The Challenge: Hackensack University Medical Center (Hackensack, New Jersey, USA) wanted to improve the diagnosis and care of patients whose primary diagnosis was acute myocardial infarction (AMI). With approximately 600 heart attack patients arriving in the medical center's emergency department annually, this was (and still is) an important and challenging undertaking.
The Background: Hackensack University Medical Center (HUMC) is a sprawling 683-bed, not-for-profit, tertiary-care, teaching and research hospital serving northern New Jersey and New York. Located just seven miles west of New York City, HUMC is the largest provider of inpatient and outpatient services in the state of New Jersey. With more than 70,000 inpatient admissions and more than 59,000 emergency/trauma department visits a year, it is one of the nation’s busiest hospitals.
HUMC is a high-performing hospital. In 1995, HUMC was among the first hospitals in the nation to receive the Magnet Award for Nursing Excellence, recognition granted by the American Nurses Credentialing Center. HUMC was redesignated a Magnet Hospital in 1999, and again in 2003. In 2002, 2003, and 2004, HUMC was chosen by US News & World Report as one of the nation’s top hospitals for cardiac care and surgery.
Recognition of this sort is an honor HUMC has worked hard to achieve. At the same time, hospital staff believes that improvement never stops. As part of Pursuing Perfection, HUMC decided to focus on improving a wide range of care processes, the centerpiece of which was making their care of patients with acute myocardial infarction more reliable and focused on improved outcomes.
The Situation: Because prompt diagnosis and treatment of heart attack patients have been shown to decrease both morbidity and mortality, guidelines for care of AMI patients have evolved in recent years to promote earlier and more aggressive treatment of chest pain. Treatment for most patients no longer relies simply on the administration of “clot-busting” medication to destroy or reduce the clot that is blocking the coronary artery.
Today, the treatment of choice for many heart attack victims — especially those with ST elevation acute myocardial infarction (STEMI), which indicates a dangerous clinical situation involving the heart muscle — is to physically open the artery with a catheter, a balloon, and a stent. Evidence of this trend can be found in HUMC’s own statistics: Between 1994 and 2003, the annual number of interventional cardiac catheterizations at HUMC increased by more than 262 percent. Currently, the number of STEMI patients seen at HUMC ranges from five to 15 per month.
“This treatment is well established, and the evidence shows that it works,” say Louis Teichholz, MD, HUMC Chief of Cardiology and Medical Director of Cardiac Services. “The question is, how do you do it right, quickly, and consistently for every patient?”
Providers who care for heart attack patients have a saying: “Time is muscle.” The clot that causes an AMI deprives the heart of oxygen and other nutrients, causing muscle cells to die. The sooner the artery is cleared and proper blood flow to the heart is restored, the better the patient’s chance of recovery.
From left to right, Louis Evan Teichholz, M.D., Chief of Cardiology and director of Cardiac Services; Denise Patriaco, RN, APN; Cardiology and Peter Gross, M.D., Chairman of the Department of Internal Medicine and Pursuing Perfection Grant Leader.
HUMC has a cardiology performance improvement committee that oversees the work of several subcommittees focused on AMI, congestive heart failure, invasive cardiology, and cardiac rehabilitation. The committees function as multidisciplinary teams that include physicians, nurses, and others. They meet monthly to further the hospital’s cardiac improvement agenda; the work entails analyzing systems that support specific care processes, creating metrics to measure their effectiveness, supporting tests of change, and implementing system changes that have been shown to improve care.
The goals of the improvement effort are made clear: All patients who arrive in the emergency/trauma department (ETD) with suspected AMI should be given aspirin and a beta-blocker right away. They should receive an electrocardiogram (EKG) within 10 minutes of arrival. And if appropriate, they should undergo a catheterization procedure within 90 minutes of arrival, with balloon dilation of the artery within 120 minutes.
The Solution: With HUMC’s history of quality improvement work, staff members were already comfortable with quality improvement techniques and concepts. “The AMI work was really an extension of things we had been doing for a while,” says Louis Teichholz. “Pursuing Perfection helped us think about it in a more systematic way, pushing us to set up mechanisms that guarantee that we will get the right care to the right patient at the right time.”
Using strategies promoted by Pursuing Perfection, HUMC has made technology and teamwork the essential elements in getting AMI patients speedy and appropriate care. With its own staff of hospital-based paramedics, HUMC emergency staff works especially closely with emergency responders to coordinate care. Paramedics can save precious time by taking EKGs of patients while they’re en route to the hospital; the results are digitally sent to awaiting ETD staff. “Often by the time the patient arrives in the emergency room we have already started activating care,” says Teichholz.
