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Journal of Cardiovascular Nursing:
doi: 10.1097/01.JCN.0000267824.27449.65
Articles

Improving Outcomes for Acute Coronary Syndrome Patients in the Hospital Setting: Successful Implementation of the American Heart Association "Get With The Guidelines" Program by Phase I Cardiac Rehabilitation Nurses

Flynn, Frances M. RN, MS, BC-CNS, BC-CVNI; Cafarelli, Mary RN, MSN; Petrakos, Karen RN; Christophersen, Patricia RN

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Author Information

Frances M. Flynn, RN, MS, BC-CNS, BC-CVNI Advanced Practice Nurse, Critical Care Division, Advocate Christ Medical Center, Oak Lawn, Ill.

Mary Cafarelli, RN, MSN Advanced Practice Nurse, Critical Care Division, Advocate Christ Medical Center, Oak Lawn, Ill.

Karen Petrakos, RN Risk Reduction Nurse, Cardiac Rehabilitation, Advocate Christ Medical Center, Oak Lawn, Ill.

Patricia Christophersen, RN Risk Reduction Nurse, Cardiac Rehabilitation, Advocate Christ Medical Center, Oak Lawn, Ill.

Corresponding author Frances M. Flynn, RN, MS, BC-CNS, BC-CVNI, Critical Care Division, Advocate Christ Medical Center, 4440 West 95th Street, Oak Lawn, IL 60453 (e-mail: fran.flynn@advocatehealth.com).

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Abstract

A treatment gap exists between published guidelines for secondary prevention of cardiovascular disease and application of these guidelines in clinical practice. The "Get With The Guidelines" program is a quality initiative developed by the American Heart Association to help acute care providers bridge this gap, thereby decreasing morbidity and mortality from cardiovascular disease. This article describes how cardiac rehabilitation nurses successfully implemented the program using a prospective case-management model in the acute care setting. An overview of the program including purpose, benefits, tools, and resources is provided along with start-up considerations, potential barriers, training needs, and keys to success.

Every year, more than 1 million Americans have a new or recurrent coronary event (acute myocardial infarction [AMI] or death).1 Within the first year of surviving an AMI, 25% of men and 38% of women die. Within 6 years of surviving an AMI, 18% of men and 35% of women have a recurrent AMI, 7% of men and 6% of women experience sudden cardiac death, and 22% of men and 46% of women become disabled with heart failure.2

The burden of coronary heart disease is substantial. It is the leading cause of permanent disability in the US labor force and accounts for 19% of disability allowances by the Social Security Administrator.2 Although AMI patients are at high risk for recurrent events and death, the risk can be significantly reduced by discharging patients on a combination of therapies demonstrated to improve survival.3 In addition, patient education aimed at secondary prevention, including therapeutic lifestyle modification and medication instruction before hospital discharge empowers patients to take an active role in the long-term management of heart disease.

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The Treatment Gap

In an effort to reduce the risk of recurrent cardiac events, the American Heart Association (AHA) and the American College of Cardiology (ACC) published evidence-based guidelines for the management of patients with coronary heart disease, including ST-segment elevation myocardial infarction,4 unstable angina, non-ST-segment elevation myocardial infarction,5 and secondary prevention guidelines for coronary artery disease (CAD).6,7 These guidelines are well supported by large, multicenter, randomized, clinical trials. However, despite the evidence and strong expert consensus supporting evidence-based practice, a significant treatment gap exists between expectations for care in published national guidelines and actual care delivery in clinical practice.8-11 Various barriers to physician adherence to guidelines have been reported in the literature. Barriers are categorized based on knowledge (lack of awareness or familiarity), attitudes (lack of self-efficacy, lack of outcome expectancy, the inertia of previous practice or external barriers), and behaviors (external barriers related to patient acceptance and environmental factors such as lack of time, reminder systems, resources, and reimbursement). It is suggested that a "knowledge-attitude-behavior sequence" is necessary to overcome barriers. This model is helpful when developing strategies to overcome identified barriers.12

