The care of STEMI patients has progressed substantially since CPC construction was popularized nationally (Fan et al., 2019), but there is a lack of focus on the possible reduction in efficiency of care during nursing handover. Although the results showed that the time spent on all items was within the recommended range of CPC guidelines, compared with the non-handover period group, the handover period group showed a significant delay in important nursing operations, which eventually contribute to the delay of D2W. For STEMI patients, this may lead to more serious myocardial damage(Ibanez et al., 2018; Menozzi, 2018).
The management of nursing handover is considered to be the primary factor causing this result. As a multi-disciplinary department, the ED is faced with more emergencies and more critical patients than other departments. However, in China, many EDs have the same nursing handover regulation as other departments, during the handover period, only a small number of nurses will stay at the nurse station, and other nurses 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, which may cost lots of time and energy (Kumar et al., 2016). Perhaps this can well explain why there is no significant difference between the two groups in D2FMC and FMC2FE. When the patient comes to the emergency department, the nurses who stay in the nursing station immediately make a primary triage of the patient and fetch a doctor then nurses will do the ECG for the patient before the doctor arrives as they have been taught by CPC guidelines (Zhao et al., 2020). But, after the doctor diagnoses that the patient has potential STEMI through ECG (Gulati et al., 2021), there is a significant difference in the time of further treatment. During the non-nursing handover period, sufficient human resources can enable nurses to carry out multiple operations at the same time, and can even ask colleagues for help when the operation meets some troubles (such as blood collection, IV). By contrast, during the period of nursing handover, fewer human resources with distract attention will make those normal actions precious. Additionally, a national survey indicates in China, there is a huge difference in nursing human resources between day and night in general hospitals. The average nurse-patient ratio is 1:8 during the day, while it can reach 1:23 at night (Shen et al., 2020), which will undoubtedly worsen the situation of nursing handover at night. In addition, the emergency department is a department with a high incidence of nursing interruption. In a Chinese study, 2333 interruptions were observed in 25965 minutes of work in the emergency department, and most of them had negative consequences (Lin et al., 2021) when a nursing interruption occurs during the nursing handover, it may make the situation exacerbated.
Ambiguous responsibility could be another reason for this result. Nursing handover is defined as the handover of nursing responsibilities (Kim & Seomun, 2020). In this period, after 8 hours of shift, outgoing nurses may reluctant to take the responsibilities of patients who visit during the handover, while incoming nurses are still in handover and have not officially started work. This may cause more nurses present in ED during the handover than the rest of the time, but fewer nurses participate in the treatment. At this point, both the smooth triage of patients in the triage (to determine the responsibility) and the good 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 (Thomson et al., 2018).
In addition, the nurses' behavior followed the doctors' orders, but in most hospitals, the doctors' handover time was similar to or overlapped with that of the nurses. This leads to the fact that during handover, doctors also face the problem of fewer human resources and distract attention, when faced with difficult cases, the lack of help from experienced colleagues makes the time of diagnosis and prescribing prolonged, which could also delay the nurses’ operations.
Although this study found that under the CPC mechanism nursing handover would still prolong the D2W for patients, there was no significant difference in patient outcomes between the two groups. This may result from several reasons. Firstly, the time between symptom onset and arrival at the ED in patients with STEMI may influence patient outcomes. Patients may not be present in time because of less severe symptoms, inconvenient visits, or lack of relevant medical knowledge, and these delays may be longer than the d2w delay caused by nursing handover. Secondly, patients' status of emotions and nutrition, and different adherence to medical treatment during hospitalization could also affect the outcomes of treatment. Thirdly, it is possible that the sample size of the study was not large enough to detect relevant issues.