On the Same Page for Cardiac Care
Monday August 15, 2005
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Patti Rossetti, RN (left), confers with Mary Lou Landis, RN, on the Get With The Guidelines-Coronary Artery DiseaseTM program. Regional Medical Center Bayonet Point recently won the American Heart Association's GWTG-CAD quarterly performance achievement award, signifying that the hospital's eligible heart patients were treated and discharged according to the association's secondary prevention guidelines for cardiac care - well above the national benchmark. Photo by Maria Lyle Photography.
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The award-winning program, projected to save 80,000 lives annually, is viewed as a valuable tool that not only makes life easier for nurses, but also contributes to saving health care dollars, earning accolades, and providing good patient care.
HCA's Regional Medical Center Bayonet Point was recently awarded the association's GWTG-CAD quarterly performance achievement award. The recognition signifies that during the first quarter of 2005, 90% of the hospital's eligible heart patients were treated and discharged according to the association's secondary prevention guidelines for cardiac care, well above the national benchmark.
"Our award is based on meeting the GWTG indicators for cardiac patients, including blood pressure under 140/90 and - unless contraindicated - aspirin, beta blocker, ACE inhibitor, and lipid-lowering medications by discharge," says the hospital's quality management coordinator, Patti Rossetti, RN, who heads up the Hudson hospital's program. "Heart-healthy teaching for smoking cessation, weight management, and cardiac recovery activities was factored in, as well. Obviously, these indicators are nothing new, but now we're working on consistency in delivery, which is a slow but rewarding process."
Seek out the motivator
The program begins by identifying an acute care hospital champion, someone who agrees to be the initial "rah, rah" person responsible for leading and mobilizing teams to implement treatment and discharge guidelines. An assessment is made of the hospital's current acute treatment and discharge protocols, which serves as a baseline to compare and measure future success.
In early 2002, after Regional Medical Center Bayonet Point elected to adopt GWTG-CAD, it kept coming within a heartbeat of earning the association's performance award. So, in the fall of 2004, it ramped up its efforts, made a full-time commitment, and brought Rossetti on board to facilitate the process.
The hospital was already gathering similar data on its patients with acute myocardial infarction (AMI) for the core measure quality performance initiative from the Joint Commission on Accreditation of Healthcare Organizations. So the new program was simply the expansion of an existing one.
Data is collected throughout a patient's hospital stay from electronic records, making it easier than previous time-consuming chart review. "This allows us to do many more concurrent reviews, as opposed to retrospective reviews," says Rossetti.
Consistency is key
Using a multidisciplinary approach involving cardiologists, neurologists, primary care physicians, nurses, pharmacy personnel, and dietitians, GWTG-CAD's goal is to narrow the gap between what health care professionals already know about cardiovascular care and the care that's actually delivered. This is accomplished by using a set of secondary prevention guidelines developed by AHA to track and evaluate the hospital's application of targeted treatment and discharge protocols. "We know our physicians and the nurses are up on the current cardiac therapies, but my job is to make it easier for them to comply with standardized order sets," says Rossetti. "Consistent adherence to the guidelines means we're all on the same page for good patient outcomes."
For example, Rossetti noticed that before the GWTG-CAD program, many coronary bypass patients had standard lab work done on admission, but a lipid profile wasn't included in the physician's original order set unless specifically requested.
"A heart patient could actually go from admission to discharge without a documented lipid panel, including the total cholesterol," says Rossetti. "Now this may be because the physician had done the test in his office recently, but we don't have the ability to extract that information from the office chart and the test is one of the GWTG indicators. So we worked with the physicians to get that test added to our order set." Until the order forms have been updated to reflect the change, Rossetti has the authority to go to the unit every day to check if every patient's lipid panel has been done and if not, she can write the order. An added bonus for the patient is that the lab stores a vial of the blood from the original stick so there is no need to draw more.
Compliance boosts efficiency
According to the American Heart Association, just over one million Americans have a heart attack or other coronary event each year, and more than 450,000 of these are recurrent events. It makes sense, then, for health care providers to take advantage of a "teachable moment" that comes right after an acute event and practice aggressive risk-factor management before the cardiac patient goes home.
