Treating chest pain in 90 minutes or less
Hospitals work to apply best practices for acute MI
From the April ACP Hospitalist, copyright © 2007 by the American College of Physicians.
By Paula S. Katz
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Sidebars: The 100,000 Lives Campaign IHI's seven measures of perfect AMI care Tips for success |
When a physician from a small town in Wyoming calls LDS Hospital in Salt Lake City about transferring a patient with chest pain, he'll probably talk to Dean A. Mayer, ACP Member. Dr. Mayer, a hospitalist, will coordinate not only that patient's hospital care but also the actual transfer and discharge.
Dr. Mayer's unique position was created two years ago as LDS, which is part of the 20-hospital Intermountain Healthcare group, attempted to ease the pressure on its busy cardiology group and work toward better outcomes of acute myocardial infarction (AMI).
It's one of many attempts to improve AMI care across the country. Hospitals have been inspired in part by the Institute for Healthcare Improvement (IHI)'s 100,000 Lives Campaign, which ran from December 2004 to June 2006, and by measures from CMS and the Joint Commission, as well as a new program developed by the American College of Cardiology (ACC). The IHI's AMI goal is now part of 12 patient safety interventions in its 5 Million Lives Campaign, which was announced in December 2006.
Although the IHI recommends seven standard measures to improve AMI care (see sidebar), door-to-balloon (DTB) times have received the most attention. The ACC has noted that it's critical to do more than simply recognize the problems that inflate DTB times beyond the recommended 90 minutes; hospitals must also change the overall structure of care. That means enacting new measures, such as empowering an emergency department (ED) physician to activate the hospital's catheterization laboratory or making sure everyone knows what elevator is being used to bring the patient in. This, many say, can only lead to better outcomes.
Roles for hospitalists
As Dr. Mayer uses his internal medicine training to meet the hospital's cardiology needs, he has found that the road to better outcomes begins with a lot of trafficking. He coordinates with the transferring hospital, the air transportation staff, LDS' nurses, and finally the appropriate cardiologists in his 14-physician group, the Utah Heart Clinic, which provides cardiac care for the hospital.
Once a patient is on a floor, Dr. Mayer is there again with the teaching hospital's resident team, which includes two pharmacists, telling the patient more about his condition and medications.
Hospitalists who aren't coordinating care for AMI patients still have a critical role in keeping them informed about heart failure and appropriate diet, exercise and medication management, said Donald Lappe, MD, medical director for Intermountain's cardiovascular clinical program, chair of the cardiovascular department at LDS and chief of cardiology.
But, he emphasized, hospitalists have to do more than just get the patient through the hospital. "Now that care is more fragmented, the hospitalist is an important part of best practice and educating the outpatient doctor," he said. As a result, filling out the discharge forms appropriately is more critical than ever because it allows the patient's physician to understand her condition and fine-tune the care, Dr. Lappe noted.
Overcoming the challenges
Hospitals trying to improve their AMI performance may struggle with how to prepare cardiologists for what some see as a culture shock.
"In some hospitals, cardiologists still prefer that the team for the cardiac cath lab not be activated until the cardiologists in the ER determine that the patient is having an AMI," said Fran Griffin, RRT, MPA, a project director at IHI. But the hospitals most successful in bringing down their DTB times have found that moving away from finger pointing to standardized problem solving reassures physicians that their clinical autonomy will remain intact (see sidebar).
That's what Colleen Kordish, RN, cardiovascular outcomes coordinator, had in mind when she coordinated all computers and other clocks at Advocate Good Samaritan Hospital in Downers Grove, Ill., to verify the hospital's 100-minute DTB data.
"Most physicians didn't believe ... we could be that bad," she said. Only when everyone realized it was a process problem, not a staff problem, did she get staff buy-in, she said.
The 300-bed hospital addressed the problem by substituting cell phones for pagers, adding an extra EKG machine in the ED, teaching the ED technicians how to do EKGs, and instituting a cardiac alert protocol that empowers paramedics or hospital staff to initiate an alert. The result? The hospital's DTB time dropped to an average of 63 minutes, and physicians fostered a culture that considers a false alarm acceptable, Ms. Kordish said.
Relying on evidence also reassured many physicians when Intermountain began looking at its 150-minute DTB performance across its facilities in 1997. Two years later, after staff introduced changes that ranged from allowing ED doctors to activate the cath lab to providing an opt-out order set for its own hospitals, the numbers started dropping. Intermountain's DTB time is now within the 55- to 65-minute range, and 95% of its patients go home on warfarin when indicated, Dr. Lappe said.
Intermountain also shares evidence-based literature to support each therapy, brings its cardiologists together to set goals and uses e-mail to get the word out about changes in practice guidelines.
Sharing best practices is key to the ACC's new campaign, "Door to Balloon: An Alliance for Quality," which is aimed at improving the timeliness of therapies for heart attack patients, said John E. Brush, Jr., ACP Member, chair of the ACC's quality strategic directions committee. Dr. Brush reported that more than 600 hospitals have signed up for the program at the alliance's Web site (www.d2balliance.com). (For more on the alliance, see "Q&A: Improving door-to-balloon time for acute MI" in the February 2007 issue of ACP Hospitalist.)
The future is now?