Karen Setti, RN, CCRN, APNC, Critical Care, likens the ensuing scene in the ETD to “ants on a sugar cube. Nurses surround that patient immediately, starting IVs, getting labs, administering meds.” Setti is an acute care nurse practitioner in the cardiac intensive care unit and a member of several committees focused on improving cardiac care. She says that Pursuing Perfection at HUMC helped nurses gain additional training in the care of AMI patients, and this has improved their ability to respond rapidly and effectively. New standing orders also enable them to activate tests such as EKGs so there is more information available when the physician arrives on the scene.
When a patient’s EKG shows ST segment elevation, a “thrombo-page” goes out from the ETD that simultaneously alerts the catheter (or cath) lab and an interventional cardiologist (cardiologists who specialist in cardiac catheterization or angioplasty). The ETD staff is responsible for giving the patient aspirin and beta-blockers, and getting him or her to the cath lab as quickly as possible.
“It sounds simple, but it’s sometimes difficult,” says cardiac chief Teichholz. “Patients are sick, things are happening quickly, information is still being gathered. How do you guarantee the cath lab gets called? What are your back-up mechanisms in case that fails? How do you make sure the aspirin and beta-blocker are given? How do you ensure that everything gets documented? You have to set up systems to make sure nothing falls through the cracks. That’s what Pursuing Perfection teaches.”
To facilitate quick contact with an interventional cardiologist, for instance, “every primary care physician and non-interventional cardiologist has given us the names of two interventional cardiologists to call for their patients,” explains Karen Setti. “We used to have to call the attending physician, and wait for him or her to call us back with a name.”
In an effort to “raise the bar,” the ETD nurses are now responsible for giving aspirin and beta-blockers before the patient leaves for the cath lab. “This has become an ingrained part of the ETD nurses’ routine,” says Theresa Colarusso, RN, BSN, MPA, CEN, HUMC’s Performance Improvement Coordinator. Nevertheless, there is a back-up system. “The ETD nurse gives a verbal report about the patient to the cath lab nurse prior to the patient’s transfer. If the report doesn’t include information about aspirin and beta-blockers, the cath lab nurse is responsible for asking if they have been given and documented. If they have not, the ETD staff is expected to administer them without delaying the patient’s transfer to the cath lab.”
Concurrent review has also become a critical part of the improvement process, says Colarusso. “The emergency care given to all thrombo-page patients is reviewed within 24 hours by the Chair of the ETD and the Director of the Coronary Care Unit, who chairs the AMI Committee. During multidisciplinary rounds, the care team reviews the care given to AMI patients after they leave the ETD. Any care that falls outside of guidelines, whether in the ETD or an inpatient unit, is reviewed by the AMI Committee.”
Continuous analysis, reinforcement, and re-education are all necessary to maintain standards of care. “When our time-to-treatment numbers started to slip,” says Colarusso, “we did an FMEA and discovered delays between the EKG results and calling the interventional cardiologist. We implemented a massive re-education program in the ETD to remind people about the importance of speed in caring for AMI patients, and the next month there was a big improvement.”
The Results: HUMC has improved significantly in what cardiology chief Teichholz calls “the true bottom line” of AMI care: mortality. More aggressive care of emergency AMI patients, combined with improved sub-acute care for AMI patients on inpatient units — thanks in large measure to multidisciplinary rounds, says Teichholz — have reduced HUMC’s mortality rate from AMI to approximately five percent, significantly below the national average of 10.9 percent (based on a national sample of Medicare patients). Moreover, HUMC’s mortality rate is now below the expected mortality rate for its hospital type, as shown in the chart below.
At the same time that HUMC has been taking part in Pursuing Perfection, it has also been part of a large demonstration project sponsored by the Centers for Medicare and Medicaid Services and Premier, Inc. This project focuses on improving the care of patients with five specific diagnoses, including AMI. The results of that project so far not only confirm HUMC’s success at improving AMI care, but also indicate the value of the broader Pursuing Perfection effort.
HUMC and McLeod Regional Medical Center in Florence, South Carolina, are the only two Pursuing Perfection hospitals taking part in the demonstration project. They've also now distinguished themselves as the only two hospitals, out of the 278 in the project, that are top performers in four of the five targeted conditions.
What the Team Members Say: “One of our challenges is that we have a very large, extremely busy emergency department. We probably see more AMI patients in a month than some hospitals see in a year. That’s a challenge, but it also helps us learn more. And being part of the Pursuing Perfection network has been extremely useful, being able to share ideas with other organizations. It’s hard to improve in a vacuum.” – Louis Teichholz, MD, Chief of Cardiology, HUMC
“The most important change in the way we care for AMI patients is the high degree of collaboration among physicians and nurses. Everyone is highly trained, and everyone knows they need help in making sure that all the right things happen for the patient. Every time there’s a problem, a group comes together to analyze what went wrong and resolve problems jointly. It all requires a high level of trust.” – Karen Setti, APN, acute care nurse practitioner in the cardiac intensive care unit
Learn more about Pursuing Perfection at Hackensack University Medical Center
