Education earns high comparative AMI rankings
Improvement spurred by desire to be the best’
For some quality teams, being good is just not good enough. That was certainly the case at Providence Hospital, part of the St. John Health System in Southfield, MI.
"We were always good, but we wanted to be the best," recalls Shukri David, MD, chief of cardiology, who was a key member of the team that has earned the hospital high rankings in quality improvement for acute myocardial infarction (AMI) as compared to the state and country by the Centers for Medicare & Medicaid Services (CMS).
Today, the facility ranks well above the state and the nation in the following measures:
- percent of heart attack patients given beta-blockers at discharge;
- percent of heart attack patients given beta-blockers at arrival;
- percent of heart attack patients given aspirin at discharge;
- percent of heart attack victims given aspirin at arrival;
- percent of heart attack patients given adult smoking cessation advice/counseling.
Years of work
David says the efforts began about four years ago, when the hospital adopted new clinical pathways.
"We conducted a 100% view of cases coded AMI," adds Cheryl Pistolesi, RN, CCRN, performance improvement coordinator.
"Since then, the Joint Commission [on Accreditation of Healthcare Organizations] has required core measures to be submitted, and we also submit them to the national system, Ascension Health, to our local system, St. John Health, and the Blue Cross-Blue Shield Center of Excellence [program]," she notes.
To successfully conduct these benchmarks, David explains, "we needed to identify key leaders to help us get the message out. In a hospital as large as ours [460 beds], we really needed to involve a lot of people and touch many different departments."
This was necessary, he explains, because AMI patients often are exposed to multiple areas of the hospital. "We started out with physician champions — designated doctors for each area," David says. These areas included the emergency department, the cardiology and cardiac care units, as well as general cardiologists on the floors.
The next step, he says, was to sit down with physicians and educate them about why they needed to fill out all the hospital forms.
"While they all knew these patients needed beta-blockers, they still needed to be reminded," notes David, adding that these patients can come in at all times of the night and early morning and may be admitted, for example, by interns. Accordingly, the team gave lectures on the appropriate subjects and demonstrated that the data showed the efficacy of the drugs indicated on the forms.
"These physicians also incorporated our residents," Pistolesi adds. "We used family practice and the department of medicine to disseminate all education to our residents."
This was done annually as part of their ongoing education, she explains. "It helped heighten awareness of what we measure, why, and so on," she says.
The forms themselves represented significant modifications over pre-existing forms, David notes. "Eventually, we standardized them across the system, but it was an evolutionary process that took several years," he says. "Now, patients in all areas get the same service."
David points out that for physicians who assert they already know what they need to do, he responds: "So do pilots, but they still need a checklist, and there is a certain minimum we need to do; we understand we are only human, so we need a way of checking what we do."
The forms, Pistolesi adds, are constantly being re-examined "to bring the bar up." If the hospital is performing in the 95th percentile, she notes, "We want to know how we can get to 100%."
Making real changes
St. John is carrying its philosophy into other areas of care to create significant improvement in heart attack management.
"For example, our cardiac cath team has to live within 30 minutes of the facility and be here within 30 minutes [of being called]," David says.
"One big problem nationally is that 92% of hospitals can’t activate their cath team in 90 minutes. But we now have a 24/7’ team, and we have them hooked up, for the first time, to our EMS services with cellular phones that are able to transmit EKGs to the ER. Once the data come across and it looks like a heart attack, the team is activated," he says. The first six cases using this new system saw the patient treated in less than 60 minutes, David reports.
St. John also has local targets for the aforementioned indicators. "For example, when [AMI] patients hit the emergency room door, they get aspirin," he notes. "Our target is 99%, and we are at 99%. If the patient doesn’t receive aspirin, you really need to document why. For beta-blockers, our target is 95%, and we are at 98% to 100% most of the time."
"We look at the data on a weekly basis," says Pistolesi. "As it is being imported into our system, we are getting a running summary, so we have opportunities to concurrently look at cases and see where we can improve." To do that, the appropriate team is brought together and it works through its PI process, she explains. "For example, I handle the ER and cardiology."
The key to ensuring that improvement is ongoing, according to Pistolesi, is "keeping the staff motivated and constantly providing feedback showing their rate of compliance. It has to be on their dashboard’ at all times and in front of them. When the gauges start to read a little bit of concern, we need to examine why through PI."
"We have used the stick’ approach as well," David adds. "As we’ve been able to refine the process, if physicians are not compliant with these pathways, they get talked to. We have not yet limited their admitting privileges, but when they receive a call from the department chair, it makes a big difference."
Need More Information?
For more information, contact:
- Shukri David, MD, Chief of Cardiology, Providence Hospital, 16001 W. 9 Mile Road, Southfield, MI 48075. Phone: (248) 849-3000.
- Cheryl Pistolesi, RN, CCRN, Performance Improvement Coordinator, Providence Hospital, 16001 W. 9 Mile Road, Southfield, MI 48075. Phone: (248) 849-3000.
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