As many hospitals focus on their own DTB rates, others say another future goal, one the IHI didn't suggest, is already here: allowing a transferring hospital to activate the cath lab.
"We used to stabilize and then transfer the patient," a process that took hours, said Benjamin Chaska, MD, medical director and patient safety officer at the 17-bed St. Peter Community Hospital in Saint Peter, Minn. But now, inspired by the challenge of adapting the IHI's campaign to a small hospital, Dr. Chaska initiates a standardized order set-he has one for each of three regional centers posted on a wall-and uses a single phone call to fast-track the patient to one of the hospitals.
"At the other end they hold the cath lab open for the patient just on our say-so," he said. As a result, DTB times from St. Peter to the hospitals-some as far as 70 miles away-have dropped to less than 90 minutes.
On the receiving end, a lot of the bugs that have been worked out have saved time-and probably lives. For example, at the 619-bed Abbott Northwestern Hospital in Minneapolis, one of the hospitals where St. Peter's transfers patients, a security guard meets every helicopter so there's no confusion about which of the seven elevator banks will be used. Also, IVs are always started on the right arm because the patient will be shifted to the left on the cath table.
"Little things made a huge difference," said Barb Tate Unger, RN, director of emergency cardiac services for the Minneapolis Heart Institute at the hospital. The hospital gets about 40 AMI patients a month, and DTB time is 46 minutes from the time a patient leaves a partner hospital to the time a balloon is inflated in the Abbott Northwestern cath lab, she said.
"Thanks to our 33 partner hospitals' willingness to collaborate and test new strategies, the Level One Heart Attack Program has accomplished great times. Because our partner hospitals do so much work on the front end, we're able to be much faster on the back end."
Meeting AMI needs is an evolving, hospital-specific process that LDS' Dr. Mayer said keeps him thinking of new ways to meet his facility's needs. So far he's added mid-level staff and is planning to start rotating in some Saturdays to make sure the handoffs are foolproof. The system's effectiveness, he said, shows in patient satisfaction as well as patient outcomes.
"I make sure patients are communicated to in an optimal fashion and their questions answered," he said.
And although patients follow up with their cardiologists after discharge, Dr. Mayer gives them a unique connection to their experience at LDS: his business card.
Paula S. Katz is a freelance writer in Vernon Hills, Ill.
The 100,000 Lives Campaign
The Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign ran from June 2004 to December 2006. This article is the second in a retrospective series examining the campaign's initiatives:
- Deploy rapid response teams
- Deliver reliable, evidence-based care for acute myocardial infarction (AMI)
- Prevent adverse drug events
- Prevent central line infections
- Prevent surgical site infections
- Prevent ventilator-associated pneumonia
For information on IHI and links to AMI-specific tools and case studies, go to www.ihi.org. An updated how-to guide on AMI is available online.
IHI's seven measures of perfect AMI care
The ultimate goal for hospitals seeking to improve care for patients with acute myocardial infarction (AMI), according to the Institute for Healthcare Improvement's 100,000 Lives Campaign, is nothing less than perfection. That means providing all of the following components in appropriate time frames, unless there are contraindications.
- Administer aspirin within 24 hours before or after hospital arrival.
- Prescribe aspirin at discharge.
- Administer beta-blockers within 24 hours after hospital arrival.
- Prescribe beta-blocker at discharge.
- Prescribe angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers at discharge for patients with systolic dysfunction.
- Initiate reperfusion in a timely manner: thrombolytics within 30 minutes of hospital arrival or percutaneous coronary intervention within 90 minutes of hospital arrival.
- Provide smoking cessation counseling during hospital stay.
These steps are also part of standards from the CMS, the Joint Commission, and the American College of Cardiology.
Tips for success
Here are some tips for making changes in your hospital's acute myocardial infarction (AMI) care from those who spoke with ACP Hospitalist:
Ensure clinical agreement. Look at the literature for evidence-based material and check core measures in cardiology, recommended Donald Lappe, MD, medical director for the cardiovascular clinical program at Intermountain Healthcare in Utah and chair of the cardiovascular department and chief of cardiology at LDS Hospital in Salt Lake City. This will help solidify a team approach.
Make it practical. Translate the science behind the initiatives to day-to-day practice. For example, create a colorful, simple, one-page flow sheet.
Have a standard automatic response for AMI. This should go into place once the emergency department physician determines there is an AMI. For example, one hospital used a "thrombo pack" with all checklists and items needed ready in one place, said Fran Griffin, RRT, MPA, a project director at IHI for the AMI initiative.
Create an automatic way to contact people. For example, an ED secretary can make one call or an operator can make an overhead announcement and group page. This can save critical minutes.
Have standardized protocols on the floor, as well as for discharge instructions and order sets. The best protocols have an opt-out approach-the physician has to check a box only if he does not want to prescribe something, for example.
Test on a small scale. That way you can compare notes and ease people into the change, Ms. Griffin advised.
Inform your patients. Let them know you've activated a chest pain protocol team, advised Benjamin Chaska, MD, medical director and patient safety officer at St. Peter Community Hospital in St. Peter, Minn. That way when all the commotion begins—he said his hospital's AMI response initially looked like something out of ER—the patient understands it's a precaution to get the right treatment as quickly as possible.
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