Keywords

Emergency department, Myocardial infarction, treatment-seeking delay, Women

 

Authors

  1. Arslanian-Engoren, Cynthia PhD, RN, ACNS-BC, FAHA, FAAN
  2. Scott, Linda D. PhD, RN, NEA-BC, FAAN

Abstract

Background: Minimizing the time from myocardial infarction (MI) symptom onset to the implementation of lifesaving interventions decreases morbidity and mortality of women who experience an MI. However, not all women seek timely evaluation and treatment for their MI symptoms.

 

Objectives: The aim of this article is to describe reasons for decision treatment delays among women who experience an initial MI.

 

Method: A secondary analysis of narrative data collected as part of a qualitative study examining the triage experiences of women (N = 14) who presented to the emergency department with symptoms of acute MI. The data were analyzed using the Krueger method.

 

Results: Women with severe symptoms sought immediate evaluation. However, 9 of the 14 participants reported delays in seeking immediate evaluation and treatment for MI. Four of the participants who delayed were health care professionals (3 nurses, 1 respiratory therapist). Content analysis revealed 3 themes accounting for the delay: lack of association of symptoms with MI, personal/professional obligations, and refusal to arrive via ambulance.

 

Discussion: Some women who experience MI continue to delay despite symptoms of nausea, indigestion, and fatigue as well as a family history of heart disease and recommendations to the contrary. Reducing delays will improve survival and minimize morbidity and mortality for women who suffer an acute MI.

 

Article Content

Minimizing the delay, the time from myocardial infarction (MI) symptom onset to the implementation of lifesaving interventions, decreases morbidity and mortality of women who experience a MI.1,2 Recent improvements in door-to-balloon time have been noted for women with acute MI who receive an electrocardiogram within 10 minutes of emergency department (ED) arrival3 as recommended.1 However, not all women seek timely evaluation and treatment for their MI symptoms. This continues to occur despite organized national efforts by the American Heart Association4,5 and the Centers for Disease Control and Prevention6 to educate women about MI symptoms and to prompt them to seek early and emergent evaluation and treatment within 1 hour of symptom onset.4 The 3 phases of delay include (1) time from initial symptom onset to the decision to seek medical attention, (2) time from the decision to seek attention to the time to first medical contact, and (3) time from first medical contact to hospital arrival.4 Phase 1 continues to be the longest phase of delay and the one in which most improvement could be achieved.4 A recent call to action recommended increased awareness among women and health care providers of the sex-specific symptoms of women and clinical presentation.7

 

Reducing treatment-seeking delays for symptoms of MI remains one of the greatest challenges in the cascade of events that is needed to improve survival and quality of life among women who experience a MI.1 Further exploration of the reasons why women continue to delay seeking prompt evaluation and treatment for their MI symptoms is needed and will be used to inform future interventions to reduce treatment-seeking delays. A secondary analysis, an efficient and effective nursing research approach,8 was conducted to describe reasons for decision treatment delays among women who experience an initial MI.

 

METHODS

A secondary analysis was conducted on data collected as part of a qualitative, descriptive study that examined the experiences of women who presented to the ED with symptoms of acute MI.9 In brief, the original study, determined to be exempt from ongoing review by the University of Michigan Institutional Review Board, used focus group methodology and the collective experiences of the participants as the unit of analysis. A total of 14 participants who were at least aged 18 years, had an MI within the past 2 years, were treated in the ED, understood English, and who did not arrive to the ED via ambulance were recruited using mail communications, Web site postings, and directing mailings. The participants reported perceptions of both supports and barriers to the MI triage experiences and reported perceptions of age and sex biases.

 

DATA ANALYSIS

This secondary analysis used the Krueger method10,11 to analyze the participants' narrative data. The orally described and audio-recorded data were transcribed verbatim to ensure accurate transcription, to enhance ecological validity, and to provide an accurate account of the dialog and meaning extrapolation. The verbatim transcripts and field notes were read multiple times for accuracy of content and a general understanding of the experience. Repeated readings were conducted to understand the experience from the perspective of the participants. Main ideas or key words were extracted from the narrative data. Emerging themes were examined by questions and then overall. An initial categorization scheme was developed to establish the coding scheme to be used in the analysis. Coding categories were then developed. The data were sorted into developed coding categories, along with supporting statements. Supporting statements were reviewed to ensure that they captured the essence of the experience for the participants. The data were reexamined to see what was left out, and revisions were considered. A final review of the narrative descriptions, identified themes, and supporting statements was conducted to ensure that it was accurate, comprehensive, and completed.

 

The unit of analysis was the collective experiences of all of the participants. Redundancy and saturation across the focus groups were conducted assessing for commonality in description and experiences. As individuals act as self-observers, the data were accepted at face value. At the completion of each focus group, a summation was provided, and the participants were afforded the opportunity to clarify, confirm, or correct the summation. All participants agreed that the presented summary captured their experiences.

