Ten Detroit-area hospitals are taking better care than ever of their heart attack patients, a new study finds, thanks to a simple tool kit that helps physicians, nurses and patients remember to take advantage of all the proven therapies that national guidelines recommend.
Now, a higher percentage of the hospitals' patients receive certain key treatments in the hours, days and months after their heart attack. In some cases, the rate has approached 90 percent.
Those findings were presented at the recent annual Scientific Session of the American College of Cardiology by Kim Eagle, MD, chief of cardiology and co-director of the Cardiovascular Center at the University of Michigan Health System. UMHS made similar gains in an earlier study, using a related strategy. Eagle served as the co-principal investigator of the new 10-hospital study, the first to test a way of meeting guidelines developed by ACC and the American Heart Association.
Eagle and his colleagues hope the encouraging results will lead hospitals around the country to adopt the approach, which combines reminders, standard orders and education to help close the gap between what the evidence shows is best, and what heart patients actually get.
"Physicians, nurses and patients are not all-knowing," says Eagle. "We have a lot of information that's always changing, we're often in a rush, and it's very easy to forget simple things in the heat of the moment. As a result, many patients don't get all the guideline-recommended treatments, even for something as common as heart attack. This program provides tools that can be used by all of us, and we've seen amazing improvements in the quality of care."
The study was called the GAP (Guidelines Applied in Practice) Initiative in Michigan. It was a partnership of the ACC, the Southeast Michigan Health Care Quality Forum of the Greater Detroit Area Health Council, and the Michigan Peer Review Organization.
The study tracked how many patients at each hospital received guideline-recommended tests and treatments, from the emergency room through discharge. Among the items on the checklist: aspirin and clot-busters soon after the heart attack; drugs like ACE inhibitors and beta-blockers; procedures like angioplasty and blood cholesterol tests; and advice on diet and smoking. The tool kit includes training for medical staff, clinical guides for nurses, care standards, patient education materials, pocket cards, discharge checklists and counseling for patients, and more.
The UMHS project began in the mid-1990s, after a national survey found that heart attack patients across the country weren't getting all the care that guidelines - which are based on studies involving thousands of patients - said they should. Eagle and colleagues decided to evaluate heart attack care at UMHS, with a surprising result: Despite being a major academic medical center, UMHS didn't provide certain therapies to as many as half of its heart attack patients.
"There were gaps in the care, situations where we thought that we were doing certain things in a routine way, but we weren't," says Eagle. The situation was the same around the country. "Based upon that reflection in the mirror, we decided to create a program to try to improve."
That program, designed cooperatively by doctors, nurses and other staff, went into use at UMHS in 1997. Last fall, Eagle and his colleagues published the first results from that initial test in the Archives of Internal Medicine. Beta-blocker use, smoking advice, and use of clot busters in the ER all improved dramatically.
"What we saw was very striking," says Eagle. "When we could get the physicians, the nurses and the patients to agree on our goals, and provide them with tools based on the national guidelines and used at the point of service, we found we could achieve a sizable improvement."
The gains made at UMHS caught the attention of the ACC, which then selected southeast Michigan to be the pilot site for its new Guidelines Applied in Practice program to improve guideline adherence. Eagle was selected to lead the first GAP project on heart attack. The ACC's GAP program is currently developing projects on other common cardiovascular conditions such as stable angina and heart failure.
The GAP project was designed to find out whether the tools and strategies could work at different kinds of hospitals, including academic medical centers, community teaching hospitals and non-teaching hospitals. It also wanted to test use in hospitals with diverse patient populations and heart attack volumes.
So, ACC, MPRO and GDAHC approached hospitals in greater Detroit and selected 10 that agreed to implement the tool kit on a pilot basis in 2000: Bi-County, Harper, Henry Ford Wyandotte, Mt. Clemens General, Oakwood Dearborn, Oakwood Heritage, Providence, Sinai-Grace, St. Joseph Mercy and St. John. ACC, MPRO, GDAHC and the hospitals were all essential partners in the project.
The newly released results suggest the program can work in many environments, particularly when hospitals customize it for their staffs. For example, beta-blocker use jumped from 65 percent to 74 percent, while 65 percent of patients - as opposed to 53 percent before - got counseling on quitting smoking. Emergency aspirin use went from 81 percent to 87 percent.
"The ACC is committed to improving the quality of cardiovascular care by bringing guidelines into practice," says George Beller, M.D., ACC president. "We're very excited about the success of our initial efforts in the Guidelines Applied in Practice program. The results of this first GAP Project show that the ACC, in partnership with local organizations, can make a real difference in patient care. We're looking forward to applying more widely what we've learned about improving acute myocardial infarction care. There's great potential here to improve the care of patients with other conditions, too."
Eagle emphasizes that the tool kit is not a "cookbook" for heart attack care, and that patients and medical staff still approach each case individually. But the program does help encourage use of broadly applicable tests, treatments and advice that most patients can benefit from.
"If you think about going on an airplane, what do the pilot and co-pilot do?," Eagle asks. "They have a checklist of 10 to 15 things that make for a perfect takeoff, and another checklist for a perfect landing. They refer to that document every time to make sure nothing is forgotten, because they're dealing with life and death. This is the same way - a heart attack is life and death, and we're all making sure that the patient's experience on each 'flight' is maximized."
Eagle also attributes part of the program's success to its emphasis on patient participation. "We believe that having the patient go over the key drug therapies, lifestyle changes, and follow-up plan reinforces the importance of all those strategies," he says. "It helps them understand why they're going home on a certain drug, or why a certain diet or lifestyle is important, and it increases the likelihood that they'll actually follow those kinds of recommendations."
Follow-up studies are now under way, even as other hospitals are being invited to join the next phase of the project, set to begin later this year.
Tools in the GAP Initiative "Tool Kit":
· standing orders for medications and tests;
· pocket cards of medications and guidelines for medical staff;
· a "clinical pathway" that guides nurses through their daily activity;
· a special patient information form;
· stickers for the patient's chart;
· a chart that shows the hospital's overall performance;
· a discharge checklist for doctors or selected nurses to review with patients; and
· patient education materials, including written and verbal instruction on therapy and lifestyle.
Guideline-recommended therapies, tests and counseling used in the GAP Project:
· aspirin in the emergency room and after discharge to prevent clotting;
· beta-blockers to reduce arrhythmias;
· angiotensin converting enzyme, or ACE, 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; and
· referral for outpatient rehabilitation.