System improved heart attack care in study

Reminding clinicians about therapies boosts use

By incorporating a system of reminders, standing orders, and checklists into routine care, hospitals in Michigan significantly improved the percentage of patients receiving certain proven treatments and lifestyle counseling for heart attack patients.

After the system was put in place, there were jumps in the use of individual treatments that ranged from 5.6 percentage points to 34.8 percentage points, according to the latest phase of a study sponsored by the American College of Cardiology (ACC) in Bethesda, MD, and led by members of the Michigan ACC chapter under the direction of researchers at the University of Michigan Cardiovascular Center of the University of Michigan Health System (UMHS) in Ann Arbor.

The combined results from three studies conducted in 33 Michigan hospitals were presented at the ACC’s 52nd Annual Scientific Session meeting in Chicago, March 30-April 2, 2003. The study, called ACC AMI GAP (the ACC’s Acute Myocardial Infarction Guidelines Applied in Practice), seeks to find ways to help physicians and hospitals deliver the care outlined in heart attack care guidelines developed by the ACC and the American Heart Association (AHA). The guidelines are based on the best available evidence of what drugs, tests, and lifestyle changes work best for patients, preventing complications and recurrences.

The new results of the three projects conducted between 2000 and 2003 compare the care given to 1,892 heart attack patients treated at the 33 hospitals before the studies began, and 2,065 heart attack patients treated while the system was in place. The study measured use of aspirin, beta-blockers, and ACE inhibitors early and late in a patient’s care; cholesterol tests and cholesterol-lowering drugs; and counseling on diet and smoking cessation.

These results combine the data collected in three stages of the GAP project: a pilot study in 10 hospitals in southeast Michigan, a phase II study in five hospitals in the Flint/Saginaw region of Michigan, and a phase III study in 19 more southeast Michigan hospitals, including UMHS.

All hospitals were offered a tool kit of reminders, checklists, stickers, standard orders, reference cards, and educational materials that made it easier for physicians, nurses, and patients to follow the ACC’s guidelines. (See box, below.)

GAP Tool Kit

Tools in the Guidelines Applied in Practice (GAP) initiative tool kit (available on-line at include:

  • 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 hospital’s overall performance;
  • discharge checklist for doctors or selected nurses to review with patients;
  • patient education materials — written and verbal instruction on therapy and lifestyle.

Guideline-recommended therapies, tests, and counseling measured in the study include:

  • aspirin in the emergency department and before discharge to prevent clotting;
  • beta-blockers to reduce heart rhythm problems;
  • angiotensin-converting enzyme inhibitors, to aid the heart’s recovery;
  • blood cholesterol tests and, in appropriate patients, drugs to lower cholesterol;
  • smoking cessation counseling (smoking doubles the long-term risk of heart attack);
  • diet counseling with emphasis on low-fat diets.

Source: American College of Cardiology, Bethesda, MD.

Here are some of the key findings:

  • Use of aspirin and beta blockers early in a patient’s hospital stay increased 6.6 points and 5.6 points, respectively. Pre-discharge prescriptions for the same drugs rose 12.4 points and 6.3 points, respectively. There also was a 7.7 percentage point increase in prescriptions for ACE inhibitor drugs given before patients went home. A 9.6 percentage point jump in cholesterol tests also was seen.
  • The biggest gains were in the area of diet and smoking-cessation counseling, and in prescriptions for cholesterol-lowering drugs, which rose by 14.3 points. There was a 34.8 point jump in the percentage of patients who got advice about stopping smoking, and a 21.6 point rise in the percentage who saw a dietitian or nutritionist before they went home.
  • The highest percentage achieved was 94% for pre-discharge aspirin.

The very nature of the way medicine is practiced today created the rationale for the GAP project, notes Kim A. Eagle, MD, the Albion Walter Hewlett Professor of internal medicine and chief of clinical cardiology at the UMHS and one of the authors of the study.

"It’s fair to say today’s health care workers live in a very complicated, very fast-paced, very busy environment," he says. "Within that context, it’s understandable that occasionally things can be unconsciously omitted in treatment. The knowledge base available in cardiology today is so enormous, it’s incredibly clear that to be able to prioritize that base and be able deliver exactly the right care at a moment’s notice is beyond the capability of a normal human being. Providing priorities within the key processes themselves is a way of ensuring that priorities of care are adhered to."

