AMI team buckles down to improve outcomes

LOS, mortality among improvements

Length of stay for acute myocardial infarction (AMI) patients at Middletown (OH) Regional Hospital has decreased from 4.9 to 3.3 days. The facility also has made impressive strides in cutting its door-to-needle (DTN) time to about a quarter of what it used to be, and AMI mortality rates are nearly half what they used to be. Twice as many patients are discharged on aspirin or beta blockers now than were previously, and better EKG technology is being used.

In 1993, a multidisciplinary team at Middletown Regional set out to improve the treatment and outcomes of AMI patients. Five years later, most of the team’s goals have been realized.

The team improved care along the entire continuum, from prepresentation to rehabilitation. "We looked at the integrated management of the AMI patient all the way from pre-hospital emergency care, through the system, and through post-discharge," says Carol Turner, RN, vice president of clinical and information services at Middletown. "We wanted consistent, high-quality management of information that would improve — and demonstrate improvement of — outcomes and decrease lengths of stay." The team defined several priorities for performance goals for AMI. (See related story on Middletown’s refined system, p. 49.)

Improvements didn’t cost an arm and a leg

Turner says it didn’t cost her facility a lot of money to better its processes. Some improvements didn’t cost anything at all except for training. Instead, costs were shifted. "It’s not easy to put a dollar amount on these initiatives," she says. "You can do a lot to improve your system without driving up costs."

Middletown, a not-for-profit community hospital with 310 beds and 1,200 employees, offers diagnostic caths, but no angioplasty or open-heart surgery. "There are several tertiary care centers in the area," says Turner. "We wanted to make sure everything up to the decision for angioplasty or an open-heart procedure was done here and done well. As the only hospital in Middletown, we felt it was our responsibility to educate the emergency team to improve the care of the AMI patient coming to us."

The initial efforts focused on educating the largely voluntary EMS squads regarding AMI patients, so they’d know the latest thinking, technology, and treatment protocols. After the team educated them on the need to have twelve-lead EKGs in the field, the squads had fundraisers so they could equip their vehicles.

As a result, DTN time decreased from an average of more than 84 minutes in early 1993 to 22 minutes four years later. "Actually we did one in seven minutes the other day," says Turner, "and my understanding is that the outcome was good." It does depend somewhat on where the patient is coming from, but demographics haven’t changed since Middletown implemented these changes. Patients were coming from the same locations when DTNs were at 84 minutes. Turner attributes improvements to a systems approach.

A top priority for the initiative team was to fix the diagnostic phase of managing AMI. Before the improvement effort, this phase was fragmented, and there was little coordination or collaboration in the process. Information was not being shared beyond the individual services.

Improvement also was needed in these areas:

• the ED’s triage process;

• acquisition of EKG and baseline laboratory tests;

• physician exam and EKG interpretation times;

• the cardiology consult process;

• decision making for administering thrombolytic therapy;

• thrombolytic mixing and administration;

• time used for repeat EKG.

Key processes are shifted

The team charted the triage process and that of diagnosis and initiation of treatment in the ED. Front-door protocols were modified. When a patient comes in with AMI symptoms — chest pain, pain radiating into the arm, diaphoretic cold sweats — he or she doesn’t wait in the ED to register. An EKG is immediately done by order to an EKG department. Decentralizing the EKG department meant training staff throughout the hospital.

All cardiologists now have fax machines at home, as well as at their offices, to allow quick review of admission EKGs. Some physicians bought their own machines for their homes or cars once the team identified fax capability as essential to improved patient care. The hospital obtained new monitors equipped with EKG analysis capability. All nurses underwent competency evaluations for EKG interpretation.

Pharmacy staffers defined and improved the process of obtaining, mixing, and administering thrombolytic therapy. Middletown’s original protocols called for a cardiologist to see the patient before the decision to use recombinant tissue-type plasminogen activator (T-PA), and the pharmacy, not the ED, mixed the T-PA. Those processes of care were changed. T-PA is now fixed and ready to administer in the unit. ED techs were cross-trained to administer EKGs. "We developed the competencies to make sure we had an EKG team in place rather than relying on the EKG department," says Turner. All nurses were evaluated for drug mixture and administration.

Because of Middletown’s achievements, last fall the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, awarded the hospital the Ernest A. Codman Award, which recognizes excellence in the use of outcomes measurement to achieve quality improvement. Obtaining the award gave the facility public recognition for its initiatives.

For more information about the AMI pathway, contact Carol Turner, RN, vice president of clinical and information services at Middletown Regional Hospital, 105 McKnight Drive, Middletown, OH 45044. Telephone: (513) 424-2111.