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When
a typical day is filled with emergency admissions stacked
three deep and a beeper that won't quit, knowing the indicators
of high-quality care may not be the same as delivering high-quality
care. The ACC Foundation's Guidelines Applied in Practice
(GAP) Program has shown that simple aids can bridge that gap.
"It's
very easy in that environment to skip a step," said Kim
A. Eagle, MD, in the November 2002 issue of the College's
ACCEL audiojournal. "We need to develop a system that
guarantees that we think about those key indicators."
Dr.
Eagle is the Albion Walter Hewlett Professor of Internal Medicine
and chief of clinical cardiology at the University of Michigan
in Ann Arbor. He was one of the principal investigators of
the first GAP project, which focused on implementing the ACC/AHA
guidelines for the management of AMI.
By
weaving evidence-based practices into the care process, the
GAP initiative makes quality less a matter of memory and more
a matter of routine. GAP tools are simple: critical pathways
for nurses, pocket cards for doctors, standardized order sets,
discharge check lists, and information sheets for patients.
At
the same time, performance targets were narrowly focused.
For the early care of AMI patients, they included the administration
of aspirin and beta-blockers, initiation of reperfusion therapy,
and measurement of LDL cholesterol. Later targets focused
on the prescription of aspirin, beta-blockers, or ACE inhibitors
at discharge; initiation of treatment for elevated LDL cholesterol;
and counseling, if indicated, for smoking or diet.
The
list isn't long, but it packs a punch, Dr. Eagle said. "There
are a lot of other things that cardiovascular specialists
do that add significant value, but there's a certain number
you should never forget, and it's a fairly small list. My
argument is, let's focus on those first," he said.
That
focus paid off. In the 10 Michigan hospitals participating
in the first GAP project, early aspirin use rose by 6 percentage
points and beta-blocker use by about 10 percentage points.
Late aspirin use rose about 10 percentage points, and the
other late performance measures by 5-10 percentage points
each.
Additional
GAP projects are now under way in Oregon and Alabama, thereby
expanding the program to include the management of heart failure
and stable angina.
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