One of the challenges was to motivate physicians and nurses to adhere to the recommendations. "For years, being a medical doctor or nurse has been equated with a level of independence, which is understandable — making the diagnosis and designing and tailoring the therapy," Eagle explains. "But it’s very hard for an individual memory to retain and keep track of everything. What the ACC and the AHA are leading and inviting hospitals and employers to do is to participate in the ongoing development of scientific methods that engineer care in such a way that the most important treatments are always remembered. It’s clear these professional societies have now accepted the mantle that creating knowledge without creating the science of how that knowledge is applied is falling short of their mission. Their participation, first and foremost, is why this project is successful."

Second, says Eagle, the project involved not only national experts who helped create guidelines, but local experts — physicians and nurses who were identified as champions. "They were given the opportunity to mold the tools to a look and feel that fit their hospitals," he explains.

Finally, Eagle says, the GAP project has the involvement of the entire community, so a communitywide plan could be developed to spur improvement at all sites.

The GAP project was geared to create change within a period of one year. Here are the key steps:

  • Invitation to participate. These came from the president of the ACC and were sent to the CEOs, the head of cardiology, the QA manager, and the project leader of cardiac care (usually a quality nurse) at each hospital.
  • Hospital selection. "We tried very hard to accommodate as many as wanted to participate," says Eagle. "In the pilot, we could only use 10 out of 22. We wanted a diversity of urban, nonurban, teaching, nonteaching, and so on."
  • Project kickoff. In each project, all of the team members were brought together to take advantage of their diverse talents. Collaborators from the community also were included. The program included a presentation of overall goals, introduction of team members, discussion of goals and timelines, and so on.

    "We presented a global picture of our goals, but each hospital had the chance for a nurse and physician leader to present their thoughts," says Eagle.

  • Learning sessions. Each session covered specific problems, such as how to identify patients, create an individual look for the tool kits, actually measure what’s happening before and after the intervention, and get the charts created in such way that the data could be transported to the data extraction center at the Centers for Medicare & Medicaid Services.
  • Monitoring tools. This involved how the hospitals would monitor whether the standards and tools were being used, how to get the guides to all the physicians and nurses, and how to get information sheets to the patients.
  • Re-measurement. The teams measured adherence to key quality targets before the project started, and then after it had been up for three to six months.
  • Data analysis. This was conducted by the Michigan Peer Review Organization.
  • Results presentation. This was conducted not only at the ACC, but for each of the three projects a results presentation was held, to which all hospitals were invited.

    "They also received their own results in a confidential, sealed envelope," Eagle notes.

He contends the GAP project is making an important statement. "We’ve proven that it is possible to prioritize key ingredients in AMI treatment and embed them into patient care by creating reminder mechanisms for doctors and nurses that improves overall rates," he says. "The key to improvement is to create a system that reminds us of our priorities every time. The use of that system is the key to our overall success."

Of course, the rate of usage varied from facility to facility. "That reflects the complexity of the care providers and the differing degrees of buy-in," says Eagle. "Remember, we tried to do something very quickly, and every institution has a biology of its own; we have to find ways of addressing those unique features, but in general, we observed that improvement breeds improvement. Even in hospitals where we did not observe the kind of improvement we wanted, I hope we saw something positive that will lead to further change."

As for "take-home messages" for quality professionals, Eagle notes the following: "I can’t overemphasize the importance of physician leadership, and of employers and insurers creating partnerships," he says. "The only way we can improve is to get together. I really believe the carrot approach is best — let’s invest resources instead of pointing fingers and blaming someone else for lost opportunities. I believe in the future, we will create systems that allow us to track key priorities for high-risk, high-volume conditions, and we will have the mechanisms to provide data to care providers and patients every time. When we have done that, we will have a better health system."

Based on the success seen in the new results, Eagle says, there’s momentum for the project to expand into other states and to incorporate additional care guidelines. He and his colleagues recently have helped a group of hospitals in Montana adopt the GAP tool kit, and similar programs have begun in Kansas, West Virginia, and Ohio. The concept also is taking hold overseas — hospitals in Italy have initiated a GAP project, and another effort is being planned in Spain.

Need More Information?

For more information, contact:

• Kim A. Eagle, MD, Chief of Clinical Cardiology, U-M Health System, Ann Arbor, MI. Telephone: (734) 936-5275.

• GAP Project web site: