For STEMI patients, each hour of D2W delay is correlated with an increase in mortality of approximately 3–8% [3, 18]. Although the care of STEMI patients has progressed substantially since CPC construction was popularized nationally [12], the D2W time can still be accelerated [14, 15]. This study found that although both groups met the requirements of the CPC mechanism, there was a significant delay in the nursing handover group on FMC2BS and FMC2FAD.
To reduce D2W, CPC has set strict time limits for each operation [5], such as FMC2FE < 10 min, FMC2CBR < 20 min, and FMC2FAD < 10 min, most of these operations are carried out by nurses, and all have a common timing starting point: the FMC (first medical contact). Considering the triage role of emergency nurses, the vast majority of STEMI patients have their first medical contact with a nurse [19, 20], after which the ED nurse has many tasks to perform within a short period, such as ECG, blood collection, and assisting the patient with anti-platelet medication. As aging is one of the main risk factors for STEMI [1, 12], blood sampling for STEMI patients could be more complex and time-consuming. In addition, anti-platelet drugs need to be chewed and swallowed so that nurses will instruct and feed water at the bedside.
However, the CPC mechanism fails to regulate a nurse-patient ratio to ensure adequate human resources for the care of STEMI patients. Due to the uneven development of emergency medical services and the lack of human resources for nursing [21, 22]. During the non-nursing handover period, sufficient human resources can enable nurses to carry out multiple operations simultaneously. They can even ask colleagues for help when the process meets troubles (such as blood sampling). Further, a national survey indicates the average nurse-patient ratio is 1:8 during the day, while it can reach 1:23 at night in Chinese general hospitals [21], which will undoubtedly worsen the situation of nursing handover at night. Ensuring adequate human resources is a vital issue to consider when setting up a CPC.
Despite all the competencies required of nurses by the CPC, there is no guidance on the nursing handover, to the extent that many emergency departments with CPCs share a handover regulation with other departments. Only a small number of nurses will stay at the nurse station. In contrast, others have to inspect the whole department and pay attention to hand over a large number of first-aid equipment, drugs, and even environmental sanitation, as well as bedside handover of existing patients. To make matters worse, in many provinces, pre-hospital emergency care is also undertaken by the emergency department, which means that nurses are also required to perform detailed handovers of ambulances [23], which may cost more time and energy. From nursing management, designing a unique set of handover rules for CPCs or upgrading information systems deserves more attention.
As the nursing handover is defined as the handover of nursing responsibilities [24] which is prone to unclear responsibilities, outgoing nurses may be reluctant to take the responsibilities of patients who visit during the handover while incoming nurses are still busy in the handover. This may cause more nurses present in ED during the handover, but fewer nurses to participate in the treatment. At this point, we agree that both the smooth triage of patients and the amicable relationship between the transfer in and out of the nurse can improve the quality of handover, ensure the efficiency of nursing care, and reduce the occurrence of adverse events [25]. This requires that the triage nurses have sufficient knowledge of the disease and triage process, and regular training and assessment are essential. And the working relationship between colleagues considering that there are no managers in the Chinese nursing management system, the leadership of the head nurse will play an important role, which deserves more research.
The physician’s ability to communicate about the condition, the time it takes for the patient to consent to the procedure, and the preparation time in the intervention room may all interfere with D2W, which may account for the lack of significant differences in D2W and patient outcomes. In addition, it was not possible to track ED crowding due to the inherent shortcomings of retrospective studies, which may have influenced it.
Limitations
Firstly, the sample size was not large enough, this CPC was established in 2018 with few patients in the beginning, and to avoid the interference of the Covid-19 pandemic, only cases from January 2018 to December 2019 were extracted. Secondly, as all data come from the same CPC, conclusions should be drawn cautiously when generalizing and applying. Finally, although we include Killip class, age, etc., as confounding factors to ensure the accuracy of the study results, due to the inherent shortcomings of retrospective studies, this study failed to retract the occurrence of ED crowding or nurse-to-patient ratio, which may also affect the results.
