Educational intervention for the management of Acute Coronary Syndrome

INTRODUCTION

Acute Coronary Syndrome (ACS), encompassing Unstable Angina and Acute Myocardial Infarction (AMI), constitutes a grave healthcare concern with noteworthy socioeconomic ramifications worldwide. Its associated mortality and morbidity rates are markedly high, thus underscoring its substantial social and economic significance. Consequently, considerable research endeavors have been dedicated to this domain. Nevertheless, ACS continues to pose a formidable challenge for all involved professionals. Making precise and timely decisions in managing this condition remains a complex task.(1,2)

In the United States, an estimated 8 million emergency consultations annually are prompted by chest pain or symptoms indicative of ischemic events, with approximately 5 million leading to hospital admissions. Among these cases, about 2 million lack cardiac etiology for their symptoms.(3)

Ischemic heart disease claims the lives of more than 7 million individuals annually, and in Europe, one in every 7 women succumbs to a myocardial infarction. Hospital admissions for ST-segment elevation myocardial infarction (STEMI) exhibit varying incidence rates across European Society of Cardiology (ESC) member countries.(4) Among the most extensive STEMI registries was one conducted in Sweden, which reported an annual incidence of 66 cases per 100,000 individuals. Similar data have been compiled in the Czech Republic, Belgium, and the United States, indicating that the incidence rates for STEMI per 100,000 declined from 121 to 77 between 1997 and 2005, while the rates for non-ST-segment elevation myocardial infarction (NSTEMI) showed a slight increase, rising from 126 to 132.(5,6) Consequently, STEMI incidence appears to be decreasing, with a concomitant rise in NSTEMI incidence. Mortality attributed to STEMI is influenced by numerous factors, including age, Killip class, treatment initiation delay, treatment modality, prior history of myocardial infarction, diabetes mellitus, renal insufficiency, the number of affected coronary arteries, ejection fraction, and treatment.(7) Hospital mortality for unselected STEMI patients in national registries across ESC countries ranges from 6 % to 14 %.(8) Recent studies underscore a decline in both acute and long-term mortality after STEMI, thanks to the increased use of reperfusion therapy, primary percutaneous coronary intervention (PCI), contemporary antithrombotic interventions, and secondary prevention measures. Nevertheless, mortality remains considerable, with an approximately 12 % fatality rate at 6 months and higher rates in high-risk patients. This necessitates ongoing efforts to enhance the quality of care, adherence to guidelines, and research initiatives.(8,9)

Cuban statistics have documented escalating mortality rates from 1970 to 1997, spanning from 114 to 160 per 100,000 inhabitants. Nevertheless, in 1998, a slight decline was observed, with a rate of 154, corresponding to 17,143 fatalities ascribed to ischemic heart disease.(10,11)

In our context, a comprehensive statistical analysis of the matter was undertaken by examining the medical records of patients diagnosed with Acute Coronary Infarction within the previous year. The investigation revealed shortcomings in both the patient care and post-treatment monitoring processes. Moreover, disparities in medical opinions and, most notably, a marked lack of adherence to the prescribed treatment protocols in our healthcare facility were identified. Interviews were conducted with the physicians and medical interns responsible for the management of these patients, leading to the determination that a key underlying cause of these deficiencies was their unfamiliarity with the established protocols and the guidelines governing good clinical practices.(12)

METHODS

In light of the described issue, a pertinent question emerged concerning the level of knowledge regarding the management of patients with ACS among residents and medical interns within the Department of Internal Medicine at the "Roberto Rodríguez Fernández" Provincial Hospital in Morón. Consequently, it was deemed necessary to evaluate the efficacy of an intervention program designed to enhance the knowledge of Acute Coronary Syndrome among residents and interns in the department.

To achieve this, a pre-experimental study of the before-and-after design was carried out to evaluate the impact of implementing an intervention program aimed at enhancing knowledge related to ACS among residents and interns. The study spanned from January 1st, 2021, to January 2022.

The study universe encompassed a total of 35 individuals, from which a sample of 30 participants was selected. This sample comprised 11 medical residents and 19 student interns working within the department, all of whom met the inclusion criteria: medical residents and interns who signed the informed consent form and were directly involved in the care of patients diagnosed with ACS. Exclusion criteria were defined as medical residents and interns who did not have direct involvement in the care of ACS patients or who chose not to participate in the study.

The primary data collection method employed in this research was a survey (see annex). This survey, created by the author and validated through expert opinions from the Internal Medicine Department, served as a fundamental source of information for the study. It was administered both before and after the implementation of the intervention program.

