Small rural hospital produces large QIs
July 1, 1998 5 minutes read
Small rural hospital produces large QIs
This facility's lengths of stay and DTNs improved substantially
Tiny Mount San Rafael Hospital in Trinidad, CO, has a door-to-needle (DTN) time that's faster than that of most large, urban hospitals - 36 minutes. How did they do it? The rural, 32-bed facility replicated the Health Care Financing Administration's Cooperative Cardiovascular Project (CCP) model. The result is an improvement plan that Colorado Foundation for Medical Care, the state's peer review organization, deems one of the state's six best. San Rafael has better outcomes now than ever before, and length of stay has dropped to 2.5 days.
Mike Kircher, RN, the director of strategic quality management at San Rafael, spearheaded a project last year to streamline the facility's diagnosis and treatment of acute myocardial infarction (AMI). He galvanized a multidisciplinary team drawn from the emergency department (ED), the ICU, the lab, radiology, pharmacy, and medical records. Together they deconstructed the processes of diagnosing and testing for AMI and came up with more efficient methods.
"We'd been following chest pain patients for quite a while," says Kircher. "We looked at guidelines from the AHCPR, the AHA, and the ACC, then tried to replicate what the CCP project was doing." The hospital modified its improvement activities to incorporate CCP quality indicators, focussing on DTN, use and timing of aspirin, timing of thrombolytics, administration of beta blockers at discharge, and smoking cessation. The hospital showed improvement in all of the CCP quality indicators on which it focused.
Kircher says they were somewhat limited because there is no cath lab at San Rafael, but they did track the indicators they could. Later they tracked such factors as whether patients got a second EKG within 24 hours and whether patient education was done.
He says the whole staff wanted to work as efficiently as possible, but it's easier now that they've begun working as a team. Two years ago he started collecting data, doing statistical process control, and creating flow charts, check lists, and graphs - specifically tools for improving the administration of thrombolytics. (For examples of some of these charts, see pp. 83-85.) Not everyone jumped on the bandwagon at first, he says. There was resistance among some staffers; some physicians were reluctant to recommend thrombolytics because of the side effects. But he convinced them through hard data that timing counts. In his words, "We had to twist arms." He would tell physicians, "Here's a drug that cuts mortality by 26%. How can you not think this is good care?" Eventually the team won over the rest. Of course the entire staff uses caution. Kircher explains, "It's not a no-brainer, but it doesn't take a lot of training to know whether someone qualifies for thrombolytics."
The team developed a consent form intended to provide patient education as well. The sheet summarizes the major benefits and risks associated with the use of thrombolytic therapy:
Benefits
· Restoration of blood flow to blocked heart arteries - 70% effective if started within six hours of heart attack onset.
· Less chance of death - 27% relative reduction in mortality when compared to not using thrombolytics.
· Reduced risk of heart muscle damage and disability associated with heart attack.
Risks
· Moderate-to-life-threatening bleeding - 5% to 6%.
· Stroke that may cause disability or death - 1% to 2%.
· Irregular heartbeat that may cause death - 6% to 7% risk of ventricular fibrillation or tachycardia.
· Allergic reaction - 2% to 6%.
· Low blood pressure and shock - 5% to 6% risk of shock.
The consent form also points out to patients that thrombolytic therapy is most effective if started within two to six hours of the start of a heart attack.
The team evaluated data on the selected quality indicators quarterly, then shared findings with hospital staff and physicians so they could work together to continuously modify improvement efforts. "When we identified a problem," he says, "we did some quick training with the staff."
In one instance, the ICU staff worked with the team to increase the effectiveness of patient education. Together they addressed the problem of high anxiety levels associated with AMI patients during the first few days of admission. Since anxiety interferes with patients' comprehension skills, the staff recommended giving educational books to patients and families upon arrival.
"We dropped our door-to-needle times from 70 to 80 minutes in 1993 to between 30 and 40 minutes," says Kircher. Long DTNs pose a special problem in a rural area like La Plata County, where Trinidad is located. To get to the hospital from remote ranches along mountain roads can take a couple of hours. Add to that the natural resistance of some patients to even leave for the hospital, and the time is stretched out further.
"A lot had to do with passing appropriate information on to the physicians," says Kircher. "Some physicians were waiting till the patient was in the ED, then would say, `Give the thrombolytics in the unit.' That takes an extra 15 to 20 minutes." Kircher made DTN graphs of where and when the patients got their thrombolytics, and it became obvious that that was where the delay was.
"Also we gave the ED physicians permission to decide on giving thrombolytics," he continues. "That way they didn't have to call up the patients' primary care physicians. That was another way the time was being chewed up." The facility keeps a chart of different primary care physicians - there aren't that many in that part of the state - and their preferences for thrombolytics. They also primed the nurses on how important it was to get thrombolytics going so they would push the physicians.
The hospital's team based improvement efforts on the plan-do-study-act model advocated by quality improvement experts. They identified areas for improvement by dividing processes of care into small parts that could be studied and modified.
San Rafael was invited to present a paper on its success with chest pain patients at the Chest Pain National Conference this past November in Washington, DC.
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