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Running head: IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 1

Implementation of an Acute Myocardial Infarction Clinical Practice Guideline:

Identifying and Addressing Barriers to Successful Change

Michelle Kardohely
IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 2

Abstract

A clinical practice guideline (CPG) transforms evidence into practice, standardizes appropriate

care, and supports clinical decisions; thereby, decreasing the amount of care variation and

inefficiencies for a specified patient population. Patient care quality and outcomes improve when

evidence-based practice is the standard, decreasing morbidity and mortality rates.

Communication among disciplines improves care delivery, thus decreasing ICU stay, cost per

patient day, and improving patient satisfaction. Successful adoption and adherence to a CPG are

directly related to knowledge of evidence-based practice, structural processes, and resistance to

change current practice. A large non-profit, academic healthcare institution chosen for the Acute

Myocardial Infarction (AMI) bundled payment demonstration, used the Plan, Do, Study, Act

(PDSA) model to guide the facilitation of a clinical practice guideline for percutaneous catheter

intervention patients with ST-elevation myocardial infarction. The PDSA model is an inter-

professional approach to quality improvement that can guide the development and integration of

a nursing CPG by identifying barriers and strategies to address them. A survey distributed to 45

nurses directly affected by the practice change revealed 77% percent of the nurses were

comfortable with changes in the care of percutaneous catheter intervention patients with ST-

elevation myocardial infarction. The greatest barriers to successful implementation were

operational and structural processes. The relationship between the AMI bundle and value-based

purchasing was identified as an educational opportunity.


IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 3

Implementation of an Acute Myocardial Infarction Clinical Practice Guideline:

Identifying and Addressing Barriers to Successful Change

Beginning October 1, 2017, the Acute Myocardial Infarction (AMI) mandatory bundled

payment is set to begin in 98 randomly chosen metropolitan statistical areas. The AMI model is a

90-day care, retrospective episode payment model that is quality based and performance

measured. Specifically, the metrics measured are hospital 30-day, all-cause, risk-standardized

mortality rate after an AMI, excess days in the acute care after hospitalization for an AMI, and

the Hospital Consumer Assessment of Healthcare Providers and Systems survey. As

reimbursement for Medicare fee-for-service beneficiaries shifts from the current inpatient

prospective payment model to a value-based model, it is imperative for healthcare institutions to

review care processes for patients discharged with AMI index admissions. Additionally, specific

Medicare Severity-Diagnosis Related Groups for percutaneous catheter intervention (PCI) will

initiate an AMI model episode and require review (Center for Medicare and Medicaid Services

(CMS), 2016).

Care standardization for the AMI population, such as a clinical practice guideline (CPG),

is a necessity to avoid variations in care and successfully adopt the AMI care bundle (Meyer,

2016). The American Heart Association, American College of Cardiology, and U.S Department

of Health and Human Services recognize the impact of CPGs in optimizing care for patients with

cardiovascular conditions (Arnett et al., 2014). Health care providers have the potential to avoid

iatrogenic complications, reduce the length of stay (LOS), avoid unnecessary costs, appropriately

utilize resources, decrease readmissions, and decrease overall mortality. However, CPG

compliance and adherence is directly related to knowledge translation of evidence-based

practice, structural processes, and resistance to change current practice (Gurzick & Kesten,
IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 4

2009). Furthermore, comorbidities that accompany cardiovascular disease potentially create

barriers to CPG adherence when conflicting treatments can affect patient safety (Arnett et al,

2014).

Problem

In the AMI population, several distinct categorical subgroups can be identified by

differences in pathophysiology, clinical presentation, treatment approach, outcome expectations

and level of care (Kumar & Cannon, 2009). According to the American College of Cardiology,

patients with ST-elevation greater than 1 millimeter in at least two contiguous leads on serial 12-

lead electrocardiograms and positive serial cardiac biomarkers is indicative of a ST-elevation

myocardial infarction (STEMI). Primary treatment for STEMI is immediate coronary reperfusion

with percutaneous catheter intervention (PCI). In contrast, a presentation of positive serial

biomarkers without 12-lead electrocardiogram changes is indicative of a non-ST-elevation

myocardial infarction (NSTEMI). Primary management for NSTEMI is aggressive medical

therapy to prevent further myocardial ischemia and then cardiac catheterization with PCI if

indicated (Alpert, Simmons, Douglas, Wilson, & Breall, 2017; Kumar & Cannon, 2009).

All patients with NSTEMI/STEMI undergo early (admission) and late (discharge) risk

stratification to ascertain outcome prognosticators and guide treatment. At present, two validated

multivariable risk stratification models, the CADILLAC risk score, and the Zwolle primary PCI

index, specifically address patients with STEMI who have undergone PCI. Both of these models

allow physicians to stratify patients as low, intermediate, or high-risk, based upon a weighted

score of defined risk variables that predict 30-day and one-year mortality rates (Alpert et al.,

2017; Kumar & Cannon, 2009).