 

Adequacy of the sample was determined when data saturation was achieved. Verifiability of the focus group findings was established by an experienced qualitative researcher who reviewed the data analysis and derived themes. Interrater reliability was 100% and was established using the Miles and Huberman12 formula (number of agreements divided by total number of agreements and disagreements).

 

RESULTS

A total of 14 women took part in the focus group sessions. The median age of the participants at the time of the focus group interviews was 60.5 years (range, 35-77 years), and most (n = 12) identified themselves of White/Caucasian race. At the time of their MI, half of the participants (n = 7) were married, half (n = 7) had some college as their highest level of education, nearly half (n = 6) were retired, and approximately two thirds (n = 9) had private insurance (Table 1).

  
Table 1 - Click to enlarge in new windowTABLE 1 Demographics of Focus Group Participants (N = 14)

During the focus group interviews, 4 of the participants identified themselves as health care professionals: 3 as nurses and 1 as a respiratory therapist. Of the 3 nurses, one self-identified as a psychiatric nurse, whereas the other two self-identified as a cardiac device nurse and as an ED registered nurse who used to work in the ED where she was treated. The respiratory therapist indicated that she had worked in critical care and cared for a number of MI patients.

 

Nine of the 14 participants reported delays in seeking immediate evaluation and treatment for their acute MI symptoms. The reported delays occurred despite symptoms of indigestion, nausea, and chest pain described by the participants. A list of symptoms described by participants is presented in Table 2. It is interesting to note that all 4 of the participants who self-identified as health care professionals delayed seeking immediate evaluation and treatment for their MI symptoms.

  
Table 2 - Click to enlarge in new windowTABLE 2 List of Symptoms Described by Participants

The results that follow represent the narrative descriptions from the 9 participants who reported delays in seeking prompt evaluation and treatment. Three themes emerged from the narrative data that accounted for these delays: lack of association of symptoms with MI, personal/professional obligations, and refusal to arrive via ambulance (Table 3).

  
Table 3 - Click to enlarge in new windowTABLE 3 Summary of Focus Group Themes and Narrative Examples

Lack of Association of Symptoms With MI

The participants described feeling "nauseous" and being "up all night throwing up" thinking "this is the flu" and not thinking "this is heart pain" because "I had none of the classic symptoms." One participant said, "it's just that I was so lethargic [horizontal ellipsis] and I probably didn't want to believe I was having a heart attack [horizontal ellipsis] even though we have heart issues in the family and cholesterol problems." Another said, "I have a lot of heartburn issues. I have had them forever. I had no chest pain, none of the classics at all. I was just totally worn out.[horizontal ellipsis] The only symptom I had [horizontal ellipsis] felt like there was a boulder right here when I swallowed." Similar thought processes were described by 2 other participants who said, "I was walking around for a couple of days, you know 24 hours or more, with indigestion, [but] denial that anything is going on at all," and that "looking back on my experience, I realized I was probably having symptoms before I actually had my heart attack." Nevertheless, she did not associate these symptoms with a heart attack.

 

Personal/Professional Obligations

Personal and professional obligations were identified by participants as reasons why they delayed seeking prompt evaluation and treatment for their MI symptoms. One participant said, "We were giving a bridal shower for my daughter; my sister kept saying you are pale, you are pale. I got nauseous, and then I got scared, but I didn't say a word because I am in the middle of my daughter's bridal shower, and I was supposed to be opening gifts with her." Another participant said, "My daughter was just leaving for a trip to Hawaii. She was practically getting on the plane with her and her family and other family members. I asked her if I couldn't wait until I got back [horizontal ellipsis] my friend kept saying, you need to do this [be evaluated] now. You need to do this now." One other participant said she was "out of town with some girlfriends to a cottage when I had my heart attack," which took additional time to travel to be evaluated, and another participant delayed because she was "closing out our jewelry party" when she started "having chest pains." Before going to the ED for evaluation and treatment, 1 participant indicated that she had to "let the dogs out."

 

Refusal to Arrive via Ambulance

All of the participants arrived to the ED using personal transportation, waiting for family and friends to transport them to the ED. Women who experienced severe symptoms sought immediate emergency evaluation. However, 9 of the 14 participants delayed immediate evaluation and arrived to the ED using personal transportation. More specifically, these women reported wanting family members to take them and being "tricked" by friends to go to the ED. One participant said, "I wasn't going to call an ambulance, I wanted my husband to take me," whereas another said, "my sister wanted to call the ambulance, but I wouldn't let her[horizontal ellipsis]so [she] drove me to the hospital." Another participant who described being "tricked" said, "I was tricked into going to the emergency room to start with by my 2 girlfriends, and when I got there, I really didn't want to be there. I thought we were going for a ride when I got into the car." Two participants, one of whom identified herself as a nurse, "who used to work in the ER," indicated that they drove themselves to the ED because the "kids were at school, and husband was at work," and they "really wasn't sure I was having chest pain."

