Critical Path Network: Group closing GAP in heart attack care
System of reminders boosts quality of care
A team of 10 Detroit-area hospitals, led by physicians from the University of Michigan Health System in Ann Arbor, has reported significant success in improving the odds that heart attack patients will get the medicines, tests, procedures, counseling, and follow-ups that have been shown to improve the chances of surviving and returning to a full life.
The initiative and attendant study, sponsored by the American College of Cardiology (ACC) in Bethesda, MD, is called GAP, Guidelines Applied in Practice.
The guideline-recommended therapies, tests, and counseling include:
- aspirin in the emergency department (ED) and after discharge to prevent clotting;
- beta-blockers to reduce arrhythmias;
- angiotensin-converting enzyme inhibitors to aid the heart’s recovery from damage;
- blood cholesterol tests and, in appropriate patients, treatment to lower cholesterol;
- measurement of the pumping capacity of the heart’s left ventricle;
- cardiac catheterization or other heart imaging studies in certain patients;
- angioplasty or bypass surgery in selected patients to open or go around blocked arteries;
- smoking-cessation counseling (smoking doubles the long-term risk of another heart attack);
- diet counseling, with emphasis on low-fat diets;
- referral for outpatient rehabilitation.
The guidelines continually were communicated to physicians, nurses, and in some cases, patients, through a system of reminders, checklists, stickers, standard orders, reference cards, and educational materials.
When compared with their previous records and with hospitals that did not use the system, the participating hospitals significantly boosted the percentage of their patients who got aspirin, beta-blocker drugs, and advice on stopping smoking.
Hospitals have options
Each participating hospital could choose which of the tools in the GAP tool kit they would use. Their options included:
- standing orders for medication and tests;
- pocket cards of medications and guidelines for medical staff;
- clinical pathway that guides nurses through their daily activity;
- special patient information form;
- stickers for the patient’s chart;
- chart that shows the hospital’s overall performance;
- discharge checklist for physicians or selected nurses to review with patients;
- patient education materials, including written and verbal instruction on therapy and lifestyle.
"We presented these to all the hospitals, and they selected the two or three things they felt were most appropriate," says Rajendra Mehta, MD, MS, clinical assistant professor of cardiology at the University of Michigan Health System. "Most chose standing orders and patient education, and all of them chose the physician pocket guide," he says. Some chose critical pathways for nurses."
The laminated pocket guides, about 4 inches by 6 inches, contain reminders of ideal care, such as when to prescribe aspirin or beta-blockers, or thrombolytic therapy and contraindications. "They cover all basic care needs given while in the hospital and at the time of discharge," Mehta says.
Patient education guidelines included a patient visit by the physician at time of discharge. The session included questions the patient had to answer, such as, "I was having a heart attack because . . ." Patients also had to provide the following type of information: "My cholesterol level is ___, and my goal is ____," or "I have an appointment to see Dr. ____ on (date) at (time)."
A significant factor in the program’s success was extensive communication before implementation, Mehta says.
"We communicated with the cardiologist champion and quality managers at each facility, as well as with the CEO. We wanted administrative buy-in," he explains.
The program kickoff took place in the form of grand rounds. Internal medicine, family practice, cardiology, and the ED all were invited, but this was not the first time they had been exposed to GAP.
"At the end of grand rounds, the nurse champion got up and spoke for 20 minutes, reviewing those tools that particular hospital had chosen to use," Mehta explains.
"But long before that, the program had been presented to the physicians at their monthly meetings. So we had physician buy-in even before grand rounds, which I think was very important to our success," he says.
The results indicate that they did something right. The percentage of patients receiving aspirin when they entered the hospital went from 81% to 87%, and the proportion receiving aspirin therapy guidance before they left the hospital jumped from 84% to 92%. Beta-blockers on admission rose from 65% to 74%, and stop-smoking counseling went from 53% to 65%. The highest levels of guidance adherence — more than 77% and up to 100% — were in the one-quarter of patients whose charts showed evidence that the GAP tools had been used.
[For more information, contact:
- Rajendra Mehta, MD, MS, University of Michigan Health System, Ann Arbor. Telephone: (734) 647-6522. E-mail: [email protected].]
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