13 Quality Improvement Strategies and the Link to Performance on Percutaneous Intervention for Acute Myocardial Infarction

Abstract

In an effort to encourage quality improvement in emergency care, a number of organizations (eg, Institute of Medicine, Joint Commission, American College of Emergency Physicians) have recommended that hospitals adopt various improvement practices and technologies including patient flow improvement, emergency department (ED) dashboards, and 5-level triage systems. These quality improvement strategies have been shown to be beneficial in single-site evaluations, but to our knowledge, they have not been evaluated in multisite studies. Our study explores the relationship between use of these 3 quality improvement strategies and hospital performance on receipt of percutaneous intervention within 90 minutes for acute myocardial infarction patients. In 2009, we administered a survey on quality improvement activities to chief quality officers at 1,988 hospitals; 28.8% (n=572) responded. The survey asked respondents about the use of ED dashboards and whether patient flow strategies were used widely or hospital-wide. We obtained data from the 2009 American Hospital Association (AHA) Annual Survey on hospitals' ED triage systems. We paired these data with 2008 and 2009 Hospital Quality Alliance data on the percentage of acute myocardial infarction patients with a percutaneous coronary intervention time under 90 minutes. After excluding hospitals with less than 25 cases, data were available for 271 hospitals. T-tests were used to detect differences in percutaneous coronary intervention performance scores based on whether hospitals used patient flow strategies, an ED dashboard, and a 5-level triage system. Linear regression models were used to adjust for hospital characteristics (bed size, region, ownership, network affiliation, and teaching status) obtained from the AHA Survey. Forty-four percent of respondents reported using patient flow strategies widely or hospital-wide, 46% reported using an ED dashboard, and 55% reported using a 5-level triage system. In comparison to hospitals that did not use the practice or technology, percutaneous coronary intervention performance scores were significantly (p<.05) better at hospitals that used patient flow strategies (83.9% versus 80.4%), ED dashboards (83.7% versus 80.0%) and 5-level triage systems (83.7% versus 78.4%). Even after controlling for hospital characteristics, percutaneous coronary intervention performance scores were 3.5 (p<.03) percentage points higher (ie, better) for hospitals that used patient flow strategies and 6.2 (p<.01) percentage points higher for hospitals that used a 5-level triage system. percutaneous coronary intervention performance scores were 5.2 (p<.01) percentage points higher at hospitals with 2 quality improvement strategies in place and 7.6 (p<.01) percentage points higher at hospitals with 3 quality improvement strategies in place. Use of multiple quality improvement strategies was associated with significantly and sizably better percutaneous coronary intervention performance scores, and the biggest difference in percutaneous coronary intervention scores was between hospitals that do and do not use 5-level triage. Our findings suggest that hospitals should consider adopting these quality improvement strategies.