therapy, will continue to be lost. To narrow implementation gaps, the science, which constitutes this domain, requires further merit, not only from prehospital healthcare providers, but across all healthcare disciplines, especially when attempting change. Greater capacity is required for implementation research and special focus should be dedicated towards extending existing relationships between healthcare deliverance systems, specifically in terms of the continuum of care. To formulate the safest and most cost-effective means of delivering prehospital thrombolysis, South African emergency medical service providers as well as allied and even other healthcare organisations need to consider at least one or more implementation strategies to foster a stepwise progression towards this ideal.