Color Coding, Checklists Improve Use of Evidence-Based Strategies for ACS

CHICAGO, IL—A simple, hospital-based education initiative utilizing color-coded reminders and checklists significantly improves physician adherence to evidence-based strategies for treating acute coronary syndromes (ACS), according to a study presented March 25, 2012, at the annual American College of Cardiology/i2 Scientific Session.

The study was simultaneously published online in the Journal of the American Medical Association.

Otavio Berwanger, MD, PhD, of the Cardiac Hospital of São Paulo (São Paulo, Brazil) presented results from the BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) trial, a cluster-randomized trial conducted in 34 public hospitals in Brazil. The study enrolled 1,150 patients with ACS from March 15, 2011, through November 2, 2011, with follow-up through January 27, 2012. Among the centers, 79.5% were teaching hospitals, all were in major urban areas, and 41.2% had 24-hour PCI capabilities.

Multifaceted Quality Improvement Effort

The quality improvement intervention consisted of 3 strategies:

• Nurse case managers
• Reminders
• Educational materials

As soon as a patient with suspected ACS arrived in the ED, a printed reminder (‘chest pain’ label) was attached to the clinical evaluation form to serve as a rapid triage tool. The ED nurse then gave the attending physician the clinical evaluation form with the chest pain label and an

attached checklist. The checklist contained an algorithm for risk stratification (based on clinical presentation, electrocardiogram [ECG] analysis, and cardiac enzyme levels) and recommended evidence-based therapies for each risk category. The algorithm divided patients into 3 risk categories, each corresponding to a specific color:

• Red for STEMI
• Yellow for non-ST-elevation ACS
• Green for normal ECG and cardiac enzymes

The attending physician was required to check and confirm the use (or non-use in the case of contraindications) of all suggested evidence-based interventions. Once patients were classified into 1 of the 3 categories, they received a colored bracelet (red, yellow, or green) according to their risk stratification category.

A nurse trained in the quality improvement intervention acted as a case manager and performed in-hospital follow-up of all patients. The responsibilities of the case manager included interacting with physicians to avoid gaps in the use of evidence-based interventions, ensuring that all components of the intervention were being used for every patient with ACS, and overseeing continuous training of health care staff involved with the care of such patients

Educational materials included pocket guidelines, an interactive web site containing presentations about ACS, instructional videos on how to implement the intervention, and posters containing evidence-based recommendations to be displayed in the ED, coronary care unit, and clinical floors. 

In the intervention group, adherence to the reminders and checklists was 82.7%.

Compared with the control group, significantly more patients in whom the intervention was utilized received all eligible acute therapies in the first 24 hours (primary endpoint). These results remained consistent after adjustment for important baseline covariates and after excluding statins during the first 24 hours. The same finding was true for the secondary endpoint of complete adherence to all acute and discharge therapies as well as for overall composite adherence scores.

Table 1. Primary and Secondary Endpoints

 

 

When the researchers looked at the effect of the intervention on clinical events, they found no differences in in-hospital cardiovascular event rates or 30-day all-cause mortality. While there was a lower rate of new myocardial infarction (P = 0.09) and higher incidence of major bleeding in the intervention group as compared with controls (P = 0.06), these differences did not reach statistical significance. In terms of subgroup interactions, there was a greater effect of the intervention in hospitals with PCI capability compared with those without (P = 0.004) and in patients with NSTE ACS compared with those with STEMI (P < 0.001).

Step in the Right Direction

“Our intervention increased the uptake of evidence-based therapies during the first 24 hours,mainly driven by increased prescription rates of antithrombotic therapies and statins,” Dr. Berwanger and colleagues write in the published study. 

According to Dr. Berwanger, the greatest expense of the intervention was the training of the nurse case managers.

He added that the study demonstrates that a simple and feasible strategy can be implemented and could serve “as a basis for developing and improving quality improvement programs and maximizing the use of [evidence based medicine] therapies in ACS patients.”

Dr. Berwanger said physicians in the study liked the checklist and felt it was a simple and useful intervention. He further said the nurse case managers were considered the largest contributor to the success of the program.

In a discussion of the study, session co-chair Robert A. Harrington, MD, of Stanford University School of Medicine (Stanford, CA), asked if the nurse case managers are sustainable in a public hospital system.

“I really think the nurse is the key and that is costly,” Dr. Berwanger said. The case managers in the study were not paid.

“I think if the hospital managers and CEOs start seeing the difference in quality it may be doable but that is something we will have to replicate in the real world,” he added.

Study Details

The mean age of patients enrolled was 62 years, 68.6% were men, 23.4% had a prior MI, 72% had a history of hypertension, and 31% had diabetes. On clinical presentation, 40% had STEMI, 35.6% had NSTEMI, and 23.6% had unstable angina.

 

Source:

Berwanger O, Guimarães HP, Laranjeira LN, et al. Effect of a multifaceted intervention on use of evidence-based therapies in patients with acute coronary syndromes in Brazil.  The BRIDGE-ACS randomized trial. JAMA. 2012;Epub ahead of print.

 

Related Stories:

• Japanese ACS Patients Fare Better with High Rates of Intensive Treatment
• Bleeding in ACS Patients Takes Center Stage in ESC Position Paper
• Syntax Score Predicts 1-Year Risk in ACS Patients