Physician knowledge and acceptance of guidelines are the first steps in promoting their use. However, studies indicate that physician knowledge of guidelines alone does not correlate well with adherence to guidelines in practice. Results of these studies suggest that deficits in process may play an important role in perpetuating the treatment gap.13 Implementation of standardized tools embedded with the guidelines such as checklists, standing order sets, and care maps along with standardized processes such as routine screening of the targeted patient population at the point of care are examples of methods to improve adherence to guidelines using a systems approach. The link between guideline adherence (process performance) and patient outcomes is increasingly important because the quality of care provided by hospitals is being reported based on performance process metrics by the Centers for Medicare and Medicaid Services and the Joint Commission. Several recent studies demonstrate a moderate to strong correlation between hospital guideline adherence rates and short-term mortality rates for patients with acute coronary syndrome (ACS).14-16

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Closing the Treatment Gap

The AHA estimates that 80,000 lives could be saved annually by closing the treatment gap for patients with cardiovascular disease and stroke.1 "Get With The Guidelines" (GWTG) is an award-wining, hospital-based quality improvement program sponsored by the AHA to bridge the guideline-treatment gap.17 The GWTG program improves patient outcomes by helping hospitals consistently apply AHA/ACC secondary prevention guidelines before patients are discharged from the hospital. Currently, the AHA offers 3 modules, including one for CAD (GWTG-CAD), heart failure (GWTG-HF), and stroke (GWTG-stroke). Implementing the GWTG program improves patient outcomes by closing the gap between published guidelines ("ideal therapy") and their use in clinical practice ("real therapy"). A systems approach to implementing standardized guideline tools, such as order sets and protocols, is used to increase adherence to secondary prevention guidelines for cardiovascular disease. Basic steps for implementing the GWTG program's CAD module are listed in Table 1.18

Table 1
Table 1
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The AHA developed the GWTG program based on the Cardiac Hospital Atherosclerosis Management Program at the University of California, Los Angeles; the Guidelines Applied to Practice project sponsored by the ACC; and the New England initiative, a pilot study sponsored by the AHA.3,19,20 Results of these studies indicate that the use of standardized order sets and protocols in the hospital setting are associated with significant improvements in adherence rates for secondary prevention guidelines. Furthermore, starting appropriate medical therapies for high-risk patients before hospital discharge is associated with decreased cardiac events and improved survival during 6-month and 1-year follow-up studies.3,16,21

The AHA chose to establish a hospital-based performance improvement program to reduce cardiovascular mortality for several key reasons. First, the hospital setting represents a great capture point for patients given the staggering number of patients who are admitted annually for treatment of vascular disease. Second, a vascular event such as an AMI, stroke, or new onset heart failure represents a crisis or turning point for patients and their families, increasing their motivation to set goals for therapeutic lifestyle modification and to learn important self-management skills.22 In addition, the hospital infrastructure supports the use of standardized tools and processes to reduce undesirable variance in best practices and has the resources to collect, monitor, and report outcome data to a large group of healthcare providers. Finally, initiating secondary prevention therapies before hospital discharge bridges the gap between inpatient and outpatient settings, especially for patients who see multiple physicians and fill prescriptions from multiple pharmacies.

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Patient Management Tool

Hospitals participating in the GWTG program use a "user-friendly" Web-based, interactive registry managed by Outcome Science Inc.23 The Patient Management Tool (PMT) is an electronic data collection tool used to generate both standard and custom "real-time" reports online. "Real-time" data allow immediate feedback on performance, avoiding the need to wait for reports to become available as commonly experienced with other registry programs. Data can be benchmarked against participating hospitals at the regional, state, and national levels. Custom reports allow measurement of outcome data by providers (ie, physicians and patient care units). These "reports cards" can be shared to encourage healthy competition between providers and offer ongoing feedback on their progress. The PMT automatically generates patient notes and provides hyperlinks to patient education materials. The patient notes include summary information related to the patient's diagnosis, procedures, discharge medications, and recommendations for therapeutic lifestyle changes based on AHA guidelines. These notes can be printed, faxed, or transmitted via the Web to the provider for outpatient follow-up. The registry also offers a cost-effective solution for transmitting data to the Joint Commission and the Centers for Medicare and Medicaid Services.24 The participation fee for joining the GWTG program is relatively inexpensive; fee structures vary based on the number of modules each hospital wishes to use, and costs currently range from $1,100.00 annually for 1 module, $2,065.00 for 2 modules, or $2,890.00 for all 3 modules (Outcome Science Inc [support@outcomes.com], e-mail, July 13, 2006). No comprehensive cost analysis of the GWTG program has been published; however, start-up cost is justified based on the potential quality, satisfaction, and financial outcomes resulting from successful implementation of the program. In addition, recognition and marketing opportunities associated with the AHA achievement award help to defray or offset program costs.