To address the requirement for quick and cost-effective information gathering, the survey was initially administered. Following this, an educational intervention strategy (see annex) was executed, with the aim of improving participants' knowledge and skills in the management of ACS patients in alignment with the institution's intervention protocol for this condition. Subsequently, the survey was administered for the second time, two weeks after the completion of the intervention, to fulfill the specified objectives of the study.

The survey and the level of knowledge were evaluated based on the following scales:

Survey Assessment Scale:

High: High level of knowledge: 90- 100 points

Medium: Medium level of knowledge: 60 – 89 points

Low: Low level of knowledge: less than 60 points

The scoring for the questions will be awarded as follows:

Question 1: It will have a value of 5 points awarded for selecting the correct item. (a).

Question 2: It will have a value of 15 points, of which 5 points will be awarded for each correct item (a, c, d).

Question 3: It will have a value of 15 points, of which 3 points will be awarded for each correct item (b, c, e, f, h).

Question 4: It will have a value of 5 points awarded for marking the correct item. (b).

Question 5: It will have a value of 15 points, of which 5 points will be awarded for each correct item [a) Symmetrical T-wave inversion, b) ST-segment elevation, c) Wide and deep Q wave].

Question 6: It will have a value of 15 points, of which 3 points will be awarded for each correct item [If they link items (1 and a), (2 and b), (3 and a), (4 and b), (5 and c)].

Question 7: It will have a value of 30 points, of which 5 points will be awarded for each correct item [(1 True), (2 True), (3 False), (4 True), (5 False), (6 True)].

Questionnaire validation

Question 1 - Adequate: If item (a) is marked - Inadequate: Any other variant.

Question 2 - Adequate: If items (a, c, d) are marked, or at least 2 of them - Inadequate: If only 1 correct item is marked.

Question 3 - Adequate: If items (b, c e, f, h) are marked, or at least 3 of them – Inadequate: If less than 3 correct items are marked.

Question 4 - Adequate: If item (b) is marked - Inadequate: Any other variant.

Question 5 - Adequate: If they complete items: a) Symmetrical T-wave inversion b) ST-segment elevation c) Wide and deep Q wave - Inadequate: Any other variant.

Question 6 - Adequate: If they link items (1 and a) (2 and b) (3 and a) (4 and b) (5 and c), or at least 3 of them - Inadequate: If less than 3 correct items are linked.

Question 7 - Adequate: if (1 True), (2 True), (3 False), (4 True), (5 False), (6 True) are marked, or at least 4 of them correct- Inadequate: If less than 4 correct items are marked.

A database was established in the Excel software to synthesize all the information, and the data were condensed using absolute frequencies and corresponding percentages. To analyze the sociodemographic variables, descriptive statistics were applied, encompassing measures such as mean and standard deviation.

To assess the effectiveness of the educational intervention, the McNemar statistical test was employed to identify significant differences in the level of knowledge regarding Acute Coronary Syndrome before and after implementing the educational program. The McNemar test is a non-parametric test used for paired samples with dichotomous variables. Furthermore, the Wilcoxon signed-rank test was utilized for the analysis of ordinal variables within related samples.

This study was conducted in compliance with the regulations outlined in the Declaration of Helsinki (Somerset West, Republic of South Africa; October 1996). Informed consent was obtained from all selected survey participants. The voluntary nature of participation was explained, and it was emphasized that the data would be treated confidentially, and the participants' identities would be anonymized using identification codes. Autonomy was upheld, since the moment which each participant made an individual decision to participate or not in the research. They were provided with necessary and relevant information about the study in the presence of the researcher, and both parties subsequently signed the informed consent form. Throughout the study, fair and beneficial interaction with the participants was maintained, adhering to the principles of Autonomy, Beneficence, Non-Maleficence, and Justice.

RESULTS Y DISCUSSION

The study encompassed a total of 30 participants, comprising 19 medical interns and 11 internal medicine residents. Among the residents, there were 4 in their first year, 5 in their second year, and 2 in their third year of internal medicine specialization.

Table 1 illustrates the level of knowledge about ACS before and after the intervention.

The data indicates that, before the intervention, 28 professionals (93,3 %) possessed an adequate level of knowledge, while only 2 (6,7 %) were unable to identify the correct concept of the disease. In the post-intervention assessment, all participants responded correctly. Given the initially satisfactory results, there were no significant differences found when analyzing the McNemar Test results, with a p-value equal to one. The conceptualization of a disease is the first aspect to master for its correct identification by medical professionals. Despite being a purely theoretical element, the participants demonstrated a majority proficiency in it.