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A large non-profit, Magnet-certified academic healthcare institution chosen for the AMI

bundled payment demonstration reviewed care across the institution in preparation for the

October 2017 bundle enactment. An outside consulting firm, brought in to assist in the

assessment of the current state, identified a lack of care standardization in the AMI population,

particularly the overall hospital LOS for low-risk percutaneous catheter intervention ST-

elevation myocardial infarction (PCI STEMI) patients. According to the National Cardiovascular

Data Registry percutaneous catheter intervention (2016) data, the institutions current overall

LOS for low-risk PCI STEMI patients is three days, which does not meet the national two-day

benchmark.

Stakeholders directly responsible for the care of these patients (PCI STEMI) and the most

affected by the bundle, collaborated with the consulting firm and developed an action plan to

address the factors preventing standardization. This workgroup included the cardiac service line

administrator, patient-care unit directors, and cardiac medical and interventional directors, as

well as representatives from bed management, informatics, quality, and finance.

The greatest barrier to standardization identified by the workgroup was the absence of an

order set specific to this patient population in the electronic health record. Three years ago, in an

effort to address standardization and length of hospitalization, a CPG for low-risk PCI STEMI

patients was developed. However, a new, hospital-wide electronic health record integration was

underway and the associated orders never formalized.

The workgroup acknowledged that significant operational changes in patient flow

logistics with a new CPG implementation would create additional barriers. Currently, the process

to transfer a PCI STEMI patient admitted to the Cardiac Intensive Care Unit to low-level monitor

unit is contingent on the medical resident or cardiology fellow placing the order after morning
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rounds and bed availability on the accepting unit. The preferred unit for transfer receives post-

procedural patients, which require an overnight stay from the cardiac catheterization and

electrophysiology lab, as well as unstable angina and NSTEMI emergency room patients.

Framework

The Plan, Do, Study, Act (PDSA) model, an inter-professional approach to quality

improvement, guided the project. The PDSA model approaches change in a cyclical manner;

change integration into practice culture necessitates outcome reevaluation and practice change

reinforcement. Each step is as follows: identify the goal and metrics to reach the goal (plan);

implement the plan (do); monitor outcomes for success or improvement (study); and integrate

learning and adjust goals as needed (act) (Bohnenkamp, Pelton, Rishel, & Kurtin, 2014b).

Change enactment in one part of a system affects ultimately the whole system; therefore, it is

conducive to plan change so as to remain less disruptive and have a greater chance for success

(Bohnenkamp, Pelton, Rishel, & Kurtin, 2014a).

Current Evidence

Review of the Literature

The review of the literature was conducted using multiple databases including CINAHL,

PubMed, MEDLINE, and Cochrane. Search terms included performance measures, cost, quality,

acute myocardial infarction, quality improvement, EHMR, organizational culture, evidence-

based medicine, evidence-based practice, nursing culture, clinical pathway guidelines, patient

outcomes, safety, bundled payments, AMI bundle, CMS, and metrics.

Cost. The cost of care in the ICU (any) contributes to approximately 50% of the hospital

stay (Silverman & Morrow, 2016). The number of ICU beds utilized nationally grew 15% from

2006-2010, paralleling population growth (Wallace, Angus, Seymour, Barnato, & Kahn, 2015).
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According to the Healthcare Cost and Utilization Project, 26.9% of United States hospital stays

in 2011 received ICU care, representing 47.5% of total hospital costs. Eight of the eighteen

highest conditions/procedures associated with ICU care were cardiac related, as demonstrated in

Table 1. The total ICU stay represents the percentage of ICU use for that condition. However,

the total cost attributed to the ICU stay was disproportionate to total ICU stay or severity of

illness, as seen in Table 2 (Barret, Smith, Elixhauser, Honigman, & Pines, 2014).

Table 1
Cardiac Related ICU Care and Percentage of Total Stays in the ICU
Condition %
Acute myocardial infarction, alive with MCC 70.3
Acute myocardial infarction, without MCC 60.6
Percutaneous cardiovascular procedure with drug-eluting stent, without
MCC 63.4
Heart failure and shock, with MCC 53.8
Cardiac arrhythmia and conduction disorders, with CC 53.4
Cardiac arrhythmia and conduction disorders, without CC/MCC 51.3
Circulatory disorders except AMI, with cardiac catheterization, without MCC 51.2
Heart failure and shock, with CC 43.5
Chest pain 40.1
Note. CC (complication or comorbidity), MCC (major complication or comorbidity)
Adapted from Barrett, M.L., Smith M.W., Elixhauser, A., Honigman, L.S., & Pines, J.M. (2014, December).
Healthcare Cost and Utilization Project. Utilization of intensive care services, 2011. (Statistical Brief No. 185).
Retrieved from Agency for Healthcare Research and Quality website: https://www.hcup-
us.ahrq.gov/reports/statbriefs/ sb185-Hospital-Intensive-Care-Units-2011.pdf

Chen et al. (2015) found hospitals with high AMI admissions use the cardiac care units

for high and low-risk cardiac patients managed medically and/or with revascularization therapy.