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Stakeholder Benefits

Patients, physicians, and hospitals all benefit from the GWTG program through improvement in quality, satisfaction, and financial outcomes. Potential patient benefits include better education and discharge preparation, reduced hospital readmissions, and improved survival. Physician benefits include better-educated patients and assistance with coordination of outpatient prevention services before hospital discharge. Physicians also benefit from the support the program provides, helping their private practices to achieve high performance scores for secondary prevention. This point is of increasing importance as "pay for performance" continues to be a growing trend for both hospitals and physicians practicing in the United States.25,26 The impact of using financial incentives for hospitals to join and implement the AHA GWTG program was recently studied in 13 hospitals participating in the Hawaii Medical Service Association (Blue Cross Blue Shield of Hawaii). In this study, 85% of the hospitals that this commercial insurer offered incentives to join implemented the program within a year.27 Hospitals benefit because the program supports achievement of performance process standards set by external regulatory and quality agencies, including the Joint Commission core measures, Centers for Medicare and Medicaid Services, National Committee for Quality Assurance, and, more recently, the Institute of Healthcare Improvement 100,000 Lives Campaign.28 It also serves as a tool for marketing clinical excellence in cardiovascular service and improves market share through increased referrals for outpatient services. The impact of a better mapped care process on hospital length of stay and avoidable short-term readmissions for ACS patients is unknown and deserves further study to determine the potential cost savings.

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One Hospital's Experience Using the CAD Module

The GWTG module for CAD was implemented at Advocate Christ Medical Center, a 600-bed facility located in the Midwest in June 2003. The medical center is one of the largest providers of cardiovascular services in the Chicago metropolitan area treating more than 8,500 inpatients per year. Before implementing the GWTG program, the Phase I (inpatient) Cardiac Rehabilitation1 nurses followed all patients undergoing cardiac surgery on a daily basis but did not routinely follow patients with ACS (AMI and unstable angina). This gap in services led to significant treatment gaps for patients with ACS as demonstrated by our baseline data (Fig. 1).

Figure 1
Figure 1
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The GWTG program was implemented 12 months after hospital representatives first attended a regional AHA GWTG training program upon the request of the chairman of the Internal Medicine Department. Major implementation steps are listed in Table 2. Meeting directly with the vice president of operations, with the support and attendance of the cardiology section head to present the GWTG proposal was a critical strategy for gaining administrative support. It is imperative that administrators at an executive level garner strong physician support, recognize any service or treatment gaps (as evidenced by baseline data), and understand how the GWTG program can be an effective tool for advancing clinical excellence in a competitive market.

Table 2
Table 2
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Dramatic increases in adherence rates for the module's 8 key discharge criteria were achieved within the first year of implementation, particularly in those areas where baseline data indicated the most opportunities for improvement (Fig. 1). The hospital did not meet the AHA goal of 85% at baseline in 6 of 8 quality measures, including the use of angiotensin-converting enzyme inhibitors, smoking cessation counseling, activity guidelines/referral to Phase II (outpatient) Cardiac Rehabilitation, control of blood pressure before hospital discharge, low-density lipoprotein documentation, and lipid therapy before discharge.

Advocate Christ Medical Center was awarded the AHA's Quarterly and Annual Recognition Awards in 2005. Criteria for achieving these awards are met once the organization demonstrates adherence rates of 85% or better for all key discharge measures for a consecutive period of 3 and 12 months, respectively (Fig. 2). As the first hospital in Illinois and the AHA Midwest affiliate region to achieve this level of recognition by the AHA, physicians and nurses from the medical center's GWTG team have had opportunities to share their successes with other hospitals interested in launching the program at several local and regional AHA meetings and have consulted with other hospitals that are working to adopt it. The media attention received by our organization at both the local and national level as a result of achieving these awards offset the cost of the annual participation fee and provided the organization with free advertising. Most notably, hospitals participating in the GWTG program received nationwide recognition in recent editions of Circulation and US News and World Report. In addition to these opportunities, the GWTG program supported Advocate Christ Medical Center's efforts to achieve Magnet Status in April of 2005. Results of the GWTG program were highlighted as part of the Magnet application and site visit and clearly demonstrated the leadership role of professional nurses in improving patient outcomes.