 

DISCUSSION

Findings from this secondary analysis describe reasons that contribute to treatment-seeking delays among women who experienced a MI. The participants indicated that despite symptoms of nausea, indigestion, and fatigue they did not immediately associate these symptoms with a MI; and as such, many of the participants delayed seeking immediate evaluation and treatment for these symptoms, even when they had a family history of heart disease. Furthermore, personal and professional obligations were reasons cited by participants that contributed to delays in the prompt evaluation of their symptoms in the ED. In addition, all of the participants arrived to the ED in transportation other than an ambulance, indicating that family members or friends drove them to the ED. Two participants reported driving themselves to the ED.

 

The reasons provided by participants for their delay align with those previously reported: not thinking their symptoms were severe enough to warrant calling an ambulance,13,14 not associating their symptoms with a cardiac origin,14,15 and because of family responsbilities.15,16 In addition, the reasons provided by participants in this study are strikingly similarity to those reported by Dracup and Moser17-21 who conducted much of the early and seminal work in this area beginning in the 1990s. Particularly noteworthy is the consistent finding of nonattribution of symptoms to a cardiac cause17-19 and the transportation by car to the ED20,21 as reasons for treatment-seeking delays. Similarly, the minimization of symptoms16,22 and the decreased likelihood to attribute symptoms to heart disease23-25 remain consistent contributors to treatment-seeking delays among women with MI.

 

However, despite these similarities, 1 noticeable difference was that health care providers, and in particular ED/cardiac nurses, comprised nearly half of the participants who delayed seeking prompt and timely evaluation for their MI symptoms. These participants arrived to the ED via personal car instead of emergency medical services, even though the use of personal transportation by MI patients increases time to thrombolytic therapy26 and to percutaneous coronary intervention.27

 

Four of the 9 participants who reported not calling an ambulance and delaying time to ED arrival were health care professionals (3 nurses and 1 respiratory therapist who self-reported years of critical care experience with MI patients). After an extensive review of the literature, no other studies that identified delay among health care providers who cared for MI patients when they themselves experience symptoms of MI were found. It is important to note that despite their professional and experiential knowledge these participants failed to recognize their own symptoms of MI, seek immediate evaluation and treatment for their MI symptoms, or call 9-1-1 to be transported to the ED via ambulance contrary to American College of Cardiology Foundation/American Heart Association recommendations.28 It is also particularly noteworthy because data from the nurses heart study consistently show that nurses share the many risks for heart disease (eg, family history of MI, hypertension, smoking)29-31 as nonnurses. As such, it is imperative that they be at least equally knowledgeable of MI symptoms and seek timely treatment to reduce their own cardiac morbidity and mortality.

 

Limitations and Strengths

There are 2 limitations of this study: the self-report of treatment-seeking delays and the sample size of participants available within a secondary analysis. Self-report time of ED delays may not reflect actual time to ED arrival. It will be important for future studies to include an objective assessment of ED arrival times.

 

This study examined the narratives of 14 participants who experienced an MI obtained in a previous study. Although a sample size of 14 might be considered small, the narrative data were rich in detail about the participants' experiences. Morse32 states that the essence of experiences can be discerned from 6 participants, and sample adequacy is not dependent on number of subjects. Achieving thick description of the treatment-seeking decision experience with data saturation among the 14 participants are noted strengths of the study.

 

In addition, the use of existing data is both a strength and limitation to the study. Fortunately, the existing data were sufficient to explore the phenomenon of interest. However, future studies designed to collect prospective data would allow researchers to engage in purposive sampling to enhance representativeness.

 

Implications for Practice, Education, Research, and Policy

Treatment-seeking delays by women, especially health care providers, who experience MI symptoms have implications for practice, education, research, and policy. Health care providers (eg, nurses) must obtain a firm knowledge of MI symptoms and engage in health promotive practices that include arriving to the ED via ambulance to obtain prompt evaluation and treatment for acute MI. The findings from this study indicate that this is an overlooked and understudied area of research in need of exploration. Given that heart disease is the number 1 killer of women in the United States,2 continuing education requirements for all health care providers, especially nurses, should include MI symptoms in women and the need to call 9-1-1 for prompt ED evaluation and treatment. Regulations that mandate this type of continuing education may increase knowledge and promote timely treatment-seeking behaviors for acute MI.

 

CONCLUSION

This secondary analysis examined reasons for treatment-seeking delays among women with MI. A lack of association of symptoms as being MI in origin, personal/professional obligations, and refusal to arrive via ambulance were reported. The findings reveal that some women continue to delay seeking prompt evaluation and treatment for their MI symptoms despite recommendations to the contrary. Reducing delays will improve survival and minimize morbidity and mortality for women who suffer an acute MI.

 

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