The findings are consistent with the Healthcare Cost and Utilization Project results found in

Table 1 and Table 2; the patient is billed the cost of a resource intensive admission, despite

potentially utilizing less critical care interventions (Barret et al., 2014).


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Table 2
Cardiac Related ICU Care and Percentage of Total Hospital Cost
Condition %
Acute myocardial infarction, alive with MCC 30.3
Acute myocardial infarction, without MCC UNK
Percutaneous cardiovascular procedure with drug-eluting stent, without MCC 10.3
Heart failure and shock, with MCC 31.5
Cardiac arrhythmia and conduction disorders, with CC 35.5
Cardiac arrhythmia and conduction disorders, without CC/MCC 35.2
Circulatory disorders except AMI, with cardiac catheterization, without MCC 22.9
Heart failure and shock, with CC 38.2
Chest pain 29.5
Note. CC (complication or comorbidity), MCC (major complication or comorbidity)
Adapted from Barrett, M.L., Smith M.W., Elixhauser, A., Honigman, L.S., & Pines, J.M. (2014, December).
Healthcare Cost and Utilization Project. Utilization of intensive care services, 2011. (Statistical Brief No. 185).
Retrieved from Agency for Healthcare Research and Quality website: https://www.hcup-
us.ahrq.gov/reports/statbriefs/ sb185-Hospital-Intensive-Care-Units-2011.pdf

In another report released by the Healthcare Cost and Utilization Project, Medicare and

Medicaid collectively were the primary payers (63%) of aggregate hospital costs in 2013,

accounting for 46% and 17% of costs respectively (Torio & Moore, 2016). Despite the high

percentage reported paid by Medicare, only 39% of hospital stays are attributable to Medicare,

while the remaining payers demonstrated a more proportionate cost to stay ratio. Additionally,

the Healthcare Cost and Utilization Project reported AMI as the fifth most expensive condition

billed in all payer types in 2013 and remained in this position when reported individually by

Medicare and private payers (Table 3). According to CMS (2016), AMI is the second highest

primary admission diagnosis to the ICU and percutaneous intervention with a drug-eluting stent

is fourth.
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Identifying patients who utilize the greatest amount of care resources is crucial as fee-for-

service reimbursement shifts to value-based models, such as the AMI care bundle. Index

admissions or procedures for PCIs represent 64% of the cost of the 90-day episode and an AMI

index admission represents 27%. In one analysis of PCI index admissions, the average LOS was

3.7 days, total cost was $85,203, and the mean payment by Medicare was $17,259. The average

hospital-reported cost per case (PCIs) was $17,044. This narrow profit margin validates the

tenuous position healthcare institutions are facing if unprepared for the AMI bundle; there is a

great financial risk if care delivery costs exceed Medicares fixed, target price per episode

(Clifton, 2017).

Table 3
Cost of Acute Myocardial Infarction (AMI) by Payer, 2013
Payer Condition rank (by cost) Total cost (millions) National cost (%)
Medicareb 5 $6,660 3.8
Medicaidb 13 $879 1.4
Privateb 5 $3,230 3
Uninsuredb 2 $913 4.9
All Payersa 5 $12,092 3.2
Note. aThe total cost of all payers for AMI hospitalizations and percentage of national costs. The total national cost
for 35.6 million hospital stays was $381.4 billion. The total cost for AMI was $12.1 million of the total national cost
of $381.4 billion. bThe total cost and percentage of national cost per payer for AMI hospital stays.
Torio, C.M. & Moore, B.J. (2016, May). Healthcare Cost and Utilization Project. National inpatient hospital costs:
The most expensive conditions by payer, 2013 (Statistical Brief No. 204). Retrieved from Agency for Healthcare
Research and Quality website: https://hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-
Conditions.pdf

Evolution of care. The coronary critical care unit has historically been the standard of

care for patients with AMI. However, incidences of STEMI patients and consequently, the

associated complications have decreased. Advancements in cardiac care, such as


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revascularization techniques, structural heart interventions, and secondary care, have contributed

to a progressively older population with multiple comorbidities; hence, there is a greater demand

for highly comprehensive, specialized cardiovascular critical care (Morrow et al., 2012;

Silverman & Morrow, 2016).

The coronary critical care model of care continues to evolve as the patient population

changes; therefore, recognizing the financial implications AMI care places on the health care

system is an opportunity to improve care efficiencies and cost disparities. Incorporating an

evidence-based risk assessment and care pathway is recommended for defining high and low-risk

AMI patients when triaging patients for a coronary critical care admission (Silverman &

Morrow, 2016).

Supporting evidence. The financial impact of cardiac related ICU care, notably the cost

for AMI, on the overall cost of a hospital stay is the motivating force behind the AMI bundle

enactment (Clifton, 2017). In response to the evolving, specialized care in the coronary care

units, progressive coronary care units are becoming more specialized and capable of caring for

patients traditionally admitted to the coronary care unit (Silverman & Morrow, 2016).

The following observational studies suggest low-risk AMI patients have favorable

outcomes when cared for in progressive coronary care units. Chen et al. (2015) reported risk-

standardized in-hospital mortality for STEMI patients did not correlate with ICU or progressive

care admission. Although the in-hospital mortality was not well risk-adjusted, several other

studies found similarities when comparing in-hospital mortality. Van Diepen et al. (2016)

compared outcomes between coronary care units and progressive care for low-risk NSTEMI and

unstable angina patients and found in-hospital mortality was lower or similar. Another study

proposed STEMI, Killip class I patients could be cared for in a progressive unit because adverse
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events were low in coronary care units (Silverman & Morrow, 2016). The Killip scale classifies

the degree of left ventricular dysfunction into four classes. Class I demonstrates no evidence of

heart failure, whereas Class IV is cardiogenic shock. Several risk stratification scales utilize the

Killip classification system, including the CADILLAC risk score and Zwolle primary PCI index.

Only Killip class I patients are considered low-risk. Patients that are Killip class II, III, or IV all

show some degree of heart failure/left ventricular dysfunction; therefore, considered high-risk

(Alpert et al., 2017).

Stolker et al. (2015) compared primary (in-hospital length of stay and mortality) and

secondary (ICU length of stay and mortality) outcomes, as well as standard myocardial infarction

quality metrics between non-cardiac and cardiac-specific low volume and high volume ICUs (for

AMI patients). Patients admitted to low volume ICUs had higher adverse primary outcomes with

similar secondary outcomes noted than those in high volume ICUs. Patients with STEMI in low

volume units were less likely to receive coronary reperfusion interventions. However, cardiac-

specific low volume units had similar primary and secondary outcomes as cardiac-specific high

volume units.

Intended improvement

A CPG transforms evidence into practice, standardizes appropriate care, and supports

clinical decisions; thereby, decreasing the amount of care variation and inefficiencies for a

specified patient population. When evidence-based practice is the standard, care quality and

patient outcomes improve and morbidity and mortality rates decrease. Communication among

disciplines improves care delivery, thus decreasing ICU stay, cost per patient day, and improving

patient satisfaction (Gurzick & Kesten, 2009; Fisher, et al., 2016). The proposed clinical pathway

for implementation is consistent with and supported by current evidence that low-risk PCI
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STEMIs can safely transfer earlier from an intensive care unit to a low-level care unit or placed

directly on a low-level unit. It is imperative the progressive care unit chosen is proficient in the

care of the cardiac patient.

A critical component in successful implementation and adherence to a clinical pathway

guideline is to identify and remove barriers among the nursing staff (Gurzick & Kesten, 2009;

Fisher, et al., 2016). It is the intention to identify barriers and integrate strategies for successful

low-risk PCI STEMI CPG adherence by evaluating structure (organizational), process (delivery),

outcomes (AMI standard metrics and mortality), and culture (beliefs and attitudes). Through

interpersonal collaboration and communication, nursing staff will understand the concepts

behind the shift to a business model of care and the AMI bundle enactment.

Methods

Setting

The study takes place at a large non-profit, teaching hospital. The department chosen for

this study is the CICU, a 14-bed patient care unit directly affected by the revised CPG

implementation.

Population

The populations of interest are Cardiac Intensive Care Unit (CICU) nursing staff and

low-risk PCI STEMI patients admitted to the CICU. The CICU nursing staff provides care to this

specific patient population and affected by the revised CPG implementation.

Ethical issues

All patient records reviewed for data extraction will remain confidential and without

patient identifiers attached to the data. The institutional IRB reviewed and approved this

proposal.
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Plan and Do

The PDSA model is an inter-professional approach to quality improvement; shared

leadership among multiple disciplines encourages a more collaborative approach in identifying

specific goals, delineating responsibilities, and planning interventions (Bohnenkamp, Pelton,

Rishel, & Kurtin, 2014a). Members of the workgroup, in collaboration with the consulting firm,

developed an action plan and assigned specific responsibilities to reach the outlined goals.

Unclear, inapplicable, or inaccessible care guidelines create contextual and workflow

barriers (Fisher et al., 2016). The revised low-risk PCI STEMI order set for electronic health

record integration was finalized, sent high priority to the informatics department, and hospital-

wide adoption was anticipated by July 1, 2017. A major element of the revision is the ability to

admit this patient population to the CICU under a low-level classification; with an aim to

decrease LOS and concomitantly address CMS quality metrics and the two-day LOS benchmark.