Figure 2
Figure 2
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Nurse-Managed Case Model

The AHA provides each participating organization with standardized step-by-step processes and tools for initiating the GWTG program but does not dictate or prescribe a best approach for successful implementation. Each facility's multidisciplinary team must create its own vision for improving adherence to guidelines and develop its own method for data collection and entry into the registry. Important questions that help to shape program development include the following:

* Which CAD patients should be targeted first?

* Which patient care units should be involved in the pilot?

* What is the best method for data collection?

* Who is in the best position to collect and enter data?

* How can secondary prevention treatment and education be consistently provided to high-risk patients while promoting continuity of care and avoiding fragmentation by adding another layer or type of caregiver?

Careful evaluation of the organization's current practices, culture, and available resources is critical when establishing an implementation plan; however, the prospective, case management approach developed at Advocate Christ Medical Center can be used as a model that other hospitals can adopt and modify as needed.

The hospital's model is centered on the role of its Cardiac Rehabilitation Department nurses and builds on their existing knowledge, skill sets, access, and relationships. Three nurses were selected for training and initiated a 6-month pilot program, targeting patients admitted with ACS, including those with AMI and unstable angina. Nurses selected for the position of cardiac rehabilitation "risk reduction nurse" were hired internally and had 5 or more years of experience in either Phase I (inpatient) Cardiac Rehabilitation or Progressive Cardiac Care nursing. They demonstrated high-level communication skills and the ability to collaborate effectively with physicians and nursing colleagues and were recognized as clinical experts who enjoyed the role of patient/family educator.

The risk reduction nurse sees the patients during daily rounds in the Medical Intensive Care and Progressive Cardiac Care units and develops an individualized cardiac risk profile assessment and secondary prevention treatment plan for each patient in collaboration with the physician. These services are documented on the medical record using an internally developed tool entitled the "Cardiac Risk Profile" (see Table 3). This tool provides all healthcare team members with a comprehensive patient risk assessment "at a glance." The patient also receives a copy that serves as a teaching contract.

Table 3
Table 3
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Nursing roles and responsibilities include the following:

* Assess the patient's individual risk profile and identify potential/actual treatment and/or follow-up adherence issues postdischarge.

* Develop a secondary prevention treatment plan in collaboration with the physician and other members of the multidisciplinary team.

* Complete the PMT and submit it to trained registry staff for data entry.

* Partner with attending and cardiology staff to promote guideline use and support appropriate documentation for any contraindications to evidence-based therapies.

* Educate patients regarding evidence-based medication and assist them in establishing goals for therapeutic lifestyle changes, including smoking cessation counseling.

* Coordinate appropriate secondary prevention outpatient services before discharge.

Once the risk reduction nurse has completed the patient assessment, the attending physician is contacted by telephone to discuss the plan of care and address any additional need for orders, including medications, contraindications to drug therapy, and coordination of outpatient prevention services, such as smoking cessation classes, diabetic teaching, weight management, and others. Budgeting for each risk reduction nurse to carry a telephone was instrumental in avoiding missed calls and lack of follow-through when contacting physician staff. The goal when contacting the physician is to address all needs for secondary prevention at one time, avoiding multiple telephone calls and interruptions. A private practice physician model exists at the medical center. The risk reduction nurse' initial physician contact is with the primary care physician. Some of the primary care physicians collaborate directly with the risk reduction nurses to establish the secondary prevention plan, whereas others prefer to defer treatment decisions to the cardiologist when consulted. Neither the hospital nor the physicians currently receive financial incentives for program participation; however, use of this program is viewed as a valuable resource to assist them in "making the grade" now that the organization's data are reported publicly and physicians are being held accountable for their individual practice outcomes via quarterly report cards generated by the Performance Improvement Department.

A prospective approach to data collection is preferred and strongly supported by the AHA.29 It avoids the need for time-consuming and expensive retrospective chart reviews as well as recruitment and training of resource personnel for data collection. The prospective data collection method in combination with a concurrent case management approach is proactive; treatment gaps are identified and addressed at the point of care before the patient leaves the hospital. Completion of the data collection tool takes only a few minutes when completed by the risk reduction nurse because the elements of the patient's clinical assessment correlate nicely with the elements of the PMT tool.

