Heart care methods put ED in top 5%, can help others
Work with cardiologists to implement therapies
The same strategies that landed the emergency department at Albany (NY) Medical Center in the top 5% for overall acute care of patients with acute coronary syndromes (ACS) in a national study can be used successfully in any ED, says an Albany ED physician. But be forewarned: Some interdepartmental diplomacy is key.
The Albany ED was ranked one of the nation’s leaders in the treatment of acute heart conditions when it scored in the top 5% for overall acute care and the top 15% for the administration of drug therapies in the national CRUSADE study. CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) is a research effort established to examine adherence to treatment guidelines published jointly by the American College of Cardiology (ACC) in Bethesda, MD, and the American Heart Association (AHA) in Dallas. (The guidelines are free on the web at www.acc.org/clinical/guidelines/unstable/unstable.pdf.)
The Albany ED scored among the best of the 391 hospitals participating in the CRUSADE study, but the bigger message is what the hospital learned about how best to implement the heart care strategies, says John Broderick, MD, an emergency physician at the hospital. The guidelines are available to any ED, but the key to getting such good results is how well you work with other departments and cardiology groups, he says.
"This is a microcosm of how patient care should be throughout the hospital," Broderick says. "You have to work with other departments on outcomes-based measures, then make a joint effort to implement best practices. The goal is to decrease the anecdotal finger pointing that we’ve all been familiar with in the past."
Simply following the clinical guidelines without that cooperation between colleagues is not likely to succeed, he explains.
The Albany ED was so successful with the CRUSADE guidelines because ED leaders worked closely with cardiology groups, he says. The two teams met regularly to discuss implementation of the ACC/AHA guidelines and especially to go over data showing how well particular parts of the plan were and weren’t being carried out.
A primary goal was to replace the anecdotal information with hard data, while looking for areas of weakness and then addressing them jointly, he says.
The areas of weakness always involved patients not getting the specified drugs within the windows outlined in the guidelines. By communicating frequently with each other, the ED and cardiology groups could work out any disagreements or address mistaken assumptions about who was responsible for administering certain medications, Broderick says. "That is key, because otherwise you just have one side saying the other needs to do a better job."
"When we sat down together to study the data, we could figure out where we came up short and work out how to improve," he points out.
The ACC/AHA guidelines state that drug therapies such as aspirin, beta-blockers, angiotensin converting enzyme (ACE) inhibitors, and heparin, when administered within 24 hours of condition onset, significantly can reduce adverse outcomes. In addition to ranking No. 1 in administering aspirin, Albany Medical Center ranked 34th in administering acute beta-blockers, 44th in administering GP IIb-III inhibitors, and 27th in administering heparin.
Those results are all the more remarkable when compared to how the typical hospital treats patients with heart conditions. Research from Duke University Medical Center in Durham, NC, shows that only one out of four patients with acute coronary syndromes receives the drugs at issue in the CRUSADE project, says Duke cardiologist Matthew Roe, MD, co-principal investigator of CRUSADE.1
"Despite the fact that these drugs have been proven effective in preventing death and heart attacks, they are being markedly underutilized," he says.
Roe says the ACC/AHA guidelines have shown that such evidence-based therapies as aspirin, beta-blockers, and heparin, when given early enough, can reduce the risks of recurrent heart attacks and death.
To ensure that proven therapies are given to patients in a timely fashion, the key is quickly identifying patients in the ED and evaluating their risk for future heart attacks, he adds.
The data show that 89% of patients in CRUSADE were seen first in the ED, he says.
One of the unique aspects of CRUSADE is the close and equal participation of cardiologists with ED physicians to improve the quality of care, Roe says.
"If patients sit in an emergency room for a long time before admission, it is possible that they may not get the appropriate treatments until a cardiologist sees them. By then it may be too late to get the maximum benefit from proven therapies," he says.
CRUSADE provides a platform for cardiologists and emergency medicine physicians to work together to reduce treatment delays and improve the use of beneficial therapies, Roe adds.
The CRUSADE study began enrolling patients in June 2002 and will continue through June 2004. As of January 2003, more than 30,000 patients from the 391 hospitals have been enrolled.
Reference
1. Roe MT, Ohman EM, Pollack CV, et al. Changing the model of care for patients with acute coronary syndromes — implementing practice guidelines and altering physician behavior. Am Heart J 2003; 146:605-612.
Sources
For more information, contact:
- John Broderick, MD, Emergency Department, Albany Medical Center, 43 New Scotland Ave., Albany, NY 12208. Telephone: (518) 262-3131.
- Matthew Roe, MD, Department of Cardiology, Box 3850, Duke University Medical Center, Durham, NC 27710. Telephone: (919) 668-8959.
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