To ensure accurate coding, a defined inclusive AMI diagnosis per CMS was developed and

integrated into the medical record system. Additionally, reinstatement of a provisional order set

for CICU discharge was completed.

The revised low-risk PCI STEM CPG order set is a major cultural change for the nurses.

Resistance to practice change is a substantial barrier; successful implementation depends on the

nurses perceptions of evidence-based practices and the value placed on CPGs. Self-efficacy and

knowledge of the evidence promote change. The greatest barriers to implementation and

compliance are accessibility, knowledge deficiency, workflow issues, lack of autonomy in

flexibility, and an unsupportive environment (Gurzick & Kesten, 2009; Williams, Perillo, &

Brown, 2014). In contrast, facilitators for successful implementation include communicating

clear expectations, ensuring nursing competence, and removing workflow barriers to create a
IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 14

supportive environment. An organizational climate amenable to implementation develops nurses

skilled in evidence-based practice and empowers nurses to embrace change positively (Melnyk,

Ford, Long, & Fineout-Overholt, 2014; Weng et al., 2013; Willliams, Perillo, & Brown, 2014).

Methods of Evaluation. Prior to the CPG implementation, an anonymous nine-question

survey was created to identify perceived barriers, determine the necessary resources, and assess

the readiness of the CICU nurses. An email sent to the nurses provided a brief introduction of the

investigator, a description of the project, the survey purpose, and a link to access the survey via

the online platform SurveyMonkey (See Appendices A, B, and C for questionnaire). The CICU

director supported and encouraged staff participation. One week after the initial email, the

investigator emailed a reminder and personally spoke with staff. The survey was open for 14

days. In an effort to maintain anonymity, the number of years nursing experience was the only

demographic inquired.

The survey design sought to ascertain the most relevant barriers to CPG adherence and

implementation experienced by the nursing staff and gain an understanding of the nurses current

knowledge of CMS initiatives and CPGs. Participants received a list of five potential variables

that contribute to patient transfer delays and were asked to number the selections from 1

(greatest barrier experienced) to 5 (least barrier experienced) (survey question 2 in Appendix

A). Three questions (survey questions 6, 7, and 8 in Appendix B), established an understanding

of the nurses current knowledge of value-based purchasing (VBP) and the AMI bundle

initiative. Seven potential benefits related to the effectiveness of evidence-based CPG was listed

and nurses were asked to designate a yes (agreement), sometimes, or no (disagreement)

for each (survey question 9 in Appendix C).


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The anticipation of effective behavior change considers attitude towards proposed

changes; therefore, it was essential to identify current nursing perceptions related to LOS and

low-risk AMI care (Fisher et al., 2016). Nurses were asked to indicate if they felt it was safe for

low-risk PCI STEMI patients to be transferred to progressive/low-level care in 24 hours or less

with a yes or no. If the answer was no, the nurse was asked to comment. The nurses were

asked to specify the most appropriate time perceived safe before transfer (survey questions 4 and

5 in Appendix B).

Analysis of Results

Study

Forty-five CICU nurses received the AMI Bundle Survey. The survey was open for

fourteen days with a response rate of 57 percent (N=26). Of the 26 participants (Figure 1), an

even number of nurses reported having at least one year but less than five years or twenty

years or more experience (combined 70%).

Number of Years Worked


50% 20 years or more
34.6% 34.6%
At least 10 years but less than 20 years
25% At least 5 years but less than 10 years
15.3%
11.5%
3.9% At least 1 year but less than 5 years

0% Less than 1 year


Years Worked
Figure 1. N=26. Graphical representation of the number of nurses and years worked

Identified barriers. Multiple variables affect the timely transfer of patients. In respect to

the low-risk PCI STEMI patient population, the nurses surveyed ranked potential variables

according to what they perceived as the greatest barrier (1) to the least perceived barrier (5)

(refer to survey question 2 in Appendix A). Forty-six percent of the nurses reported there are no

open beds available for transfer as the greatest perceived barrier and 31% identified the time it
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takes for orders to be placed in EPIC, the hospitals electronic health record, as the least

perceived barrier. The third most ranked (35%) perceived barrier was the receiving nurse unable

to take report, however, 27% of the nurses identified this as the second most reason for transfer

delays. The barriers, the time it takes for a patient to be seen by rounding physician and

nursing responsibilities for transfer incomplete, ranked identically as the fourth (31%) most

perceived barrier. Except for the greatest report barrier, at 46% agreement among the nurses,

there is minimal variation among the rankings observed (see Figure 2).

When asked to choose the reason for a delayed bed assignment once transfer orders were

received, 96% responded the the receiving department does not have any open beds. Only 4%

reported the receiving department does not have the appropriate bed assignment (male vs

female) (survey question 3 in Appendix A).

