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To improve AMI care, start talking
Culture trumps money when treating heart attack patients

Keywords: Managing heart attack patients: Hospital culture is more important than resources


by Paula S. Katz



Published in the July 2012 issue of Today's Hospitalist

IF YOU WANT TO IMPROVE your hospital's AMI mortality rates, put down your checkbook and beef up communication between physicians and just about everyone else. That's the conclusion of a study in the May 1 issue of Annals of Internal Medicine that looked at ways to better manage heart attack patients.

In the study, more than 530 hospitals reported on strategies used for AMI patients that correlated to lower 30-day risk-standardized mortality rates. While the mean AMI mortality rate came in at 15.4%, the research found a wide gulf between
"It's not about having formal protocols or a certain number of people, but how people communicate."

–Elizabeth Bradley, PhD
Yale University

the rates for the best and worst performing hospitals across the country: 10.9% vs. 24.9%.

So what strategies worked? The top five tactics used by the best performing hospitals may surprise hospitals that think the solutions hinge on new technology and more resources, says lead author Elizabeth Bradley, PhD. Having both physician and nurse champions reduced the AMI mortality rate by nearly a full percentage point. And fostering an organizational environment that encourages physicians to creatively problem-solve was likewise linked to lower mortality.

The other strategies that made the biggest dent included monthly meetings between clinical staff and emergency medical staff to review quality of care (a 0.70% reduction); having a cardiologist onsite at all times (a 0.54% reduction); and not having ICU nurses do double duty by also working in cardiac cath labs (a 0.44% reduction).

"You need to change from the inside," says Dr. Bradley, professor of public health and faculty director of the Global Health Leadership Institute at Yale University in New Haven, Conn. "We have to decide: Do we really solve problems here? Or do we bandage them over with more equipment and more medicine?"

In an interview with Today's Hospitalist, Dr. Bradley discussed key strategies in MI management, and why hospitals should incorporate them.

Why does throwing money at MI management not pay off?
Most people say all you need to maximize survival from a heart attack is a good cardiologist. Our study says that a good cardiologist is not all you need. You need a culture and an approach that improves quality, solves problems and boosts communication, where people can speak up if there's a mistake or problem. That kind of culture doesn't have to cost a lot of money.

Did you expect these results?
No. We were surprised that more costly strategies like buying a new cath lab, moving it closer to the ER, or getting more MRI equipment or more cardiologists didn't have an impact.

Instead, more subtle cultural issues emerged. It's not about having formal protocols or a certain number of people, but how people communicate with each other.

What's an example?
Having clinicians meet at least every month with paramedic staff improves outcomes. This is a big finding. That kind of trusting relationship can't be found very often, typically because of professional hierarchy and the work environment.

Think of how the cardiologist in a big teaching hospital relates to a technician in a truck; maybe not that often, and they probably do not know each other's name. But if an ambulance system can call ahead to the hospital and be trusted to say, "We think we have a patient with AMI," the hospital can say, "We're ready to get the patient quickly into the cath lab." All hospitals can implement these kinds of arrangements.

You talk about the importance of fostering problem-solving. How can that make a difference?
The cultural feature that trumped all others is creating an environment where clinicians feel they can creatively solve problems. Such hospitals have lower mortality rates.

In some hospital and organizational cultures, people think, "I hope it doesn't happen again, but it's not my job to fix it." But those in high-performing hospitals say, "That's a problem. We better dig into it."

Consider clinicians in the ER who found again and again that they have a problem getting patients upstairs for angioplasty fast enough on certain shifts. Do they feel they can sit down, look at data and figure out why?

In one hospital, clinicians reported a glitch in the operator system. When operators had to call an interventional cardiologist, they did not necessarily know who was on call. In the study, 40% of hospitals endorse this idea of strong, continuous problem-solving. That leaves 60% with room for improvement.

You did have one result where money made a difference: having any type of cardiologist onsite 24/7 improved AMI outcomes. Are there less costly alternatives?
Only 14% of our respondents had a cardiologist onsite all the time, and those tended to be teaching hospitals. We did a separate analysis for hospitals without a cardiologist onsite. The critical factor that emerged was having a pharmacist do rounds on patients with heart attacks to, for example, adjust medications.

In hospitals where it's not practical to have a cardiologist all the time, hospitals can re-engineer their pharmacy department to have someone who is medically trained rounding on AMI patients every day.

Just having a nurse champion not only didn't help, it actually correlated to hospitals with worse outcomes. Why?
Nurses and nurse champions are important, but having just nurse champions and no physician champions is likely a marker of a hospital that doesn't have a unified clinical voice for better quality.

Nurses can't do it alone—nor can physicians, even if they're excited by the latest guidelines and protocols. The take-home message is hospitals need a unified front of leadership.

Why did the cost-saving move of having ICU nurses trained in cath labs backfire?
People may think a nurse is a nurse is a nurse. But nurses trained in an ICU have inadequate specialization in cardiac cath. Plus, in the best hospitals for heart attacks, clinicians in a cath lab work together in a choreographed dance and know each other's patterns. If hospitals are moving people back and forth from the ICU to the cath lab to save money, it's not the same team, which can cause problems.

Hospitals that do that have lower survival rates. It's better to let nurses specialize in the cath lab and have that be all they do.

How many of these strategies do hospitals have to adopt to really make a difference?
The more, the better, according to our findings. We're starting off with mortality rates that are in the 15.5% to 16% range. We hope to bring that down in two or three years to 13.5%. Even a 1% improvement is a much bigger change than most medications can achieve.

What are you doing to make hospitals more receptive to your findings?
We're working with the American College of Cardiology (ACC) to kick off a national quality alliance, an industry-based effort to embrace this knowledge. Our goal is to work through the ACC and other professional associations to design teaching materials and interventions that can shift culture. It's important for the industry to learn from itself, not just some scholar at Yale.

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.

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