CardioExchange Archive

CardioExchange editor John Ryan interviews Elizabeth Bradley of Yale University, the lead author of an Annals of Internal Medicine study for which she and her fellow researchers (including CardioExchange editor-in-chief Harlan Krumholz) surveyed 537 hospitals to determine associations between hospital strategies and hospital risk-standardized mortality rates (RSMR) for acute myocardial infarction (AMI).

Thirty-day RSMR following AMI vary greatly across U.S. hospitals. National data show a twofold difference in RSMR at top-performing hospitals compared with the lowest-performing hospitals. In this study, data show that several strategies employed by a few hospitals are associated with significantly lower 30-day RSMR:

1. Having an organizational environment that encourages physicians to creatively solve problems
2. Having monthly meetings between hospital clinicians and EMS staff to review AMI care
3. Having cardiologists always on-site; for hospitals without this, having pharmacists rounding on all patients with AMI
4. Having physician and nurse champions rather than nurse champions alone
5. Not cross-training nurses from intensive care units for the cardiac catheterization laboratory

Currently, only 10% of hospitals report using four out of five strategies associated with more favorable RSMR.

Ryan: Dr. Bradley, one of the strongest associations you observed was the monthly meetings between hospital clinicians and the staff who transported patients to hospitals. Why do you think these meetings were so successful and what was the structure of these meetings?

Bradley: What we know was that these meetings were regular, and their content involved quality-of-care review through case presentations and analyzing protocols in general. From qualitative data published a year ago, we found that these meetings involved cardiologists and emergency department physicians along with nurses and EMS staff (typically the director of EMS) as well as representatives from paramedic staff. At these meetings, people were able to voice what went right and what went wrong.

These meetings also generate awareness that someone is paying attention and that people care about the quality of care. It is also clear that people are trying to problem solve. These meetings produced some changes to protocols that would be helpful: for example, calling ahead with a STEMI so that the cath lab can start getting ready. Ultimately, these meetings helped create a culture to address quality as well as foster relationships, and this allows for effective problem solving, which likely plays the biggest role.

Ryan: What aspect of having a cardiologist in-house is affecting care? It is interesting that the cardiologist did not necessarily need to be an interventional cardiologist.

Bradley: We do have some insight on this and you rightly point out this is not just about having an interventional cardiologist in-house. What we are looking at here is broader because the outcome is 30-day mortality, which counts deaths from admission to 30 days later, even as patients are out of the hospital. So it does not cover just the intake. It also reflects the care of patients with NSTEMI, not just STEMI. So having cardiology on-site – and not just an interventional cardiologist – is what mattered in this study.

Ryan: You observed that 52% of hospitals had a quality-improvement (QI) team in place to improve mortality in AMI. What do you think are the restrictions on the other ~50% of hospitals limiting the introduction of such teams?

Bradley: The distinguishing factor was that these QI teams were focused on the outcome of 30-day mortality, not something more specific like door-to-balloon time. Although QI teams in general have been around for a while and directed at improving prescribing patterns or timeliness of care, having a team dedicated to improve mortality more generally is pretty novel, so that is why many hospitals in this study report that they did not have such teams. More critical in multivariable analysis was not just having a QI team but having an organizational culture that encouraged physicians to creatively solve problems.

Ryan: In hospitals that had zero to one of the measures you highlight the RSMR is ~16%, whereas hospitals that introduced three to four of these measures decreased the RSMR by approximately 1%. How do you anticipate these measures could be introduced on a national level?

Bradley: We feel that many of these strategies are implementable on the national level. For example, if we found that to decrease 30-day mortality you needed to be a teaching hospital or a big hospital, these are characteristics that would be difficult to change. Most of the factors we found, in contrast, can be changed and at relatively little cost. These changes are based on a positive working environment and several practical strategies.

Admittedly, having a cardiologist on-site all the time is expensive. Only 14% of hospitals do it now and it is impractical for many hospitals. Therefore we looked in particular at the hospitals that did not have cardiologists on site at all times, and we found that a key strategy was to have a pharmacist rounding on patients with AMI. Therefore, if a hospital cannot have a cardiologist on-site all the time, having a pharmacist heavily involved in the care of these patients is very beneficial.