Percieved Nursing Barriers Ranked


100%
1 (GREATEST) 2 3 4 5 (LEAST)

50% 46%
35%
31% 31% 31%
27%

27% 23%
19% 19% 23%
8% 15% 23% 15% 12% 15% 15% 8% 8% 23% 15% 12% 12% 8%
0%
Nursing Rounding time Nurse is unable to Time for transfer No open beds
responsibilities take report order placed in EPIC available
incomplete
Barriers

Figure 2. N=26.

Length of stay. Most of the nurses (77%) felt it was safe to transfer low-risk PCI STEMI

patients to progressive/low-level care in 24 hours or less (survey question 4 in Appendix B).

Four of the six nurses who felt transfer in less than 24 hours was unsafe commented:
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Not adequate staff numbers to take care of a patient on step down unit (nurse, 20+ years).

I think that these patients should stay a minimum of 24 hours. Patients can still

have arrhythmias as well as groin complications, so, I think that 24 hours would be a

good time marker for all of these patients and then this can be adjusted if there are any

complications (nurse, 20+ years).

I have done overtime on those units and it is way too busy. If the patient

decompensates, it would take too long for the PCU nurse to notice due to their workload.

Although the cardiac patient can seem healthy, they could decompensate at a rapid rate

(nurse, 20+ years).

We see too many come back at times with CHF, arrhythmias, hemodynamic

problems. Sometimes a popped groin and/or retroperitoneal bleed (nurse, 5-10 years).

Another nurse who felt transfer in 24 hours or less was safe commented:

Should be specific criteria regarding low-risk which there are. I was on LLM one day and

got slammed and felt I was not accurately caring for the patient such as checking the site

every 15 minutes etc... (nurse, 1-5 years).

The most agreed time felt to be safe before the transfer was 12 to 18 hours (35%), followed by 6

to 12 hours (survey question 5 in Appendix B). The percentage of CICU nurses and

corresponding times believed to be appropriate for transfer to low-level can be seen in Figure 4.

When analyzing the data between years worked and perceived appropriate time on the unit, there

did not appear to be any correlation.

There were discrepancies noted in the data when analyzing individual responses. Six

nurses disagreed with a patient transfer under 24 hours; however, two contradicted their
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decisions with a period of under 24 hours (12 to 18 hours and 6 to 12 hours). Two nurses agreed

patient transfer was safe under 24 hours but indicated no less than 24 hours on CICU.

Time on CICU Percieved Safe

100%
77%
75%

50%
35%
27% 23% 23%
25% 15%

0%
Agree safe 6 to 12 hours 12 to 18 hours 18 to 24 hours No less than 24 Disagree safe
under 24 hours hours under 24 hours
Figure 4. N=26.

Value-based purchasing. A majority of the nurses demonstrated an understanding

between fee-for-service and VBP; 96% correctly defined fee-for-service (see survey question 6

and 7 in Appendix B). Similarly, when asked to pick the statements best describe VBP, 85% of

the nurses chose two of the statements correctly. Variables a, b, and c correctly describe

VBP. However, a knowledge gap is evident regarding the relationship between target cost,

reimbursement, and defined episode of care. Variable d is incorrect, as reimbursement does

focus on preventative care beyond the initial episode. Refer to Figure 5.

AMI bundle initiative. In Figure 6, the nurses knowledge of the AMI Bundle Initiative

revealed a larger knowledge deficit is present (see survey question 8 in Appendix C). Similar to

the previous measurement, the nurses picked the best statement(s) that described the AMI

bundle. Only 35% of the nurses identified the correct statements (A and B). Over half of the

nurses seem unaware the bundle is a 90-day care, retrospective episode payment model. A
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possibility may be because hospital 30-day, all-cause, risk-standardized mortality rate after an

AMI is part of the bundle metrics measured.

Nursing Knowledge of Value-Based Purchasing


100%
85% 85%
Percentage of Nurses

75%

50% Series1 Series2 Series3 Series4

23%
25% 15%

0%
1

Figure 5. N=26

Knowledge of AMI Bundle


50% Healthcare providers are responsible for the cost
and quality of care provided to Medicare fee-for-
service beneficiaries (A)
It is a 90-day care, retrospective episode payment
35%
Percentage of Nurses

model (B)
31%
27%
It is a 30-day care, retrospective episode payment
25% model (C)

Is that car insurance? (D)

4% 4% A&B
0.00%
0%
Responses A&C

Figure 6. N=26

Evidence-based clinical practice guidelines. The final survey question (see Appendix

C, question 9) asked the following question (in reference to a list of variables), Thinking

specifically about standardization of care practice guidelines (CPG) for specific disease
IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 20

processes (such as CHF and AMI), do you think that evidence-based CPGs can be effective in

achieving the following? Over 50% of the nurses agreed CPGs can decrease unnecessary or

redundant tests, establishes best practices, and provides consistent care. Slightly under 50% of

the nurses agreed CPGs eliminate cost variation, improve communication, and reduce mortality.