Establishing a nurse-managed program using the cardiac rehabilitation Phase I (inpatient) nursing staff is both an efficient and effective approach to implementing the GWTG program. First, selecting personnel who are experienced at providing risk-reduction teaching to cardiovascular patients decreases staff training and continuing education needs. Second, building on the preexisting relationship between the nurses and attending physicians minimizes potential physician resistance. Both of these factors helped to promote collaboration and teamwork among the involved care providers.

Bedside nursing staff also play a critical role in the success of the program by identifying appropriate patients for referrals. In addition, the nurse-to-nurse consultation that occurs between the bedside nurse and the risk reduction nurse promotes the type of communication and collaboration needed to individualize the plan of care and promotes the continuity of care. Lastly, the bedside nurse recognizes the risk reduction nurse as an expert resource. The risk reduction nurse assumes the majority of responsibility for patient/family teaching regarding health promotion and secondary prevention. The support function of the risk reduction nurse decreases the time demand on the bedside nurse for providing appropriate patient/family teaching before discharge as the hospital length of stay continues to decrease. This, in turn, allows the bedside nurse to focus on reinforcing important teaching points during direct patient care activities and providing ongoing evaluation and feedback concerning the patient's understanding and motivation to adopt heath promotion behaviors in the face of a chronic disease state.

It is important to note that for hospitals that already have Phase I Cardiac Rehabilitation staff who routinely follow patients with ACS, the cost and timeline for the implementation of the GWTG program is significantly reduced. Start-up program costs may be full-time equivalent neutral or at least significantly lower than those encountered in our facility because ACS patients, a large volume of high-risk patients, did not routinely participate in Phase I Cardiac Rehabilitation before the start of the GWTG program. The most cost-effective approach for implementing and maintaining the program is to choose a model for data collection that incorporates the use of existing staff such as cardiac rehabilitation nurses, case managers, or other clinical resource personnel. The need for resource personnel also varies depending on the size of the targeted patient population and the method selected for data entry. An advantage our organization had from the beginning was a preexisting registry coordinator who was responsible for entering cardiovascular data for multiple registries within cardiovascular services. Data entry using the PMT takes approximately 7 minutes per case and accounts for an additional 12 to 13 hours of registry staff time per month based on our current volumes. To date, there are 4,367 cases entered in our registry database and no additional staff resources have been required to complete data entry. The current average caseload per month is 105 cases shared between 3 nurses working part-time (2.4 full-time equivalents). An aggressive marketing plan to increase referrals for Phase II (outpatient) Cardiac Rehabilitation is currently pending resolution of significant space constraints; however, Cardiac Rehabilitation referrals for AMI patients have increased an estimated 10% in response to the risk reduction nursing visits patients who now receive through the GWTG program before hospital discharge.

The 2 main activities that increase time and workload of the cardiac rehabilitation nursing staff when implementing the GWTG program are communication and collaboration with other disciplines and collection of registry data using the PMT over several patient visits. In addition, the nursing leadership including the advanced practice nurse for the Critical Care Division and the manager of clinical operations for the Cardiac Rehabilitation Department spent 1-hour weekly meeting informally with the risk reduction team members for the first 6 months to provide support and direction as the nurses assumed their new roles and responsibilities. During this same period, the physician champion also met with the team monthly to provide a physician perspective and address physician issues as needed. Investing time upfront in the early phase of the program to meet was instrumental in achieving a smooth and effective implementation process. Team members now meet more formally as part of a monthly performance improvement meeting; the team's ongoing performance improvement initiatives and outcome data are reported up to the executive level through leadership representation on a multidisciplinary, hospital-wide ACS committee.