In the initial assessment, 26 participants (86,7 %) were able to identify correctly these causes, while 4 of them (13,3 %) could not. In the final questionnaire, all respondents (100 %) answered correctly. Although the percentages of knowledge level experienced a positive change, there were no significant differences observed when analyzing the results of the statistical test used.

It can be observed that prior to the intervention, only 16 respondents (53,3 %) possessed adequate knowledge on this aspect. By the end of the study, this figure had risen to 30, representing 100 % of the participants. When analyzing the result of the statistical test used, with a significance level well below 0,05, it can be affirmed that the achieved percentage change was significant. The predisposing factors of Acute Coronary Syndrome are important elements that every healthcare professional dealing with this condition should master. They constitute a tool for prevention, preventing individuals from falling ill, and providing support for the proper management of the patient while offering guidance to their family members.

It is evident that in the initial questionnaire, only 12 professionals (40 %) had an adequate level of knowledge. Upon administering the final survey, 26 (86,7 %) of them exhibited a qualified level of knowledge considered adequate, with only 4 (13,3 %) continuing to hold inadequate knowledge on this subject. The Mc. Nemar test applied in this analysis deemed the achieved percentage change with the intervention program to be significant, as it yielded a p-value well below 0,05. A correct understanding of the diagnostic foundations of any disease, in this case, Acute Coronary Syndrome, is a mandatory requirement for medical personnel to ensure the proper management of the condition and the patient's optimal recovery. This eliminates the need for unnecessary and costly diagnostic procedures that could be iatrogenic for the patient. These results align with those reported in the literature.(13,14)

Prior to the intervention, only 5 individuals (16,7 %) demonstrated a proficient knowledge level in this aspect, which subsequently increased to 17 (56,7 %) following the administration of the final questionnaire. The analysis using the Mc. Nemar test, revealed that the change in knowledge levels achieved through the intervention program was statistically significant, with a p-value of less than 0,05. It is of paramount importance that healthcare professionals caring for patients with this condition possess a comprehensive understanding of potential complications. This knowledge equips them to proactively prevent these complications whenever feasible, promptly identify their emergence, and take appropriate measures to address them.

Similarly, before the implementation of the training program, only 10 of the professionals demonstrated proficiency in the subject matter, accounting for 33,3 % of the total. Following the implementation of the program, 25 of them (83,3 %) exhibited a level of knowledge deemed adequate, as per the validation of the designed questionnaire. The percentage alterations before and after the intervention denoted a substantial shift, with a statistical test value well below 0,05. It is of paramount importance for the physician dealing with this condition to be thoroughly knowledgeable in its appropriate management, thereby minimizing the possibility of complications, including fatal outcomes.

Wilcoxon signed-rank test: -4,695 p = 0,000 (p < 0,05)

Table 2 demonstrates the distribution of participants based on their overall knowledge levels regarding Acute Coronary Syndrome, assessed before and after the intervention. It is evident that, in the initial questionnaire, 16 participants (53,3 %) exhibited a low overall knowledge level. Out of these, 7 transitioned to a medium level, and 9 achieved a high level. Among the 12 participants (40 %) who initially had a medium overall knowledge level, all of them progressed to a high overall knowledge level, while the 2 participants (6,7 %) who initially had a high level maintained their status. The final modifications in the overall knowledge levels, in comparison to the initial levels, showed a significant change when analyzing the results of the Wilcoxon signed-rank test, with a p-value significantly lower than 0,05.

Based on the final assessment, it can be affirmed that the implemented educational program has effectively met the initial objectives. Thus, the program design, encompassing the instructional staff, covered topics, and the duration of the activity, seems to be well-suited for eliciting a positive transformation in the knowledge levels of healthcare professionals concerning this subject.

CONCLUSIONS

Acute Coronary Syndrome is considered as one of the major global health issues, particularly in the context of Cuba, characterized by elevated morbidity and mortality rates, despite the continuous progress in science and technology.(15) Any physician encountering patients presenting any manifestation of Acute Coronary Syndrome (particularly the clinical presentation), should be equipped with a high degree of preparedness as in this condition, the timely and precise diagnosis, coupled with the prompt initiation of vigorous therapeutic interventions, holds the potential to be life-saving and profoundly influences the patient's subsequent convalescence. Hence, it is of utmost importance to uphold a continuous educational approach on the subject, accompanied by the development of diverse pedagogical strategies, such as the present one, to elevate the level of comprehension, especially among professionals in training. This equips them to adhere faithfully to the fundamental principle of a physician: “Primum non nocere” or “First, do no harm”, thereby ensuring the delivery of exceptional medical care, a commitment for all healthcare professionals.

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