The data indicates CICU nurses possess an overall good working knowledge base on the benefits

of CPGs. Fifty percent of the nurses disagreed CPGs have a flexible design for co-morbidities or

untoward events. Refer to Figure 7 for more detailed results. The first six variables listed are

benefits of CPGs. The final variable is not a benefit, but rather a drawback or limitation of CPG

use (Arnett et al, 2014).

Knowledge of Evidence-Based Care Benefits

Eliminate cost variation 31% 46% 23%

Decrease unnecessary or redundant tests 58% 19% 23%

Improves communications among all disciplines 27% 46% 27%


CPG Variables

Establishes best practices 58% 27% 15%

Provides consistent care 58% 27% 15%

Reduces mortality 42% 39% 19%

Flexible design for co-morbidities or untoward events 23% 27% 50%

0% 20% 40% 60% 80% 100%


Yes Sometimes No

Figure 7. N=26.

Discussion

Act

In preparation for the CPG order set go-live date for PCI STEMI, clear expectations were

articulated from upper management to ensure a smooth transition. However, at the present time,

the CPG has not been integrated into the electronic health record by the originally planned go-
IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 21

live date of July 1, 2017; and subsequently, a go-live date has not been determined. Despite this

setback, an opportunity to address several educational needs identified through analysis of the

survey data was available.

Educational opportunities. To engage staff to meet provisional changes in the revised

CPG, the CICU Director has begun to communicate the upcoming CPG integration to the

nursing staff during morning and evening huddles and will continue after the go-live date to

remain engaged with staff. Until electronic integration of the CPG order set is completed,

instruction on accessing the guideline cannot be completed.

The nursing education related to the AMI Bundled Payment Initiative was derived from

the survey. At the next unit meeting, the author will be presenting the findings from the survey to

the nursing staff and providing education in the areas identified.

AMI bundle initiative and value-based purchasing. An overview of the AMI Bundle

initiative will be provided, addressing the financial implications of value-based purchasing for

the hospital and how care delivery is affected. The hospital is responsible for the cost and care

quality to Medicare beneficiaries for an inpatient stay and up to 90-days after discharge. The

bundle provides a fixed, target price for each 90-day AMI episode, including the cost of a

percutaneous catheter intervention (PCI) with an AMI index admission. Thus, the PCI becomes

the largest cost driver of the 90-day episode. A higher reimbursement is given for higher care

quality, however, any cost exceeding the target price is the hospital's responsibility to repay

CMS at the end of the year. The initial penalty applied is 1.5% and can increase up to 3% (CMS,

2017).

Discuss the relationship between VBP and nursing care outcomes. In accordance with

the financial implications of VBP and higher care quality vs lower care quality, the value of
IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 22

nursing care outcomes will be presented. The current organizational culture of the institution

supports evidenced-based practice and actively collects clinical metric data to monitor outcomes.

Clinical practice guidelines are grounded on EBP and increase quality measures, optimize

efficiency, decreases cost and care variation when nurses are knowledgeable and place emphasis

on quality care (Fisher et al, 2016; Gurzick & Kesten, 2009). The following clinical metrics will

track delays at any stage and will be evaluated: hematoma, bleeding, flank pain, chest pain,

significant arrhythmia, unstable vital signs, and change in mental status. The emphasis on clear

documentation for delays will be communicated.

Present supporting evidence for early transfer. A precondition to a positive behavior

change is knowledge (Fisher et al, 2016). To attain the expectation that nurses will appropriately

triage low-risk PCI STEMI patients out of the CICU to low-level monitoring, supporting

evidence that patients who transfer to low-level cardiac care earlier or immediately after an AMI

have a decreased rate of complications, shorter length of stay, and fewer associated costs and

resources utilized will be provided.

Educate nurses on triage concepts regarding low-level status on CICU. The cardiac

interventionalist risk stratifies a PCI STEMI patient as low-risk and places the order identifying

the patient as low-level in the unit. The expectation is that the nurse will use clinical judgment to

determine readiness for transfer to low-level by 0700 the next day unless specified differently.

Physician review is not required. The nurse will notify patient logistics and request a bed

assignment, identifying the appropriate bed need (male or female) as soon as possible to assure

availability at target transfer time. It will be the charge nurses responsibility to communicate

triage issues, such as bed availabilities or changes in patients condition with the CICU director.

Consistent with standardized workflow processes, the CICU Director will address concerns with
IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 23

the director of low-level and bed management and charge nurses will appropriately staff units,

based on the number of high-level and low-level patients.