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Keys to Success

* Administrative and leadership support

* Strong physician champion

* Internal marketing

* Reputation of the AHA

* Monitoring and reporting progress

* Physician and nursing involvement

* Dedicated staff

* Prospective nurse case-management model

* Training and ongoing education

As with any broad-based quality initiative, administrative support and strong clinical leadership are vital to success. The AHA offers local and regional workshops aimed at promoting GWTG participation and assisting hospitals with program start-up. Physician and nursing leaders from our facility learned about the GWTG program by attending a regional AHA meeting. Meeting participation was helpful in involving stakeholders in the education process from the beginning and gaining their support for program implementation. Linking the program goals, benefits, and anticipated outcomes to the hospital's strategic plan and presenting baseline data to identify opportunities for improvement are also helpful strategies for gaining administrative support. A clear understanding of how the program works and the resources available to implement the program are essential for effective clinical leadership and resource utilization. Knowledge of the performance improvement process (Plan, Do Study, Act) and the ability to lead change within the organization's infrastructure are also essential skill sets for providing ongoing program direction and leadership.30

Selecting a strong physician champion is critical. The champion does not need to be in the highest ranked formal leadership position to be effective in motivating staff or influencing physician practice patterns. However, he or she does need to be perceived as a leader and clinical expert to motivate the team and act as a catalyst for change. Other desired qualities of the physician champion include an approachable manner and interpersonal communication skills that foster interdisciplinary collaboration.

Multiple strategies were necessary to market and promote the program initially. Examples include formal presentations by physician and nursing leadership; poster presentations in key locations of the hospital, including the medical staff lounge; articles with pictures of the GWTG team in physician and associate newsletters; and formal letters to the medical staff from the physician champion. Informal presentations at patient care unit staff meetings by the risk reduction nurses and distribution of "fact-sheets" during their daily rounds on the patient care units also helped to introduce and put a "face" on the program. Medical and nursing grand rounds are conducted periodically to reinforce best practices, share data, celebrate "wins," and gain feedback and support from care providers in an effort to continuously improve patient outcomes. Additional methods used to keep care providers abreast of their progress in achieving/sustaining performance goals include brief presentations at leadership and staff meetings, quarterly newsletters, and individual provider report cards.

Strategies for successfully gaining "buy-in" from the medical staff included recognizing the AHA as a leading national, professional organization; positioning the program as a partnership between the physician and the hospital that involved the primary care physicians and the cardiology service; and promoting the program as a "value added" service to patients and physician practices at no extra charge to the patient.

During the pilot phase, which was conducted from June through December of 2003, involving a small group of dedicated staff to implement the program was beneficial to promote accurate and complete data entry and to establish and evaluate standardized processes, including strategies for identifying patients and documenting evidence-based care. Initially, the risk reduction nurses entered their own data using the online PMT. This experience reinforced the staff's understanding of operational definitions for data elements and strengthened the reliability of the data. The responsibility for data entry was later transitioned to trained registry staff. Initially, weekly informal team meetings were held with the risk reduction nurses to address process issues, barriers, and to provide support and encouragement for ongoing program development. Formal monthly performance improvement meetings are now held with core team members. The GWTG clinical leaders, including both the physician and nurse champion, represent the GWTG program as members of the hospital-wide ACS Committee. The GWTG quarterly data are reported through this committee, and progress is monitored as part of the ACS annual performance improvement plan. Representation and participation of GWTG leadership in this forum has been effective in promoting intradepartmental and interdisciplinary teamwork and collaboration on a broader scale and helped sustain key physician and administrative support for the program on an ongoing basis.

Finally, training and education of the risk reduction nurses prepared them for their roles and responsibilities and was key to the program's success. Initial training consisted of an 8-hour workshop including the following:

* Introduction and overview of the AHA GWTG program

* Leadership vision of the program

* Overview of ACC/AHA guidelines and landmark clinical trials supporting guideline use

* Completion of the PMT

* Case studies: data entry exercises based on operational definitions

* Role playing: communication and collaboration with physicians/healthcare providers

* Assessment of continuing education needs

Risk reduction nurses must be able to speak to the clinical trials that support guideline use to gain the respect and credibility of medical and nursing staff. A good educational resource for program participants is regularly scheduled Web-based teleconferences offered by the AHA for its participants. Clinical updates and strategies for improving patient outcomes are addressed through these conferences. At Christ Advocate Medical Center, the GWTG program is now integrated into cardiac rehabilitation services for all patients, including both medical and postcardiac surgery patients. "Next steps" for the program include ongoing research to evaluate its impact on hospital readmission rates. Other areas of interest include the potential impact of the program on increasing referrals for the Phase II (outpatient) Cardiac Rehabilitation program and the effect of outpatient follow-up interventions on patient outcomes.

