Quality Update

Stephanie Poe, R.N., Nursing Clinical Quality Coordinator.

For years, groups such as the American Heart Association published guidelines aimed at reducing cardiovascular risks. But Hopkins and other institutions hadn’t totally embraced these standards. Now, Stephanie Poe, nursing clinical quality coordinator, is heading a project to show that adhering to them is as easy as ABC.

How did this project get started?

Actually, it was a marriage of two strategies by the Center for Innovation in Quality Patient Care, one looking to infuse evidence-based guidelines into treatment practices, the other to use medication reconciliation to improve safety. The center already had supported a medication checklist in the Weinberg ICU for transfer orders.

Why target cardiovascular patients?

For years, there’s been ample, scientifically supported data showing that certain medications and lifestyle regimens can significantly reduce the risk of recurring heart disease. Roger Blumenthal, director of the Hopkins preventive cardiology center, had been trying to introduce the use of these guidelines for some time.

So, the innovation center’s medication reconciliation committee and Blumenthal decided to mount a pilot project on Halsted 5, a 21-bed telemetry unit, focusing on coronary artery disease patients. We met with the unit’s staff to design a program that incorporates three strategies: education, medication reconciliation and outreach to referring physicians.

What kind of project was set up there?

We first educated prescribers, nursing staff and patients about reducing the risk of further cardiovascular disease through lifestyle changes like smoking cessation, diet and exercise, and by using evidence-based medications such as anticoagulants, ACE inhibitors and beta blockers. We then established a discharge reconciliation project to ensure that patients were sent home on medications recommended by AHA and the American College of Cardiology. Finally, we sent referring physicians a letter from Dean/CEO Edward Miller and Blumenthal explaining our program and encouraging them to have discussions with their patients about using these medications as part of their ongoing care.

We thought about a project name and finally settled on ABC, because it simply is about the fundamentals of cardiovascular disease risk reduction.

Did you measure the results?

We only measured the medication reconciliation piece. The short length of stay wasn’t conducive to measuring the effectiveness of our education tool.

How did the project stack up with medication reconciliation?

We tracked the discharge medications versus the national guidelines over several weeks and benchmarked ourselves against a similar program at UCLA. I’ll give you a few results: We achieved 100 percent compliance for prescribing aspirin and Plavix. For ACE inhibitors, we started below the benchmark, and after a slow beginning, we’ve stayed around 95 percent compliant. Beta blockers have been a tough nut to crack, but we’ve maintained steady improvement and find our compliance level at 85 percent.

Are you keeping a long-term eye on medication guideline use?

We’ve decided to do a quarterly follow-up on the Halsted 5 pilot to make sure we maintain compliance with the guidelines. And we’ve done grand rounds on the project for the entire Department of Medicine to increase awareness, because it has patients with coronary artery disease, even if they aren’t on a cardiology unit.

What’s next?

There’s a second pilot under way in the 28-bed cardiac surgery intermediate care unit, where the average length of stay is nine days. And we’re going to use a $10,000 grant from the Dorothy Evans Lynn Fund from the School of Nursing for a post-discharge guideline-adherence study, and we will be looking at whether providers keep these patients on the recommended drugs.