PLAN DO STUDY ACT


Define issues Finalize low-risk PCI Analyze survey Provide education
related to AMI STEMI order set results Management and
Bundle Initiative Integrate order set Unavailable beds staff communicate
Summarize into EHR identified as daily on process
evidence Conduct survey of greatest barrier Collaboration
supporting low-risk CICU nurses 77% of nurses feel among all
PCI STEMI CPG Review and revise earlier transfer to disciplines
Identify nursing dashboard metrics LLM safe Monitor dashboard
needs for tracking AMI bundle and metrics
Structural VBP greatest area Plan strategies to
Process identified for reevaluate
Outcomes education
Culture
Develop strategies
to identify barriers

Figure 8. Plan, Do, Study, Act Model used to guide the study

Limitations and Future Research

Concentrating on a variety of barriers identified by the nurses provided only an overview

of the underlying issues. A more focused study on specific barriers causing an increased length

of stay may have been more beneficial. Data extraction for definitive logistical and clinical

metrics with respect to low-risk PCI STEMI patients, such as accurate arrival and discharge

times to the unit, time of transfer order and bed assignment placed could provide the data

attributing to delays and identify factors creating barriers. The requested bed gender, the

receiving unit for transfer, the discharge disposition (home or rehab), and the overall hospital

LOS are important, too.

A request was placed with the Quality Department to extract these data elements.

Additional data included admission source (ED or transfer), admission type (urgent or emergent),
IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 24

overall CICU and hospital LOS. Unfortunately, due to communication issues and time restraints,

the data remained unavailable. In the future, clear communications of expectations are essential.

Sixteen months of crude data previously extracted by CICU management in an attempt to

quantify the average length of stay of the low-risk PCI STEMI patient in the unit was provided to

the investigator and reviewed. The data elements included: arrival and discharge times to the

CICU, the time of CICU admission to transfer order, and the time a bed assignment was received

after the transfer order placed. The decision not to use the data was made because of

inconsistencies in extraction and missing elements.

The design of the survey had several flaws realized by the researcher during analysis.

Demographics such as shift worked, FTE status (full/part time or weekend program), and gender

may have provided insight to response patterns. The last question, which addressed CPG

benefits, required an answer of yes, sometimes, or no, creating ambiguity in the overall

response. A Likert scale would have been more beneficial.

Risk-stratification models are proven to be reliable prognosticators. As earlier or direct

placement of PCI STEMIs on a low-level unit increases from the traditional coronary care unit, a

future study analyzing 30, 90,180-day and one-year complication, readmissions, and mortality

rates to validate the use of these models for this patient population.

Conclusion

The PDSA model provided an inter-professional approach to quality improvement and

implementation of a low-risk PCI STEMI CPG at a large non-profit academic institution. Using

the PDSA model, the workgroup evaluated organizational culture, structure, process, and

outcome measures for AMI care; successfully identifying barriers and strategies to address the

barriers. The standardized framework provided structure for managing change within the system.
IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 25

The study did reveal 77% percent of the nurses were comfortable with changes in the

care of low-risk PCI STEMI patient. Additionally, the nurses demonstrated a strong knowledge

base of CPGs, correlating with the organizational culture of evidenced-based practice. Clinical

practice guidelines are grounded in evidence-based practice and quality nursing care is

emphasized (Fisher et al, 2016; Gurzick & Kesten, 2009).

The greatest barriers faced by nursing to the successful implementation of the CPG were

operational and beyond the limitations of staff. Without a formal integration of the order set in

the electronic medical record, the practice guideline cannot be initiated. The survey discovered

several knowledge gaps concerning VBP and the AMI Bundle initiative. A critical component

for success is to identify and remove knowledge deficits; knowledge of the evidence promotes

self-efficacy and change (Gurzick & Kesten, 2009; Fisher, et al., 2016). Education of the AMI

bundle initiative and VBP, the relationship between VBP and nursing care outcomes, present

supporting evidence for early transfer, and on triage concepts regarding the low-level status of a

patient on CICU is underway.

Successful implementation relies on the continued reinforcement and expectations of

CPG adherence, as well as ensuring appropriate and supportive resources are available.

Physician engagement and compliance affects the ability of appropriate follow through by

nursing. Additional tracking metrics related to the length of stay, outcomes, patient satisfaction,

and cost are under consideration. Lastly, the PSDA cycle (Figure 8) can monitor and track

implemented changes and determine if intended goals were met (Bohnenkamp, Pelton, Rishel, &

Kurtin, 2014a; Bohnenkamp, Pelton, Rishel, & Kurtin, 2014b).


IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 26

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Appendix A

Questions 1 to 3 of Nursing Survey


IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 31

Appendix B

Questions 4 to 7 of Nursing Survey


IMPLEMENTATION AMI CLINICAL PRACTICE GUIDELINE 32

Appendix C

Questions 8 to 9 of Nursing Survey