Heart experts know a lot about what heart attack patients need: aspirin and clot-busters in the emergency room; drugs like ACE inhibitors, beta blockers and cholesterol fighters; tests and procedures like angiography; and advice on diet, exercise and smoking.
But at many hospitals, theres a troubling gap between what experts say is best and what patients actually getmostly because theres been no consistent way to make sure the health care team gives every patient all the proven treatments recommended by national guidelines.
Now, Health System heart specialists are reporting success with a way to close that gap between knowledge and practice. Their solution: a program that targets doctors, nurses and patients alike with care standards, educational materials, reminders and more.
In mid-November, the U-M team published the encouraging results of their own test of the program and presented early indications that such a strategy is producing similar results at 10 southeast Michigan hospitals. The paper, in the Nov. 13 Archives of Internal Medicine, also was a presentation at the American Heart Associations Scientific Sessions in New Orleans.
Among the findings: 98 percent of eligible heart attack patients in the study got clot-busting drugs in the emergency room, most in the first hour. More than 94 percent were put on beta blockers, and 90 percent got ACE inhibitorsa jump from 65 percent and 45 percent, respectively, in 1995. The use of cholesterol-lowering drugs went from 38 percent to 67 percent. Ninety-four percent of smokers were counseled about stopping and 96 percent got advice about diet.
Similar numbers, showing 90 percent or higher use for four of six key therapies, are emerging from preliminary findings at 10 other hospitals now using a similar program. The guidelines tell us that there are 10 or so interventions that we know can truly help most heart attack patients, says Kim Eagle, interim chief of cardiology and the Albion Walter Hewlett Professor of Internal Medicine. In the past four years, we have field-tested various strategies to optimize guideline-based treatment of heart attack. Weve learned that using tools directed at patients, physicians, nurses and referring physicians provides for the most successful approach.
The program was developed in the mid-90s by Eagle; lead author Rajendra Mehta, clinical assistant professor of internal medicine; and their colleagues. For the paper, they reviewed records for 497 patients treated at the U-M in a two-year period after the program began. Patients age range was 2099; 67 percent were male.
The initial results had been so positive that the American College of Cardiology (ACC), which helps issue and implement national heart attack guidelines, asked the U-M to help develop and test a similar program at other nearby hospitals of various types. That program is called the GAP (Guidelines Applied in Practice) Initiative in Southeast Michigan, and involves hospitals and the Greater Detroit Area Health Council and the Michigan Peer Review Organization.
Were delighted to now be working on the ACCs first GAP initiative, Eagle says. Working with 10 hospitals in the greater Detroit area, were striving to improve heart attack care throughout our region. The early experience is so encouraging that the ACC has invited us to take the program statewide, and is now considering a national initiative.
Showing that the program can work at non-university hospitals, at teaching and non-teaching institutions, and at community hospitals, is especially important to the project. The GAP project also includes hospitals with large and small numbers of heart attack patients, and hospitals whose patient populations are more predominantly non-white than the U-Ms.
The early GAP results suggest the program can work at all such places. The hospitals involved are: Bi-County, Harper, Henry Ford Wyandotte, Mt. Clemens General, Oakwood Dearborn, Oakwood Heritage, Providence, Sinai-Grace, St. Josephs Mercy and St. John.
Says Mehta, These results show that tools aimed at continuous education and reminder of caregivers regarding key aspects of patient care, along with education and empowerment of patients, are important elements for the success of any quality improvement initiative.
The programs tools include standing orders, pocket cards of medications and guidelines, a clinical pathway that guides doctors and nurses, classes for medical residents during their rotation in cardiology, a patient information form, stickers for the patients chart and a chart that tracks the hospitals performance. Before patients leave, doctors or selected nurses complete a checklist with them, giving a last chance for important prescriptions or lifestyle advice.
The list of key therapies includes aspirin in the ER and at discharge, clot-busting drugs known as reperfusion therapy in the ER, measurements of blood cholesterol and the pumping capacity of the hearts left ventricle, catheterization or heart imaging studies in certain patients, selected angioplasty or bypass surgery, and use of beta blockers and ACE inhibitors. Smoking cessation counseling, diet counseling and referral for outpatient rehabilitation also are key strategies. Not all patients need all these interventions, but the program ensures they get the ones they should.
Another key element is the patient education tool, a set of written and verbal materials that help the heart attack survivor understand what he or she must do to improve overall health and prognosis. This includes sticking with drug therapy, getting exercise and other rehabilitation after going home from the hospital, and the importance of not smoking.
The new study of U-M patients gave the patient-education information to half the patients. By discharge, those patients were more likely to have gotten drug therapy, and smoking cessation and rehabilitation advice. Now, the team is studying how well patients did in staying with those important treatments up to 18 months post-discharge, and provided its faculty, nurses and doctors-in-training with an annual report card that emphasizes opportunities to improve further.