Subject(s)
Angioplasty, Balloon, Coronary , Health Services Accessibility/organization & administration , Myocardial Infarction/therapy , Outcome and Process Assessment, Health Care/organization & administration , Quality of Health Care/organization & administration , Regional Health Planning/organization & administration , Delivery of Health Care, Integrated/organization & administration , Humans , Myocardial Infarction/mortality , Organizational Innovation , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: Rural ST-segment elevation myocardial infarction (STEMI) care networks may be particularly disadvantaged in achieving a door-to-balloon time (D2B) of less than or equal to 90 minutes recommended in current guidelines. ST-ELEVATION MYOCARDIAL INFARCTION PROCESS UPGRADE PROJECT: A multidisciplinary STEMI process upgrade group at a rural percutaneous coronary intervention center implemented evidence-based strategies to reduce time to electrocardiogram (ECG) and D2B, including catheterization laboratory activation triggered by either a prehospital ECG demonstrating STEMI or an emergency department physician diagnosing STEMI, single-call catheterization laboratory activation, catheterization laboratory response time less than or equal to 30 minutes, and prompt data feedback. EVALUATING SUCCESS: An ongoing regional STEMI registry was used to collect process time intervals, including time to ECG and D2B, in a consecutive series of STEMI patients presenting before (group 1) and after (group 2) strategy implementation. Significant reductions in time to first ECG in the emergency department and D2B were seen in group 2 compared with group 1. CONCLUSIONS: Important improvement in the process of acute STEMI patient care was accomplished in the rural percutaneous coronary intervention center setting by implementing evidence-based strategies.
Subject(s)
Angioplasty, Balloon, Coronary , Delivery of Health Care, Integrated/organization & administration , Health Services Accessibility/organization & administration , Myocardial Infarction/therapy , Outcome and Process Assessment, Health Care/organization & administration , Quality of Health Care/organization & administration , Rural Health Services/organization & administration , Aged , Electrocardiography , Emergency Service, Hospital/organization & administration , Evidence-Based Medicine , Female , Humans , Male , Middle Aged , Myocardial Infarction/diagnosis , Myocardial Infarction/mortality , New Hampshire , Organizational Innovation , Patient Care Team/organization & administration , Practice Guidelines as Topic , Program Development , Program Evaluation , Prospective Studies , Regional Health Planning/organization & administration , Registries , Time Factors , Transportation of Patients/organization & administration , Treatment OutcomeABSTRACT
Hospitalization represents an ideal time to address tobacco cessation. For a variety of reasons, current users do not always receive appropriate support or treatment during the hospitalization. An improvement team was created to improve the care for the hospitalized tobacco user. The team's aim was to develop a standardized process to increase the assessment, documentation, and delivery of cessation counseling, and increase community referrals upon discharge. After implementation of the project, percentages of hospitalized patients who had their tobacco use status documented in the electronic medical record increased to 80-90%. The percentage of patients admitted with heart failure or pneumonia had their rates of tobacco cessation counseling improved to 82-96%. The care of the hospitalized tobacco user can be improved and sustained by utilizing community resources and creating a team of motivated care providers. This improvement work stimulated the creation of a smoke-free institution and other preventive health measures throughout the institution.
Subject(s)
Community Networks , Counseling/standards , Hospitalization , Preventive Health Services/standards , Quality of Health Care , Smoking Cessation , Smoking Prevention , Heart Failure/psychology , Heart Failure/therapy , Humans , Patient Education as Topic , Pneumonia/psychology , Pneumonia/therapy , Preventive Health Services/organization & administrationABSTRACT
BACKGROUND: There have been few studies of the extent to which differences in the pool of patients being managed might account for geographic variations in treatment rates. OBJECTIVE: For two cardiac procedures, cardiac catheterization and revascularization, we evaluate the hypothesis that differences in "the percentage of patients for whom the procedure is appropriate" is a factor explaining variations in use rates among those hospitalized with coronary heart disease (CHD). RESEARCH DESIGN: Based on hospital utilization patterns in Massachusetts in 1990, we created 70 small geographic areas. Using 1992 Massachusetts Peer Review Organization data, areas were ranked from highest to lowest based on (empirical-Bayes-adjusted) hospitalization rates for each procedure. One thousand seven hundred four cases from 43 hospitals were sampled, roughly half each from high and low use areas. Half had a procedure and half were candidates for the same procedure but did not have it. For each procedure, medical records were reviewed to determine whether the procedure was (or, for those not having it, would have been) appropriate, based on criteria developed using a modified Delphi approach. RESULTS: Among those having either procedure, appropriateness rates were similar in high and low rate areas (P = 0.59 for catheterization and P = 0.30 for revascularization). However, among candidates for either procedure who did not have it, appropriateness for performing the procedure was greater in high-rate areas (41.4% vs. 32.1%, P = 0.05 for catheterization; 71.2% vs. 57.2%, P = 0.003, for revascularization). CONCLUSION: Among those hospitalized with CHD, appropriateness rates for two cardiac procedures are higher in areas with higher use rates.
