Critical Care Plus: Group Closing GAP in Heart Attack Care

System of reminders boosts quality of care

A team of 10 detroit-area hospitals, led by physicians from the University of Michigan Health System in Ann Arbor, has reported significant success in improving the odds that heart attack patients will get the medicines, tests, procedures, counseling, and follow-ups that have been shown to improve the chances of surviving and returning to a full life.

The initiative and attendant study, sponsored by the American College of Cardiology (ACC) in Bethesda, Md., is called GAP, Guidelines Applied in Practice. The guideline-recommended therapies, tests, and counseling include:

  • aspirin in the emergency department (ED) and after discharge to prevent clotting;
  • beta-blockers to reduce arrhythmias;
  • angiotensin-converting enzyme 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;
  • referral for outpatient rehabilitation.

The guidelines continually were communicated to physicians, nurses, and in some cases, patients, through a system of reminders, checklists, stickers, standard orders, reference cards, and educational materials.

When compared with their previous records and with hospitals that did not use the system, the participating hospitals significantly boosted the percentage of their patients who got aspirin, beta-blocker drugs, and advice on stopping smoking.

Each participating hospital could choose which of the tools in the GAP tool kit they would use. Their options included:

  • standing orders for medication and tests;
  • pocket cards of medications and guidelines for medical staff;
  • clinical pathway that guides nurses through their daily activity;
  • special patient information form;
  • stickers for the patient’s chart;
  • chart that shows the hospital’s overall performance;
  • discharge checklist for physicians or selected nurses to review with patients;
  • patient education materials, including written and verbal instruction on therapy and lifestyle.

"We presented these to all the hospitals, and they selected the two or three things they felt were most appropriate," says Rajendra Mehta, MD, MS, clinical assistant professor of cardiology at the University of Michigan Health System.

"Most chose standing orders and patient education, and all of them chose the physician pocket guide," he says. "Some chose critical pathways for nurses."

The laminated pocket guides, about 4 inches by 6 inches, contain reminders of ideal care, such as when to prescribe aspirin or beta-blockers, or thrombolytic therapy and contraindications. "They cover all basic care needs given while in the hospital and at the time of discharge," Mehta says.

A significant factor in the program’s success was extensive communication before implementation, Mehta says. "We communicated with the cardiologist champion and quality managers at each facility, as well as with the CEO. We wanted administrative buy-in," he explains.


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