Cardiac surgical unit staff nurse Mary Lou Landis, RN, CCRN, notes that patients come to her unit right from surgery before moving to the telemetry unit. They begin cardiac health education at a time when patients are especially interested in preventing another attack and are more receptive to suggestions that they stop smoking and change dietary habits. "We've always given good care," she says, "but now, the guidelines have heightened our awareness of compliance with cardiac care standards."
It's been a gradual process with maximum rewards in terms of increasing efficiency and adhering to current standards of practice. For instance, when a chest pain patient arrives in the ED and before myocardial infarction is ruled out, the patient receives an aspirin and a beta blocker, unless contraindicated, and an ECG is done ASAP. Levels of troponin - an enzyme marker indicating a cardiac event with heart damage - are established at point of care to aid in accurate diagnosis and timely treatment. Says Rossetti, "I'm happy to say that we've shortened our troponin turnaround time from 90 minutes to 20."
"From the time patients are admitted, we routinely review their home medications and then check them again at discharge and record it on the form designed to comply with the GWTG suggestions," says Donna Cappabianca, RN, RNC, a staff nurse in the cardiac procedure recovery unit. "We make sure they've had the required lab work specific to their procedure, and if it's not done, we check for the physician's notation why not - and if that's not there, we follow up with the physician to be sure we are in compliance with the guidelines. The form is a good tool because it ensures continuity of care for every patient."
Communication and feedback are essential. To keep staff informed of their progress, Rossetti developed a GWTG presentation for nurses that offered one CEU. Unfortunately, she discovered that many nurses couldn't leave their units to see it.
"So, I downloaded my presentation to our hospital intranet. Then on my rounds, I simply gather a few nurses around the computer, pull up the program, and review the results of their impressive work to improve cardiac care," she says. Being a believer in positive reinforcement, she created a "From the Heart" congratulations coupon to recognize individual stellar efforts.
Yearly performance winners
Tenet's Palm Beach Gardens Medical Center took on the GWTG-CAD program in summer 2002, also recognizing that it could easily dovetail with the quality performance AMI data it was gathering and analyzing for the Joint Commission.
"In terms of patient care and outcomes," says CNO Beverly L. Thomas, RN, BSN, MS, CPHRM, "we're a heart referral center. It just made sense to adopt the GWTG-CAD program to ensure that we provided the best care possible."
Palm Beach Gardens Medical Center received the AHA GWTG-CAD annual performance achievement award for 2004, the first hospital in Florida to earn the recognition for sustained adherence to the guidelines over a year's time.
With the AHA program, the Palm Beach Gardens hospital is seeing heightened awareness of practice standards with far-reaching effects. Thomas says that nurses are actually taking more time for patient education. Smoking cessation education has been so well-received, for example, that it's been adopted hospitalwide for all patients before discharge. Also, collaboration between nursing and pharmacy has increased, with more consistent patient education for cardiac risk management drugs at discharge.
The guidelines follow the patient right through the hospital stay, beginning with the ED. "We've revised our chest pain triage protocols to include beta blocker administration to be in compliance with the AHA guideline indicators," says Thomas. "To be fully informed and ready to go, we've collaborated with emergency medical services so that we know if aspirin has been administered in the field and if the incoming patient is a cardiac alert."
Stepped-up patient flow
The GWTG-CAD form gets initialed as each indicator is met throughout the patient's hospital stay. "The guidelines have really improved our patient flow process," says Thomas.
"We've got our eye on the next level award," says Rossetti, "which will mean that for one calendar year, we've sustained adherence to the guidelines." She's now actively involved in implementing the association's GWTG-HFTM program to address treatment and discharge procedures for heart failure patients. What's more, the heart association is developing a set of stroke guidelines. "I feel good about the changes we've made to bring consistency to our cardiac care services," she says. "And I'm confident that we can make necessary concurrent changes as we move forward in the year ahead."
It's only last year that Rossetti came to the GWTG-CAD program from bedside nursing in the open heart unit at Regional Medical Center Bayonet Point. The change has been mind-boggling. "I miss the patients and their families," she admits. "But truthfully, I've always dreamed of a job like this where I have more face-to-face communication with nurses. It helps to have been a member of the hospital's nursing family in the past, but now I feel I'm making a difference from another aspect in nursing."
Margaret M. Sloane, RN, BSN, is a freelance health care writer and Nursing Spectrum contributing writer.
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