Heart attack (myocardial infarction) patients can now breathe a little easier as the result of evidence-based practices that are helping healthcare providers deliver the best care possible and address inherent risk factors from cardiovascular disease. The Safer Healthcare Now! Acute Myocardial Infarction (AMI) Getting Started Kit provides guidelines for care based on best practices, and promotes awareness of evidenced-based care in the clinical community.
Dr. Clare Atzema, an Emergency Physician at Sunnybrook Hospital and an Adjunct Scientist with the Institute for Clinical Evaluative Sciences (ICES) says that the most valuable component of effective AMI care is the system itself. “The greatest predictor for timely and the best care has nothing to do with the patient, it is the system that is the most influential. A system that focuses on time has a trickledown effect.”
In Ontario, hospitals have significantly improved their times in how they triage a patient that presents to emergency. Between 2001 and 2005, there was a 36 per cent improvement in terms of AMI care, with the patient receiving the correct triage when they first come to emergency. Atzema says that when they emphasized speed, or time is muscle, it trickled down to staff. She reinforced that everyone needs to get on board and that negotiations between groups helped to eliminate turf wars.
Early identification and an ECG done within 10 minutes of arrival can make a difference for the AMI patient. “Minutes matter; the earlier, the better,” says Atzema. “Door to needle time of 10 minutes is acceptable, but four minutes is even better and healthcare providers can improve outcomes for their patients by making their door to ECG time even earlier.”
Atzema says that some hospitals are using innovative approaches to do ECGs quickly, so they don’t have to move the patient. “By using a store room close-by or a Geri-chair in a corner with a curtain around it, instead of waiting for a room, they are able to shave off time that is critical for the patient. As well, e-triage software could help nurses who don’t see a lot of heart attack patients and provides onsite support of actions to take, such as recommending an ECG.”
Cardiac rehabilitation (CR) is a disease management program that supports patients to follow through on the medication and lifestyle recommendations that they have been provided while in the hospital. Previously, cardiac rehabilitation was bundled in the AMI GSK for smokers; however, based on the evidence of 25 per cent lower death rates, it is recommended that all AMI patients be targeted for referral to cardiac rehabilitation.
“Our research shows that only about 15 to 30 per cent of patients are referred to cardiac rehabilitation, and most referred patients actually enroll,” says Dr. Sherry Grace, York University and University Health Network. “With a concerted effort, good communication and collaboration between the inpatient units and the cardiac rehab programs, you can set up seamless systems that make it easy for the provider to make the referral.”
Grace says that patient education on discharge includes ensuring that patients know what medications they are on and what they can safely do when they get home. Also include in the discussion that the patient has been referred for cardiac rehabilitation, that the program will be calling them to schedule an assessment and address any questions they might have.
“It is really important that the AMI patient be referred for cardiac rehabilitation from the inpatient setting, before they leave the hospital, as the wait times are much lower and patients are more likely to enroll,” adds Grace. “With inpatient referral we can target the patients who really need it, at a time when they are really feeling vulnerable and need a lot of supports. Using systematic referral strategies, you can get up to 85 per cent of patients referred to programs that work.”
For more strategies to prevent acute myocardial infarction, download the AMI Getting Started Kit, or visit the Safer Healthcare Now! website.