Another CCP success: Vanderbilt University MC
Large urban hospital also nets big gains
In response to the Cooperative Cardiovascular Project (CCP) for acute myocardial infarction (AMI), Vanderbilt University Medical Center, a large, urban university hospital in Nashville, TN, initiated an action plan that has improved several quality standards for heart attack patients including:
· Administration of aspirin upon admission - 68% in 1994 to 94% today.
· Administration of beta blockers upon discharge - 50% in 1994 to 95% today.
· Smoking cessation counseling - Only half of patients were counseled then compared with 91% today.
· Length of stay - the median has decreased from 6.25 days to 3.0.
"We attribute our success to education," says Kathy Toto, MSN, RN, ACNP, case manager and nurse practitioner at Vanderbilt. "Our entire multidisciplinary team now has the tools to give these patients what they need in a very short period of time."
Toto points out that the three-day median length of stay is remarkable, but what's more remarkable is that the staff can accomplish all they do in that short time frame. "Our length of stay has fallen to half of what it was three years ago," she says. "Itessential that we continue to provide high-quality, satisfying care despite the shortened length of stay."
But, as she points out, how much can patients really absorb when the staff is doing diet counseling, educating about smoking cessation, developing an exercise plan, and teaching new medications in three days? For one of those days, patients are often recuperating from their catheterizations. They're flat on their backs for four to six hours after the procedures. They have a pressure device on the groin and are receiving pain medications. "During that first 24 hours, we're not able to accomplish much by way of education," Toto says. "For that reason we're now moving some of our efforts toward outpatient education."
Vanderbilt's initiative included the development of these tools:
· The team revised the standing AMI pathway. Implemented this past May, the new pathway reflects advances in care and national standards recognized by the American College of Cardiology and American Heart Association. Those standards are in bold type on the pathway so they stand out. House staff are instructed to document in progress notes when deviations from standards occur. AMI pathways were developed so that the entire multidisciplinary team would know the plan, know their role in it, and work together to benefit the patient.
· The team created "pocket paths" - reformatted and reduced pathways that fit in a lab coat. They are given to nursing staff as well as physicians, interns, residents, and medical students rotating on the service monthly. The pocket paths serve as a quick reference for the multidisciplinary team.
· They devised a patient/family pathway that outlines the hospital course and helps families anticipate what will occur. It is written in laymen's terms with pictures. In addition, a patient education tool teaches about risk factors, exercise, medications, and tests.
Daily trouble-shooting solves problems
A case manager rounds with the cardiology physician team daily. In addition, she interacts with staff nurses daily to discuss care plans and exchange patient information. Toto says these interactions are critical in the success of the pathways.
"We started doing monthly house staff inservices," says Toto. "At a teaching hospital like ours, every month there's somebody new, and they are the ones who write most of the orders. It's important to patient care as well as to the staff's education to understand the pathways." The inservices are presented by the cardiac care unit and telemetry floor medical director in conjunction with a case manager. Mandatory staff nurse inservices also were held to acquaint nursing staff with the paths and specifics about the AMI patient.
Toto says a helpful outcome of this project is just now in the pipeline. "We're working on a computerized system for discharge orders to be posted at our Web site to facilitate the collection of discharge data," she explains. Those will include the medications patients go home on, exercise guidelines, whether or not smoking cessation counseling occurs, cardiac rehab referrals, and so on. When discharging a patient, if a standard of care is deviated from - for example if a patient was not sent home on aspirin - the physician will have to justify why that happened, Toto says. The discharge orders will go to a databank so the outcomes can be collected electronically. That information, formerly collected by chart audit, now populates Vanderbilt's cardiovascular outcome monitoring tool. Also generated will be a list of medications by patient.
"The hook to get the house staff to use the computerized discharge orders," says Toto, "is the program's ability to generate prescriptions so they don't have to be handwritten. If the program didn't do something that was a help to house staff, they probably wouldn't go there." The program will also generate patient information sheets to reinforce and facilitate discharge teaching and follow-up.
Vanderbilt's is an ongoing project. "We're starting to do outpatient data collection as well now and starting to look at lipid management more closely. This is an area that frequently can be overlooked," says Toto. The medical center is formulating a plan for a nurse practitioner-run risk factor modification clinic to address those issues.
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