| | Acute Myocardial Infarction: Interventions prior to Discharge
Purpose
To evaluate the care of patients who receive primary treatment for acute myocardial infarction (AMI) at Gundersen Lutheran (GL).
Background
Each year in the United States, 900,000 people develop a myocardial infarction (heart attack). Approximately 25% of these people will die during this event.(1) A large number of patients experience second heart attacks. Many patients may have the second heart attack prevented by the use of aspirin and beta-blockers. Non-fatal stroke is also reduced by use of aspirin. Patients may also experience left ventricular systolic dysfunction (LVSD) as a result of their heart attack. Angiotensin converting enzyme (ACE) inhibitors reduce mortality in patients with LVSD after AMI and reduce the risk of recurrent myocardial infarction. Patients who smoke need to be counseled to discontinue smoking, as this practice has been associated with increased risk of recurrences. Since May 1995, the Cardiology Department has utilized an AMI care path which includes the use of aspirin, beta-blockers, ACE inhibitors, and smoking cessation education. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considers these to be core measures of institutional quality.
Aims
1) All patients presenting with AMI will have aspirin, beta-blocker, and ACE inhibitor prescribed at discharge, if indicated.
2) All eligible patients presenting with AMI will receive smoking cessation advice or counseling prior to discharge from the hospital.
Methods/Measures
Gundersen Lutheran maintains a database of all patients admitted for acute myocardial infarction to measure patient care and outcomes. Numerators for all the rates are the number of patients who met the criteria listed in the aims. Denominators are defined below, with results multiplied by 100.
The data represent results for patients with acute myocardial infarction admitted to Gundersen Lutheran, according to methodology required by JCAHO. Excluded are patients less than 18 years of age, patients transferred to another acute care hospital on the day of arrival, those transferred in from another hospital, patients who expired and those who left AMA (against medical advice), patients discharged to hospice and patients with documented participation in clinical trial testing alternatives to ACE inhibitors as first line heart failure therapy. Patients were excluded from the beta blocker measure if systolic blood pressure was less than 90 on the day of discharge or day prior to discharge while not on a beta blocker, if they had one or more beta blocker contraindications/reasons for not prescribing in the medical record (beta blocker allergy, bradycardia, second or third degree heart block on arrival or during hospital stay and do not have a pacemaker) or other documented reasons for not prescribing at discharge.
Fisher’s Exact chi-square test was used.
Benchmark
Benchmarks were obtained from all hospitals that participate in the Maryland Hospital Association Quality Indicator Project.
Results
Conclusions
1) Gundersen Lutheran’s results are significantly better than the benchmark for prescription of aspirin and beta blocker at discharge (p <0.001 and p <0.001) and for use of ACE inhibitor for left ventricular systolic dysfunction (p<0.001).
2) Advice to adults regarding smoking cessation shows Gundersen Lutheran to be significantly better than the benchmark (p<0.001) for the nine month period.
Next Steps
1) Continue efforts to exceed benchmarks and provide quality care to patients with heart attacks.
2) Improvement efforts will include an analysis of all patients who met criteria, but did not receive aspirin, beta-blocker, ACE inhibitor prescription or smoking cessation advice prior to discharge.
3) Consider analyzing length of stay and cost data in the future.
References
(1) Ryan J., Anderson J., Antman E., et al. (1996). ACC/AHA Guidelines for the Management of Patients with Acute Myocardial Infarction. A report of the American College of Cardiology/American Heart Association task-force on practice guidelines (Committee on management of acute myocardial infarction). Journal of the Amercican College of Cardiology. 28(5): 1328-1419.
Activity Leaders
Diane Larson,RN, Administrative Director, Heart Institute
Paul Schoenfeld, MD, Chairman, Division of Cardiology.
Acknowledgments
Judy Weibel, RHIA, Health Information Management
Jane Robinson, RHIA, Quality and Performance Improvement
Michelle Mathiason, MS, Biostatistics |