Heart Disease constitutes a major public health problem and it is the leading cause of morbidity and mortality in most developing and developed countries. Cardiac disease is actually a number of diseases and conditions of the heart, or affecting the heart, and the body’s circulatory system. The diseases range from arrhythmia (irregular heart beat) to cardiac arrest (heart attack) and hypertension (high blood pressure). Each year cardiac (or heart) disease kills twice as many people as cancer and eight times as many people as car accidents or infections. Cardiac diseases have a great influence on health. Because of their nature, it should be noted that immediate diagnosis and management are key points in saving lives.

Accident and Emergency Nursing is devoted to accident and emergency nurses and their interests. A&E nurses need to be up-to-date on a wide range of topics. There are a wide range of situations with which the A&E nurse is expected to cope, such as cardiac care, and reflects the scope of the A&E nurse’s responsibilities. The growing number of practical and personal skills needed in A&E nursing creates the many medico-legal issues in A&E nursing and caters for all levels of staff working in emergency settings throughout the world.

As the procedure of resuscitation of cardiac patients with pulmonary arrest are of high importance and are initially carried out in A&E department, therefore, nurses have to deal and face with many difficulties which may result in the low level of healthcare offered to those most in need.

The Effect of the Quality of Nursing Care in Health Services
According to Doughty and Marsh [1984: 11], C.C.U. & A&E nurses need to assure themselves and their patients that they are delivering a high standard of quality nursing care. Previously the health care industry was considered above being questioned about the quality of care, but nowadays, health care is a major industry and each hospital is accountable to its consumers. The availability and quality of health care is determined by the values and expectations of the consumers.

Consumers expect value for their money and count on the existence of services when needed. More and more patients are demanding to be informed partners in decisions regarding their health, and their concerns are now directed at the whole spectrum of their care whilst in a health care institution. As Doughty and Marsh [1984: 4] emphasise, patients now complain, demand, report and sue and have realized that the quality of nursing care is an important factor in patient outcomes.

From a historical perspective, the concern for high quality health care dates back to the 5th Century BC, when Hippocrates established a code of medical ethics, obliging future doctors to swear “never to do harm to anyone”. The history of quality assurance activities in nursing can be traced back to Florence Nightingale’s attempts to improve the conditions of care to the soldiers of the Crimean War in 1858. Her standards to assess the care of the soldiers has been established as one of the first documented efforts of quality improvement work, and since then, assurance of quality nursing care has remained a priority for nurses throughout the world [Kahn, 987: 21]. Subsequently, nursing has developed into a profession with an emerging unique body of knowledge and this has resulted in a growing interest in the improvement of quality nursing care. Whilst this may be true, Cantor [1983: 3] maintains that nurses have not traditionally concerned themselves with the problems revolving around health care delivery nor the health needs of society as a whole.

Nurses have seen their role at the bedside, dealing with the needs of the individual patient, and were unlikely to consider whether their nursing care was delivered in the most effective and efficient way with the maximum utilisation of scarce resources. Therefore it is important that nurses understand the importance of one of the underlying concepts of quality care, and that is accountability.

Bennett [1989: 155] states that to be accountable, we must be answerable for our own decisions and actions, not only to other members of the health team, but to the consumers of health care, whether individual, family or community. Donabedian’s now classic work on quality assurance argues that the hospital is a major component of organized care in the health care system and therefore establishes the standards of care which safeguard the quality of care and is held responsible for the maintenance of those standards.

Bennett [1989: 158] defines standards as being desirable and achievable levels of performance consistent with quality, and if we are concerned with all aspects of quality care then three dimensions can be identified: structure, process and outcome. These dimensions are central to the definition of quality assurance developed by the Royal Australian Nursing Federation [RANF, 1985: 3] “A planned systematic use of selected evaluation tools designed to measure and assess the structure, process and/or outcome of practice against an established standard, and the institution of appropriate action to achieve and maintain quality.”

Peters [1991: 1] describes quality as “elusive” and cites Donabedian as writing that quality represents our concepts and values of health, our expectations of the provider-client relationship, and our view of the role of the health care system.

Role of Education in the Quality of Health Services
Coronary artery bypass grafting (CAG’s) is currently the most widely accepted and successful means of treating patients with coronary artery disease in the short term (Simons & Simons, 1987). Whilst this surgical procedure is not curative, when used in conjunction with coronary artery disease risk factor modification [Tirrell & Hart, 1980, Sivarajan et al., 1983, Scalzi, Burke & Greenland, 1980, Marshall, Penckofer & Llewllyn, 1986], it is a means of improving both the quality of life (Barbarowicz et al., 1980) and the prognosis of those suffering from this often crippling disease.

