Implementing hospital strategies such as encouraging physicians to solve problems creatively and designating physician-nurse champions instead of only nurse champions, can significantly lower hospitals’ 30-day risk-standardized mortality rates (RSMR) with acute MI (AMI), according to a study published May 1 in the Annals of Internal Medicine. The mean 30-day RSMR at hospitals that used all five strategies identified in the study was more than a full percentage point lower than those that implemented only two strategies.

While top-performing hospitals achieve 30-day RSMRs as low as 10.9 percent, the rates of low performers hover around 24.9 percent. Past research has pointed to some practices that can help lower 30-day RSMRs, such as the use of beta-blockers in appropriate patients, and have identified hospital characteristics associated with lower 30-day RSMRs, such as being a teaching facility. But the practice differences account for only a fraction of the gap between top and bottom performers, and some hospital characteristics are not modifiable.

That leaves hospitals that want to improve their performance with little guidance on how to achieve those goals. Elizabeth H. Bradley, PhD, from the Yale School of Public Health in New Haven, Conn., and colleagues attempted to lend hospitals a hand with their study, a cross-sectional survey of 537 acute care hospitals. The research builds off a previous qualitative analysis that identified strategies based on organizational values, personnel issues, communication and coordination. The current study was designed to find statistical associations between the strategies and RSMRs.

The hospitals were randomly selected from acute care hospitals that publicly reported AMI discharge data to the Centers for Medicare & Medicaid Services (CMS) between July 1, 2005, and June 30, 2008, and that also were included in the 2008 American Hospital Association survey. Of the 590 hospitals invited to participate in 2009 and 2010, 91 percent agreed. The 30-day RSMR was based on hospital discharges between Jan. 1, 2008, and Dec. 31, 2009.

Researchers found that 35.3 percent of the hospitals were teaching institutions; more than half—57.6 percent—had fewer than 300 beds; nearly half had an annualized volume of more than 125 patients and 73.2 percent performed PCI for patients with STEMI.

They also found numerous strategies with significant associations with RSMRs, most of which corresponded to findings in the qualitative study. Among the strategies that significantly helped lower RSMRs:

• Meetings among hospital physicians and the staff who transported patients to the hospital to review AMI care;
• Having cardiologists always on site; and
• Encouraging physicians to creatively solve problems.

Strategies associated with higher RSMRs included having nurse champions rather than a nurse-physicians team or only a physician as champion, and cross-training critical care nurses for the cardiac cath laboratory.  

A secondary analysis also found that hospitals in which a pharmacist rounded on AMI patients led to lower RSMRs. “The size of the effect for individual strategies may be viewed as modest; however, in aggregate, they exceed an absolute difference of 1 percent in RSMRs,” Bradley and colleagues wrote. “If a change this large could be achieved nationally, thousands of lives could be saved yearly by using interventions that have negligible risk and could be implemented with relatively few new resources.”

But few hospitals integrated most of the strategies identified in the primary analysis. Only 1.1 percent used all five, but that group also had the lowest mean 30-day RSMR, at 14.3 percent. The majority used between one and three strategies, for a mean 30-day RSMR that ranged between 16 and 15.2 percent.

“Some of these strategies are not resource-intensive but require new ways of working across disciplinary and organizational groups,” the authors wrote. They cited the example of physicians meeting monthly with staff who transported AMI patients as an effective but not costly strategy, yet only about a quarter of hospitals implemented it. “Such efforts may improve communication and coordination among staff, a key aspect of organizational environment identified in our previous qualitative work.”

They calculated that having a nurse-physician champion strategy was associated with a 15.1 percent RSMR while having a nurse only champion was associated with an RSMR of 16.2 percent. They suggested that may be a sign of an organizational environment that is not conducive to quality. Cross-training critical care nurses may also be an effort to cut costs that has unintended effects on quality care.

They cautioned that the survey study was observational and did not establish causal relationships, but that the strategies may help improve patient outcomes and, in aggregate, may lead to reductions in hospital RSMRs.