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Overcoming Barriers

Potential barriers to successful implementation may be related to organizational, physician, or patient-related issues. Organizational barriers may include lack of administrative support, access to personnel and/or technological resources, and political or territorial issues both within and between disciplines and departments. Our organization had a history of collecting a lot of data from multiple registries. Therefore, an important barrier the team had to overcome from the outset was the misperception that the GWTG program was "just another registry program." It was made clear from the beginning that the prospective, case-management model would avoid the risk of collecting more data for "data's sake." It was also emphasized that the program was strongly supported by important opinion leaders including physician leadership from cardiology. The program at our facility is colead by nursing leadership from 2 separate departments as previously mentioned. As a result of this partnership, territorial issues needed to be addressed at times and consensus-building activities were necessary to establish unified goals and vision for the program. Additional barriers encountered early in the program included office space and computer access. Although the team still struggles with space and computer access, this barrier has been significantly reduced with the transition to computer-based charting hospital-wide.

Physician barriers encountered during the early phase of the program included lack of knowledge or acceptance of published guidelines, misconceptions about the purpose of the program, inaccurate assumptions about their own performance (how well they are actually adhering to the guidelines), and lack of "buy-in" as to the value of the program and its benefits to the patient, physician practice, and the hospital. In the few isolated cases where physicians had significant concerns about the program or specific guideline use, the physician champion has been successful in intervening one-on-one to clarify the purpose of the program and the current evidence supporting guideline use in practice. Strategies to overcome identified barriers and sustain results include ongoing evidence-based education programs for physicians and nurses, sharing outcome data periodically with medical and nursing staff, celebrating "wins" and recognizing physicians and nursing staff for their continued efforts and achievements.

Patient-related barriers may include inability to comprehend or accept responsibilities for complying with guidelines due to cognitive, emotional, or cultural values that conflict or differ from those needed to motivate and empower the individual patient to accept responsibility for self-care activities. Lack of social support systems to reinforce self-care behaviors and transportation and financial limitations for follow-up visits and medication postdischarge may also present barriers for patients. Regardless of motivation or ability to learn, all patients are assessed for appropriate medication use based on the AHA guidelines and entered into the registry database.

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Summary

Implementing the GWTG program proved to be a successful initiative due in part to focused implementation phases that included nursing oversight and monitoring, administrative and leadership support, the use of clinician champions, training and ongoing education, and ongoing monitoring of results. Several summary points help to highlight the GWTG program:

* The GWTG-CAD module improves patient outcomes for high-risk patients with CAD.

* The GWTG program works by bridging the treatment gap between evidence-based guidelines and "real-world" practice in the hospital setting.

* The AHA provides participants with many resources and tools to support program implementation and ongoing program performance.

* Adherence rates for key discharge measures are continuously monitored and reported by a multidisciplinary team to promote ongoing performance improvement within the hospital setting.

* Use of cardiac rehabilitation nurses is a "perfect fit" for the implementation of the AHA GWTG program.

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Acknowledgments

Thanks to Darcie Brazel, RN, MS, CNAA, BC; M. Dia, MD; Nancy Gaziano; Lynn Hennessy, RN, MS; Wendy Micek, RN, PhD; Sue O'Dwyer, RN, MS; M. Silver, MD; P. Silverman, MD; and Vicky Williams, RTR, BS, for their leadership and commitment to this program.

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1The Evidenced-Based Guidelines for Cardiovascular Disease Prevention in Women: 2007 Update published by the American Heart Association recommends that "cardiac rehabilitation" be referred to as "cardiovascular rehabilitation. However, the authors' department is referred to as "Cardiac Rehabilitation" and hence was used throughout this article (available at www.acc.org./quailityandscience/clinical/topic/topic.htm#guidelines). Cited Here...

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"The Lifestyle Course" is a psycho-educational program or lifestyle course for patients. The aim of the course is to help acute coronary syndrome (ACS) patients regain their emotional balance and coping skills by adopting a healthy lifestyle. Four one and one half hour modules address stress, emotions, communication, and saying 'no'. This course, originally developed in the Netherlands, was the winner of the clinical project award at the 7th Annual Cardiovascular Nursing Spring meeting in Manchester, England. For more information see www.nijsmellinghe.nl/

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Keywords:

coronary artery disease; "Get With The Guidelines"; improving outcomes; secondary prevention

© 2007 Lippincott Williams & Wilkins, Inc.

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