Most, if not all Cardiac Care Units must provide patients with some form of post-operative rehabilitation education prior to their discharge from hospital following initial recovery after cardiac surgery. This education takes the form of written information, informal or formal presentation of information. Tirrell & Hart [1980: 492], in a study of 30 post operative coronary bypass patients, reveal that an “in-hospital postoperative exercise training... helped”, only two thirds of post cardiac bypass patients to maintain long term compliance with the exercise regimen provided, and suggest that a follow-up programme may help to overcome their non-compliance. Barbarowicz et al [1980: 128] studied patients who had been divided into two groups, one of which had attended slide-sound programmed teaching and the other “informal, unstructured and individualized contact with a nurse”. Knowledge scores were obtained, and the mean difference increase of the slide-sound group was found to be greater than that of the other group. They suggest that current education practices for CAG’s patients require review, and recommend the use of slide-sound presentations which conserve staff time. Scalzi, Burke and Greenland (1980) studied two groups of coronary patients, an experimental one which received an organized education programme (designed to increase knowledge of coronary artery disease and methods of risk factor reduction), the other, education from health care individuals only on patient request. They found that patients’ post test knowledge and compliance scores were not significantly improved in the experimental group, leading the researchers to conclude that patients’ knowledge retention whilst in hospital is impaired, but that such programmes give a necessary opportunity to ask questions, thereby reducing anxiety. Marshall, Penckofer and Llewellyn (1986) assessed the effectiveness of a structured teaching guide used by nurses in educating the patients and their families about normal recovery postoperative to CAG’s, comparative to an unstructured approach. Patients who had been presented with the structured teaching, showed greater total compliance with health risk factors. Wilson-Barnett (1981) reports that of 54 patients who had been employed preoperative to CAG’s, 18 had returned to work within three months, 20 between four and eight months, and 16 patients did not resume.

Sivarajan et al., [1983: 72] studied 258 patients who had received varied programmes of rehabilitation education on smoking, diet and exercise following myocardial infarction. Results indicated that the group teaching programme on risk factors “demonstrated only limited effectiveness”.

Nursing Care at C.C.U. and A&E
Adverse events in hospital associated with medical management are estimated to occur in 4%1 to 17%2 of admissions. Further analyses of such events found that up to 70% of them were preventable 3 4. One of the more serious and clinically important adverse events is unexpected cardiac arrest. Despite the availability of cardiac arrest teams and advances in cardiopulmonary resuscitation the risk of death from such an event has remained largely static at 50-80% [5, 6].Unexpected cardiac arrests in hospital are usually preceded by signs of clinical instability 7 8. In a pilot study we noted that 112 (76%) patients with unexpected cardiac arrest or unplanned admission to intensive care had deterioration in the airway, circulation, or respiratory system for at least one hour (median 6.5 hours, range 0-432 hours) before their index event9. Furthermore, these patients were often reviewed (median twice, range 0-13) by junior medical staff during the documented period of clinical instability. Despite this the hospital mortality for these patients was 62%. Such patients should receive better assessment either for aggressive resuscitation and management or for clear institution of “do not resuscitate” orders with palliative care.

A medical emergency team has been proposed as a pre-emptive response system to manage these patients[9, 10]. In this system when clinical observations reach certain predefined critical limits the primary care nurse or medical officer calls for the team, which responds immediately. Proof that a medical emergency team, most importantingly nurses, can reduce the amount of incidence of and mortality from unexpected cardiac arrest is eagerly awaited, as such a proposal is intuitive. However, the number of such arrests can be influenced by several factors, including the number of “do not resuscitate” decisions made. Buist et al’s paper fails to take this into account, and suffers from other methodological errors too[11]. Some patients receive cardiopulmonary resuscitation despite it being futile, and thus the resuscitation status of critically ill patients must be established. However, any increase in do not resuscitate orders inevitably reduces the incidence of and mortality from unexpected cardiac arrests. The introduction of a medical emergency team increases the number of do not resuscitate orders[12].

Buist et al report that, in 1999, the medical emergency team made 13 such orders for patients who subsequently died but do not report the overall incidence of these orders in the hospital in either year studied. Buist et al [11] determined whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital. They found that early intervention by a medical emergency team reduced the incidence of unexpected cardiac arrest in hospital by about half. Furthermore, the subsequent mortality was reduced from 77% to 55% after the system had been introduced. In their hospital, this was a reduction in mortality by two patients per thousand hospital admissions. Critically ill patients may be identified by clinical signs of dysfunction of the airway, breathing, or circulation. At Dandenong Hospital11, the “traditional” system of management of these patients was hierarchical and depended on the skill, experience, judgement, and timely involvement of relevant staff members. These factors varied considerably and resulted in a poorly standardised and unstructured approach[9].

Early intervention should prevent further deterioration to the point that a cardiac arrest call is made. The observed reduction[11] in calls and associated mortality is consistent with that conjecture.

The implementation of the response system[11] required considerable cultural change throughout the hospital with an education programme and audit process, which could explain some of the observed effects. On the other hand, the potential effect could have been underestimated. During the early phase of implementation junior medical and nursing staff seemed unwilling to broach the traditional system of referral. There were probably still unexpected cardiac arrest calls and unplanned admissions to intensive care that could have been prevented by better use of the medical emergency team.

