Transcript (STEMI) Patient Discharge Instruction Checklist: Can We Do Better?

ST ELEVATION MYOCARDIAL INFARCTION (STEMI) PATIENT DISCHARGE INSTRUCTION CHECKLIST:
CAN WE DO BETTER?
Maryann Rabusic-Wiedener, Shauna Johns, Tina Ainsworth, Debra Lundberg, Maureen Stewart, Barb Stolee, Dr. James McMeekin, Dr. Mouhieddin Traboulsi for the Calgary Health Region
BACKGROUND
New treatment strategies for STEMI patients have led to shorter hospital stays.
Practices such as primary percutaneous coronary intervention and the use of
glycoprotein IIb/ IIIa inhibitors have improved STEMI patient outcomes and
accelerated this population to earlier discharge dates. Due to shortened hospital
stay, patient retention of cardiac education information is in question. All cardiac
rehabilitation must happen in the community; therefore discharge instructions for
follow-up care must be concise, consistent and comprehensible. Preliminary data
suggests that STEMI patients within the Calgary Health Region (2006) did not
attend cardiac rehabilitation programs (42%), were noncompliant with medications
(22%), had hospital readmissions (17%), and experienced adverse events (8.3%).
OBJECTIVES
The purpose of this study is to determine whether application of a standardized
discharge process has any influence on readmission rates, adverse events,
medication compliance, follow-up care with physicians, and cardiac rehabilitation
program attendance on the STEMI patient population.
METHOD
CONCLUSION
• Sample size for the pilot group was too small to make generalizations
• Follow-up with patients or staff for their comments on the usefulness
of this D/C cardiac checklist would be desirable
• Did not measure pre/post discharge teaching methods
• Follow up difference in groups, 3 months vs. 1 year, may explain the
difference in medication adherence
• Discharge process is complex and one that will need continual
evaluation to optimize
RESULTS
Medication Compliance Pre/Post Implementation of Discharge Checklist
Long Term Compliance
Short Term Compliance
100
100
90
90
80
80
70
70
60
60
ASA
BB
ACEI/ARB
30 days post discharge 2006
STATIN
30 days post discharge 2007
ASA
BB
ACEI/ARB
1 year post discharge 2006
STATIN
3 months post discharge 2007
Comparison of Patient Behaviours Pre and Post Discharge Checklist Implementation
DISCUSSION
• Plavix was not included as duration of therapy is not standard.
• Discharge regime was relatively standard pre/post: ASA 100%, BB
88% & 83%, ACEI/ARB 92 &100%,STATIN 100%
• Post implementation (2007) there was a trend toward better
compliance at 3 months to some drugs
• Readmission rates at 30 days decreased by 27% from 2006 to 2007
• No effect observed on adverse events
• Secondary prevention behaviours (attendance at Cardiac Rehab &
GP visit) were improved post implementation
• STEMI Clinic was also running during the months of March/April
2007, may have influenced behaviours
A discharge checklist was designed and implemented to provide nurses with a
standardized set of educational topics to be addressed with STEMI patients
Short Term Comparisons
Long Term Comparisons
prior to discharge. Both the patient and nurse sign off the checklist to ensure
accountability for information provided and received. The pilot group of 24
GP Follow-up
GP Follow-up
STEMI patients from March/April 2007 had the “Discharge Checklist”
Cardiac Rehab Attendance
Cardiac Rehab Attendance
implemented as part of their discharge process. This group of STEMI patients
Adverse Events
Adverse Events
was monitored at one month and again at three months for readmission rates,
Readmission
Readmission
adverse events, medication compliance, follow-up care with physicians, and
cardiac rehabilitation program attendance. As a control group, we took 24
0
5
10 15 20 25
0
20
40
60
80
STEMI patients from March/April 2006 and compared their readmission rates,
Percentage
adverse events, medication compliance and cardiac rehabilitation attendance at
Percentage
one month and one year to the 2007 pilot group. The data was evaluated to
1 year post discharge 2007 3 months post discharge 2007
30 day post discharge 2006 30 day post discharge 2007
see if any changes in patient behaviour could be detected in the use of a
standardized discharge checklist.