GAP program improves patients’ quality of care
CMs critical to the process
Following evidence-based practice guidelines and standardized treatment protocols can significantly improve the quality of care of patients being treated for a heart attack, according to the results of a recent study performed under the auspices of the American College of Cardiology Foundation’s (ACCF) Guidelines Applied in Practice (GAP) initiative.
Kim Eagle, MD, chief of clinical cardiology at the University of Michigan Health System in Ann Arbor and the study’s principal investigator, says that many groups and academic divisions of cardiology have created effective partnerships with nurses and physician assistants who act as "care extenders" to ensure quality patient care in the management of acute myocardial infarction (MI).
He adds that case managers can be critical to this process by ensuring that the system is properly employed and key quality indicators are applied.
According to Eagle, all members of the team must have a comprehensive understanding of the priorities, and mechanisms must be in place to ensure they are followed.
"The GAP model really says that we need to make sure that all of the people involved in the care itself — the patient, the doctor, the nurses, and/or care extenders or case managers — are in agreement in terms of meeting certain priorities for care and documentation of that care," he explains.
The GAP tool kit includes:
• pocket guideline, an easy-to-use, condensed version of the ACC/American Heart Association Practice Guidelines for the Management of Patients With Acute Myocardial Infarction;
• standard order sets, which serve as a trigger for physicians to make decisions about proven therapeutic measures in heart attack patients and allow physicians to easily order and document appropriate care;
• critical pathway for nurses, which helps them track patients through the normally expected course of events during hospitalization;
• materials for patients to use after they leave the hospital that remind them about the importance of taking their medications, improving their diet, and other activities aimed at preventing future cardiovascular events.
Eagle says the pathway acts as a daily reminder of how and when various tasks must be performed on behalf of patients during their care. The role of nurses is especially important in that process, he says. For example:
- How does the team make sure all of the key steps take place on time?
- When does the patient move out of the coronary care unit?
- When does the dietary team see the patient and his or her family?
- When does the exercise physiologist provide the patient education about exercise?
- When does the smoking-cessation team help patients reinforce the discontinuation of smoking?
- Are patients receiving the right tests?
- Were the right medications added as discharge approached?
- Has the discharge document been examined to make sure that all the key items have been addressed?
According to Eagle, when the system is used correctly, the level of adherence to the targets of quality is exceptionally high.
"The case manager can be a very important person in terms of achieving those goals."
The GAP program addresses patient care from admission to discharge, he says. "We make sure we are addressing the key priorities and documenting when we have not — such as when we are not giving aspirin because the patients are allergic, or when we can’t give a beta-blocker because they have active wheezing."
Effective quality assurance means providing evidence-based care and also documenting when the patient is not a candidate for evidence-based care due to some pre-existing conditions, he says.
According to Eagle, the tool kit helps ensure that the physician, nurse, and patient all are in agreement on the key priorities of care from admission to discharge and beyond. "When there is a system to remind all three of the key targets for care throughout the patient’s stay, the level of adherence to these priorities improves, and patients get better care."
Another key ingredient is the use of standardized order sets and the use of a standardized discharge tool or contract. From the case manager’s point of view, the combination of the tools, especially the standardized order and the discharge document, are essential to support a systematic process for moving the patient through the care that is delivered, says Cecelia Montoye, RN, MSN, CPHQ, co-principal investigator and GAP project manager.
Don’t let patients fall through the cracks
Those tools will help caregivers focus on the most important areas of the guidelines, she explains. While case managers are depended upon to perform these functions for each patient, Montoye points out, they are not present 24 hours a day every day of the week.
"Some patients will slip through the cracks, and the standardized order and discharge document can help other staff members make sure that all of those important aspects of care are provided," she says.
According to Montoye, the tools can be modified by hospitals for their own situation according to the care they provide.
"The discharge document can help make sure the patients are ready to go home and receiving the care they need after they go home. That is something that a case manager often has to backtrack on after the patient has left," she says.
The results of the program were significant, according to ACCF. For example, before implementation of the ACCF-GAP program, only 65% of heart attack patients received beta-blockers within 24 hours of arriving at the hospital. That figure rose to 74%. Similarly, the percentage of patients receiving aspirin within 24 hours of admittance rose from 81% to 87%, and the percentage of patients who were prescribed aspirin on discharge from the hospital rose from 82% to 92%.
These changes mean fewer people will die from their heart disease, Eagle says. Use of beta-blockers in patients admitted for a heart attack has been shown to reduce the risk of death one year after discharge by 20% to 25%. Similarly, use of aspirin in heart attack patients at admission and at discharge can reduce the risk of future heart attacks by a similar percentage.
Smoking-cessation counseling, which improved from 53% to 65%, is particularly important because studies have shown that quitting smoking can reduce the risk of a second heart attack and heart disease-related death by 50% or more.
"The GAP project provided for greater consistency of care regardless of age or gender, and closed the gap of care that existed for the elderly and female patients in several areas of care," Eagle says. "For patients, this means an improved quality of care while they are in the hospital and improved outcomes after discharge," he adds.
[For more information, contact:
- Kim Eagle, MD, University of Michigan Health System, Ann Arbor. E-mail: [email protected].
- Cecelia Montoye, RN, MSN, CPHQ. University of Michigan Health System, Ann Arbor. Telephone: (734) 546-6663.
The GAP tools for heart attack treatment may be downloaded at no cost from www.acc.org/gap/mi/ami_gap.htm.]
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