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THE CHAMPLAIN GET WITH THE GUIDELINES INITIATIVE |
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ABOUT GET WITH THE GUIDELINES
Introduction The Champlain Get with the Guideline Initiative - Acute Coronary Syndrome (GWG-ACS) Initiative is a regional quality improvement program that seeks to ensure that all patients admitted to hospital for a heart attack, or with cardiac symptoms who are at risk of heart attack, receive life-saving best practice care as a standard of care when admitted to hospitals in the Champlain Local Health Integration Network (LHIN). The aim of the Champlain GWG-ACS Initiative is to create a regional quality improvement system for monitoring delivery of these best practices within Champlain LHIN hospitals and in the community. Acute Coronary Syndrome Acute Coronary Syndrome (ACS) patients include those patients admitted to hospital with acute myocardial infarction (heart attack) as well as those patients admitted with cardiac-related symptoms who are at risk for heart attack. In 2006-07, there was an estimated 6,259 ACS patients admitted to hospitals in the Champlain LHIN. This represents approximately 6.11% of the total hospitalizations in the Champlain LHIN. Considering that 22% of all hospitalizations were due to CVD (including acute myocardial infarction, ischemic heart disease, heart failure, cerebrovascular disease, diabetes, and other circulatory disease), ACS accounts for almost one-third of hospitalizations. Moreover, in 2006-07, a total of 16,159 emergency room (ER) visits in the Champlain LHIN were due to ACS, representing approximately 6% of the total ER visits within the Champlain LHIN. Evidence-based Secondary Prevention of CVD The Ontario Ministry of Health and Long-term Care (MOHLTC) and the Champlain LHIN have identified 30-day post-hospital acute myocardial infarction (AMI) mortality and in-patient re-admission rates for AMI as LHIN Scorecard indicators. Evidence-based guidelines are available and there is strong evidence that implementation of these guidelines results in reductions in AMI mortality and re-hospitalization. There is, however, a well documented care gap in the delivery of these guidelines in practice. In-hospital initiation of cardiovascular protective medications as the standard of care for CVD patients has been shown to substantially reduce the risk of future cardiovascular events as well as subsequent hospitalizations and visits to emergency. Furthermore, it has been shown to prolong life among the large number of patients suffering from CVD. These statements are supported by accumulating evidence showing the association between adherence to evidence-based guidelines and patient outcomes. Best Practice Guidelines for Secondary Prevention in ACS Patients
The Practice Gap - ACS Large clinical trials have provided evidence for the development of standardized evidence-based guidelines (EBGs) to treat ACS. Compliance with these guidelines significantly improves survival1. Despite the development and dissemination of EBGs, their use among patients with ACS is sub-optimal. Baseline rates from the Ontario EFFECT study indicate medication utilization for AMI patients identified as ideal for ASA, beta blockers, ACE inhibitors, and statins within the hospitals of Champlain LHIN (n=12 hospitals, 1615 AMI patients) was 83%, 78%, 68%, and 59% respectively. These results exemplify the treatment gaps that exist within the Champlain regional hospitals and illustrate that between 17 to 41% of opportunities to provide guideline recommended care were missed in current practice. Moreover, a number of patients, for a variety of reasons, come off the best practice guidelines during the first 6 months post-hospital discharge. This is a major risk to patients, and it raises concerns about the continuity of care as patients move between the hospital and community settings. The failure to reach clinical treatment goals in the hospital setting is largely due to the absence of a system to ensure adherence as part of the standard of care. Actively changing systems of care have reduced the gap in the application of secondary prevention guidelines in hospitalized CVD patients 2.Get with the Guidelines The most successful hospital-based quality improvement program for the delivery for cardiovascular care is the Get with the Guidelines (GWG) initiative, developed by the American Heart and Stroke Association (AHSA)2,3. GWG involves multiple organizations and physicians who champion the process among their hospital teams of cardiologists, neurologists, primary care physicians, nurses, and pharmacists. Several studies of the American College of Cardiology’s Guidelines Applied in Practice (GAP) initiative showed that embedding ACS guidelines into practice was associated not only with higher use of evidence-based therapies (i.e. more frequent use of in-hospital medications and treatments), but also corresponded to better patient outcomes. The latter included fewer in-hospital episodes of congestive heart failure and major bleeding events, higher discharge rates of aspirin, B-blockers, statins, and ACE inhibitors, fewer re-hospitalizations for heart disease and myocardial infarction, and reduced combined death/ cerebrovascular accident/ myocardial infarction during the first 6 months after discharge and at one year after discharge 4,5,6,7. Hospital implementation of a standard discharge protocol is effective in increasing utilization of evidence-based therapies and leads to improvements in cardiovascular re-admission rates, medication adherence rates, and mortality rates in cardiovascular patients. The Champlain Get with the Guidelines Initiative The University of Ottawa Heart Institute (UOHI) pioneered a Canadian version of the GWG initiative. The core of the program is a paper-based patient management tool, developed in accordance with evidence-based secondary prevention guidelines, which provides data collection, embedded reminders and guideline summaries, and quality performance reports. The tool emphasizes compliance with instructions to advance the understanding of the best approaches. The Get with the Guidelines Initiative:
Key Components of the Champlain GWG Initiative The GAP Discharge Tool
The core of the Champlain GWG-ACS Initiative is a paper-based patient management tool, developed in accordance with evidence-based secondary prevention guidelines, which provides data collection, embedded reminders and guideline summaries, and quality performance reports. The tool emphasizes compliance with instructions to advance the understanding of the best approaches. Nursing staff assesses each patient prior to discharge for compliance against the EBGs. If any of the best practices are not in place, the most responsible physician is contacted, and the necessary actions are taken. In addition, the patient receives a copy of the tool to take to his/ her family physician to ensure the plan of care is well understood and to enhance continuity of care. The Guidelines in Practice tool will be adapted to fit the needs of the individual institutions. A tool kit has been developed which includes care maps, tools, data abstraction processes to support integration of the tool into routine hospital practices and ensure processes are in place to support tool completion, data collection, and quality assurance reporting.
Facilitation
A coaching approach to knowledge dissemination will be used to implement the tool in hospitals throughout the Champlain District. The implementation process will: (a) provide educational programs to physicians and hospital staff; (b) monitor accuracy of tool use (i.e. all appropriate patients receive the discharge tool); and, (c) ensure the tools are properly completed (e.g. care pathway, initiation of standard orders, and discharge tool). An estimated 5 to 10 days per institution is required for initial implementation with an additional 5 to 10 days of support for quality assurance activities.
References
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