Rethinking Heart Attacks: HealthTrust Convenes Collaborative Summit to Explore Opportunities for Improving Patient Management Across the Care Continuum
Five healthcare systems from within the HealthTrust membership gathered in Nashville, Tennessee to brainstorm ideas for improving the management of patients with AMI (acute myocardial infarction)—aka, heart attack. The Collaborative Summit for Managing AMI Patients, held over two days in mid-September, replicated the successful, accelerated learning format utilized earlier this year to help members improve their perioperative pain management practices, says event organizer David Osborn, Ph.D., senior vice president of inSight Advisory Services for HealthTrust.
Small-group intensives and individual visioning exercises were followed by report-outs and lively, full-room discussions on assigned topics specific to acute care, post-acute care, initiative implementation, and measuring and evaluating success. Attendees left with actionable steps they could take back home to move their health system toward a more effective approach to AMI patient management.
V. Seenu Reddy, M.D., medical director for HealthTrust, started off day one with a recap on the current state of AMI care that is characterized by variation across geographies. The scope of cardiovascular disease is immense. In the United States, a heart attack kills someone every 40 seconds, making it the leading cause of death. Access to care issues may be partially responsible for disparities in incidence rates, says Reddy, and opportunities to improve patient care lie squarely with hospitals. Heart attacks and coronary heart disease are among the 10 most expensive hospital principal discharge diagnoses.
Key Themes Emerge
Summit attendees divided into working groups on day one to scan reference
materials, develop an “ideal” AMI program, discuss physician engagement and alignment strategies, and determine appropriate ways to measure and evaluate success. The readings included clinical research on AMI care, professional guidelines, and articles related to post-acute care, program implementation, physician engagement, and data and analytics.
On day two, interdisciplinary efforts by the five health systems jumpstarted the creation of institution-specific action plans. Overall, six key takeaways emerged from the summit for improving AMI patient management across the care continuum:
- Enhance processes and workflows to improve care delivery and outcomes. For example, hospitals can partner with local emergency medical services (EMS) providers to educate and reinforce electrocardiography (ECG) interpretation skills. They should ensure that patients’ first
contact person in the emergency department (ED), if nonclinical, is educated on both typical and atypical AMI symptoms, and that checklists are utilized throughout the course of a hospitalization. Better protocols and assessments could be developed for patients at risk for poor outcomes. Organizations could also address any barriers to prompt delivery of care, such as delays in getting laboratory test results.
Patients need to be tracked into the post-acute setting for a minimum of 90 days. Post-acute care goals should include referral to cardiac rehabilitation to reduce the risk of readmission. Follow-up calls within seven days of discharge can address patient concerns related to medications, activity, diet and pain.
- Hardwire change wherever possible to create meaningful, sustainable results. This would include changes to order sets, protocols and decision support systems. Use of standardized checklists will help ensure workflows are followed for every patient. The system of care, not just the decisions of individual providers, need to be addressed.
Education is needed across the board: staff on standardized order sets, protocols and checklists; post-acute providers to align patient messaging and increase utilization of cardiac rehabilitation; and primary care physicians (PCPs) on their patients’ event and the protocol for smoothing their transition from inpatient to post-acute care.
Electronic health records can be utilized to maintain order sets. Compliance with order sets and protocols needs to be measured. Hospitals can build physician trust in ECGs taken in the field, by doing a comparative study of results based on who did the testing.
- Broaden improvement efforts beyond hospitals so change is sustainable at all points in the care continuum. Health systems should lead the way, but all providers—regardless of care site—must be engaged in efforts to change behaviors and outcomes. Education needs to begin at admission and continue post-discharge, and there should be a standardized process for handing off patients to a PCP or other post-acute provider.
Among the to-dos for hospitals: begin cardiac rehab before patients are discharged; educate staff on standardized orders and protocols; include pharmacists in discharge planning and teaching to address medications, side effects and potential problems with noncompliance; and educate PCPs, as well as patient families, about the importance of medication and cardiac rehabilitation compliance. Community education efforts should include how to recognize the signs and symptoms of an AMI.
Post-acute providers need to be aligned with and reinforce patient education concerning behavior change (e.g., exercise, nutrition and stress management) throughout the post-acute care process. They also should implement multiple education methods.
- Focus on metrics that provide the most opportunity for improving patient outcomes and systems of care. Measures are needed for both ST-elevation myocardial infarction (STEMI) and non-STEMI patients. Registry and case mix data can help identify weaknesses in processes and outcomes. Multiple metrics are important to improving outcomes, including door-to-balloon time (speed of getting AMI patient to a cath lab for percutaneous coronary intervention).
Benchmarking performance to other regional and national facilities can identify strengths and weaknesses. Physicians, nurses and staff need to be involved in selecting the appropriate metrics to track for maximum impact. Among the rules of thumb: Don’t focus on too many metrics, opt for the actionable ones, know your audience and be aware of unintended consequences.
- Develop the business case for health system resources to manage the care of AMI patients. Addressing this challenge will lead to better clinical outcomes, including fewer readmissions and complications, as well as higher patient and caregiver satisfaction levels, and reduced cost of care. Justification for the targeted investment should cover the financial implications, including penalties for hospital-acquired conditions and readmissions.
- Make some quick changes to create positive results and momentum. Clinical and administrative leadership should be educated on the opportunity to enhance care, to gain their support and advocate for the resources needed to achieve it. Initiatives that start small often gain the steam necessary for expansion based on early, positive results. Providers need to identify changes that can be made in the short term that will be impactful—scheduling patients for
cardiac rehab at discharge, for example, and educating family members on the importance of medication and cardiac rehab compliance.
On the final day of the summit, all participants worked to define the goals, strategy and barriers for their respective health systems. Based on their outlines, they then shared with all other attendees the specific, immediate actions they could take at their organizations within the next 30 days.
For some, an important first step was to do a gap analysis to identify areas of opportunities. For example: What do patient readmission rates look like at 30, 60 and 90 days? How often are patients being referred to cardiac rehab? Are there significant medication compliance issues?
Developing AMI care checklists and creating or expanding the use of standardized order sets across hospitals were among summit participants’ other goals for the first 30 days following the event.
The following HealthTrust members sent teams of physicians, pharmacists, nurses, and administrative, clinical and service line leaders to the summit:
> Community Health Systems – Franklin, Tennessee
> HCA Far West Division | Good Samaritan Hospital – San Jose, California
> RCCH HealthCare Partners – Brentwood, Tennessee
> Scripps Health – San Diego, California
> Trinity Health – Livonia, Michigan