The areas of questions and the scores given to each area can be summarized as follows:

1-crisis management in both units (23%)
2-daily care in both units (27.4%)
3-patient education (37%)
4-pharmacological cover in the two units (44.8%)
5-job description and getting acquainted with job goal (43.1%)

The second set of questions was meant to study the demographic information and different aspects of personal experiences. The results were gathered in two separate questionnaires and then evaluated. After that the answers were compared with chi-square Fischer and other tests.

The Discussion on the results and the literature review, the conclusions drawn from this investigation and the recommendations, can be listed as follows:

1. A co-ordinated disease management approach may be implemented that includes early assessment in the hospital, comprehensive education, and behaviour modification in order to improve disease management and improve patients’ quality of life.
   
2. In order to obtain better outcomes for the patient, to control and reduce costs and to take the work load off the A&E unit, the further care of cardiac patients after resuscitation in A&E should be moved to specialists in C.C.U. or heart failure clinics.
   
3. A staff nurse as part of a multi-disciplinary heart failure team has an important role in educating patients and their families on the disease process, management and control of symptoms and also providing support following diagnosis of cardiac disease.
   
4. Nurses are the integral providers involved in educating, coaching, monitoring and supporting patients and their families during the cardiac disease process. The staff nurse can assess the signs and symptoms of cardiac destabilization, provide emotional support, counseling, develop behaviour modification techniques, monitor therapy compliance and also act as the healthcare liaison for the patient and their family. This will add extra pressure on nurses. In order to take some work load off nurses, counselors can be a good idea to deal and offer support emotionally to the patients and their families.
   
5. Scalzi, Burke & Greenland (1980) propose that patients’ knowledge retention whilst in hospital is impaired. Simons & Simons (1987: 580), in a study of 97 post CAG’s patients revealed that only 20% had attended a cardiac rehabilitation service and recommend that “a closer partnership needs to be forged between cardiac rehabilitation services and general practitioners, so that the risk factors can be monitored carefully throughout the first year after coronary artery bypass graft surgery and followed by further dietary or drug therapy as indicated”. Hart and Frantz (cited in Marshall, Penckofer and Llewellyn, 1986) indicate that “failure of the physician to support the role of the nurse as a patient educator” is one of the impediments to an effective teaching programme.
   
6. In order to reduce the amount of work load pressure on nurses, and consequently offer better healthcare, nurse triage can be developed to classify patients into those with problems that are of a primary care type and those with accident and emergency needs who are more likely to require investigations, procedures, referral, or admission. By developing a triage decision tree, more authorities are given to nurses to decide and differentiate between accident and emergency and general practice patients. Those presenting with minor injuries considered to be unlikely to require radiography were channeled to see a general practitioner, while those likely to need a radiographic investigation were directed to an accident and emergency doctor. This scheme will increase the standard of healthcare and give more incentives to the nurses to present their ultimate ability to deal with all difficult aspects of patient care.
   
7. Cardiac failure is a major public health problem. Hospital admissions are often unplanned readmissions have a high mortality rate. The departments of C.C.U. and A&E are the most important life saving departments within a hospital. The majority of cardiac failure patients need to be resuscitated and stabilized in the A&E before transferring them to the intensive care unit at the cardiac care unit. Therefore, the level of organizations and management are required to be of high standard to ensure the best care for the patients.
   
8. With regard to personal qualities of nurses, no significant evidence of any lack of personal characteristics of nurses (such as education, knowledge professional skills and training), in any of these two departments was found, and elimination of personal characteristics did not reveal any significant statistical evidence in the quality of service offered.
   
9. Significant statistical difference between the nurse’s motivation, concepts and the Dean’s support was apparent (p<5%).
   
10. In response to the second questionnaire distribution, more than half of nurses in both departments were found to face some kind of difficulties such as daily work load and poor management, which has affected their healthcare efficiency.
    
11. . Further observation was found to be that any big gap between the training periods and practice can have some damaging consequences and it can affect their continuity of care, performance, motivation, decision making and most importantly their nursing concept during their practice.
    
12. Rather than employing a new system of nurse practitioners it would be cheaper to refer the patient directly to primary care services in the community after triage provided that those services are adequate.
    
13. With regard to the staff nurse recruitments, proper consideration and criteria are taken into account in the selection procedure of staff nurses for either of the two units under investigation.
    
14. Regular education, job training, meetings and seminars need to be provided as they are essential to keep their professional knowledge and performance up to date and at a high standard level.
    
15. Interval tests and training may be necessary for those nurses failing to meet the standard criteria in order to ensure a high quality of health care.
    
16. Like Buist et al,3 we have recognized that care preceding admission to the A&E care unit can be improved.4 To do this, a combination of a bedside physiology based scoring system is required to be chosen,5 increased education of nurses in the recognition of critically ill patients, and use of “outreach” nurses with skill in intensive care who can both support patients on the ward and help with their admission to the intensive care unit.
    
17. Unexpected cardiac arrest is a serious and clinically important adverse event that carries a high mortality. 5 6 Such an event is often preceded by signs of physiological deterioration,7-9 which indicates that it is often neither a sudden nor an unpredictable event. Early intervention11 when a patient shows signs of clinical instability could reduce the incidence of cardiac arrest and hence mortality.