Hospital Strategies Can Lower AMI Mortality Rates, But Few Use Them

Download this article's Factoid in PDF (& PPT for Gold Subscribers)

Encouraging creative problem solving, enhanced communication between physicians and support staff, and limiting cross-training of nurses can help improve outcomes for patients with acute myocardial infarction (AMI), according to a cross-sectional study of acute care hospitals in the United States. But the study, published in the May 1, 2012, issue of Archives of Internal Medicine, also found that very few hospitals actually use these strategies.

Researchers led by Elizabeth H. Bradley, PhD, of Yale University School of Medicine (New Haven, CT), surveyed 537 hospitals and used data from the Centers for Medicare and Medicaid Services to evaluate the link between hospital strategies and risk-adjusted mortality rates. All hospitals had an annualized AMI volume of at least 25 patients.

The web-based survey involved information on patients hospitalized with AMI from January 2008 through December 2009. Among the areas queried by the survey were:

• Hospital practices and protocols
• Senior management involvement
• Communication and coordination among groups
• Broad staff presence and expertise
• Problem solving and learning

Key Strategies Decrease 30-Day Mortality

The mean risk-standardized mortality rate at 30 days was 15.4%. In multivariate analysis, 5 hospital-based organizational strategies were associated with lower risk-adjusted mortality rates (table 1).

Table 1. Effective Hospital-Based Strategies

Hospitals with only nurse champions—advocates who specifically focus on AMI care—had higher risk-standardized mortality rates than those where AMI advocacy was provided by both physicians and nurses (P = 0.002), only physicians (P = 0.033), and no one specific (P = 0.015). Hospitals with both physician and nurse leaders in AMI care had the lowest risk-standardized mortality rates (15.1%), whereas the 7% of hospitals with only nurse advocates had among the highest (16.2%).

The positive influence of the strategies held true regardless of hospital teaching status, geographic region, and AMI volume. Although fewer than 10% of hospitals reported using at least 4 of these strategies, 30-day risk-adjusted mortality rates decreased with increasing number of strategies implemented (table 2).

Table 2. Mortality Rate at 30 Days by Strategies Used

In a secondary analysis, hospitals in which pharmacists performed rounds on all AMI patients had lower risk-adjusted mortality (P < 0.025) than those where pharmacists had no specific role. In this model, the addition of hospital teaching status, geographic region, and AMI volume did attenuate the effects of cross-training nurses and of clinicians being encouraged to creatively solve problems (P > 0.10).

“Previous research has shown that inclusion of pharmacists in multidisciplinary rounds can increase adherence to core quality measures, reduce length of stay and drug-drug interactions, and improve quality of care,” the study authors write. “Despite these benefits, only approximately 35% of hospitals in our study reported that pharmacists rounded on patients with AMI.”

The negative effect of cross-training nurses, they conclude, may be due to “inadequate specialization in critical care nursing, as well as unintended effects of what might be a hospital cost-saving strategy.”

Can Organizational Issues be Overcome?

According to the authors, the study demonstrates a clear statistical link between aspects of organizational environment and mortality rates. Specifically, the findings show that problem solving and effective communication and coordination, previously identified as essential aspects of quality improvement, are important components of keeping mortality low in AMI patients.

But in an accompanying editorial, Frank Davidoff, MD, of the Institute for Healthcare Improvement (Wethersfield, CT), questions how to account for the broad array of processes that operate in every organization as well as the innumerable combinations of solutions that may exist at local levels.

“Stated differently, there are simply no ‘silver bullets,’” Dr. Davidoff writes. “Moreover, looked at this way, organizational context becomes an ‘emergent property’ of the web of relationships in organizations among people, events, technologies, and environments—a moving picture that’s shaped and reshaped over time, rather than a still-life image of structures.”.

Always Room for Improvement

In a telephone interview with TCTMD, Marian C. Hawkey, RN, of Columbia University Medical Center (New York, NY), said awareness of the efficacy of these strategies should prompt more hospitals to start using them if they are not already doing so.

“If an institution can’t meet some of these requirements because of specific issues such as infrastructure, that’s one thing, but that’s why guidelines and recommendations are important,” she said. “It gives a framework to work from. Will there be things that aren’t possible to accomplish everywhere? Of course. But the attempt should first be made before you say you can’t do it.”

Hawkey added that more research is required to understand whether the cross-training of nurses is harmful because certain cath lab-specific practices are not being followed or if there are other issues.

“With cross training, it’s hard to know exactly what that means,” she said. “In some instances it may mean floating nurses to the cath lab when they need to make up for staffing deficiencies, or it might be a much more formal process of training. Even though critical care nurses are very adept at different techniques and practices, the cath lab is a very specific environment, so it would be important to know what happened differently that accounted for this gap.”

The finding of higher mortality at hospitals where nurses alone advocated for AMI care is probably on target, Ms. Hawkey said, not because nurses are incapable of driving change, but perhaps because there is insufficient support from physician leadership in those environments.

 

---

Sources:
1. Bradley EH, Curry LA, Spatz ES, et al. Hospital strategies for reducing risk-standardized mortality rates in acute myocardial infarction. Ann Intern Med. 2012;156:618-626.

2. Davidoff F. Is every defect really a treasure? Ann Intern Med. 2012;156:664-665.

 

 

Related Stories:

• Guideline-Based Treatments Linked to Improved Survival for STEMI Patients
• 'Get with the Guidelines' Initiative Improves AMI Care for Minorities
• Dramatic Reduction in AMI Mortality Seen in Elderly

Click here for a listing of companies that provide support to the Cardiovascular Research Foundation, owner and operator of TCTMD.