Mr. Medicare Patient and his wife Mrs. Medicare were sitting on the couch watching a football game one Sunday, when Mr. Medicare began to feel ill. It began with a feeling like indigestion, which he attributed to the spicy chicken wings that they were eating while watching the game. However, the initial indigestion feeling worsened, even after he chewed an antacid. He began to feel short of breath and broke out in a cold sweat. He told his wife, Mrs. Medicare, what he was feeling. Recognizing Mr. Medicare's symptoms as those of a heart attack, Mrs. Medicare brought him into the emergency room through the emergency department lobby as opposed to coming by ambulance.
Mr. Medicare did not complain of chest pain or of pain radiating down the arms, but his other symptoms prompted staff to treat him as a possible heart attack patient. For the staff nurse working the emergency department triage area, this meant activating a rapid response team. Any time a person presents with chest pain that could be a heart attack, the rapid response team is required to perform certain tasks within a certain time frame to meet core measures for the acute myocardial infarction (AMI) measure for the best possible patient outcomes. Tasks that are required to be performed include an electrocardiogram (ECG) within 5 minutes of arrival, the ECG read and interpreted by a doctor within 5 minutes of the test being performed, drawing the patient's blood to evaluate heart enzymes within 25 minutes of arrival, and having the patient take an aspirin within the first 24 hours of arrival.
Mr. Medicare's symptoms were the classic symptoms one would expect with anyone experiencing a heart attack, but he did not feel the most significant indicator of AMI: chest pain. In this way, Mr. Medicare's experience was similar to at least 20% of AMI victims; not all heart attack victims feel the most classic of all heart attack signs: chest pain. Instead, some heart attack patients never experience the classic chest pain, but present in atypical fashion. For example, a feeling of indigestion could be a heart attack, even without the chest pain. Therefore, the policy issue involved is whether the hospital should use core measures for atypical acute myocardial infarction presentations such as epigastric or lung pain as well as typical acute myocardial infarction presentations such as chest pain, left arm pain, and jaw pain to improve the quality of care and positive patient outcomes for chest pain cases?
This policy issue is a problem for a number of different reasons. The two most pressing reasons are cost and quality of care. First, the core measures that have been identified as the best primary treatment for a heart attack can be very expensive and would be unduly expensive for; the core measures that have been adopted to treat heart attacks would be cost prohibitive for those patients who are simply suffering from gastrointestinal distress or pulmonary pain. However, the reality is that early intervention is key to helping patients suffering from acute myocardial infarction (AMI). In fact, the Joint Commission has implemented required core measures for acute myocardial infarction (AMI) (Moore, 2012). These core measures include a thrombolytic drug administered within 30 minutes of arrival, cardiac catheterization (PCI) within 90 minutes of arrival, and aspirin as well as a beta blocker given within the first 24 hours of arrival, unless otherwise contraindicated. Unless otherwise contraindicated, aspirin, a beta blocker, and a statin drug must be ordered upon discharge, with instructions and education provided with the medications. If the ejection fracture is less than 40%, the patient should also be given an ACE inhibitor drug upon discharge. All AMI patients should be given smoking cessation education as well. All actions and medications must be documented in the chart and reflected on the medication administration record with any contraindications and this becomes a permanent record in the patient's chart. Therefore, quality of care would suggest that patients with signs of heart attack receive quality care and treatment. However, if the patient is not experiencing AMI, then this treatment would actually compromise patient care.
Patients are not the only stakeholders who are concerned with whether these core measures are implemented for patients presenting with atypical conditions. Other stakeholders would include the hospital, nurses and doctors, the government that provides the Medicare insurance, and all people of the United States who pay taxes and elect the government officials that represent them.
Nursing is connected to this issue because the current practice is for nurses to call for the core measures chosen by the Joint Commission when a patient presents with typical symptoms of a heart attack. However, not all patients suffering from AMI present with the classic symptoms of heart attack, which can make diagnosis more difficult. A nurse's professional experience and expertise are then critical in helping diagnose a patient, because atypical symptoms may be indicative of an AMI, but may also not be indicative of an AMI. Due to the fact that the diagnosis is not always clear cut, core measures need to be implemented with patients who complain of typical signs and symptoms such as chest pain and arm pain, as well as atypical signs and symptoms such as epigastric pain. This requires the expertise of the nurse to differentiate the kind of symptoms the patient is experiencing and make a clinical correlation and put the appropriate protocols into action. The nurse is the first person the patient sees and when doctors are busy with other patients, patients rely on the expertise of nurses to help them.
Hospitals should use core measures developed by the Joint Commission, Centers for Medicare and Medicaid Services, the American Heart Association and the National Quality Forum for atypical acute myocardial infarction (AMI). There are a number of reasons for this decision. First, a large number of AMI patients present with atypical symptoms. In one study, atypical AMI was found in 20% of patients (Chowta, Prijith & Chowta, 2005). In another study, more than half of all patients reported initial atypical symptoms (such as gastric pain accompanied by vomiting) followed by a more typical indicator of AMI (Body, et al., 2010). What these results suggest is that many patients with AMI experience atypical symptoms, and early reporting patients may even have those symptoms without experiencing the more typical AMI symptoms. Next, from a financial perspective, it makes sense to implement the core measures. While those core measures may have initial upfront expenses that increase costs for the hospital, the long-term economic consequences are positive. Hospitals are tasked with completing certain assigned tasks within a specified amount of time or their reimbursement for the patient is reduced (HHS, 2011a). Funding is also granted based on the quality of care that the individual receives and not just the time-based care that other agreements are based on (HHS, 2011b). Thus, funding is reduced when quality and timely care goals are not met. Therefore, since atypical symptoms are frequently linked to AMI, implementing core measures with atypical symptom presentation should improve quality, and, therefore, increase hospital reimbursement. Finally, patient care standards are highly in favor of core measures for atypical symptom presentation. A patient that complains of an atypical symptom that could be a result of AMI is less likely to be treated, under typical protocol for AMI. This could result in further damage to or the death of the patient (Laine, Grisoli & Bonello, 2011).
Hospitals can take every precaution to ensure that they are providing the best patient care by promoting guidelines that require the use of core measures when patients present with atypical symptoms of AMI. This would benefit various stakeholders, including: payers, providers, employers, patients, and policymakers. In this scenario, the taxpayers are the payers and they have an interest in their money being spent efficiently. The insurance company providers have an interest in keeping costs low. Hospital employers are interested in providing quality patient care and in keeping costs low. Patients are interested in receiving the best care possible, and, when they are not paying for that care or have already paid for that care, cost is not a motivating factor. The policy makers who are responsible for this issue include the American Nursing Association (ANA) and other nursing organizations, which focus on the quality of patient care (Moore, 2012) and the Joint Commission, which is committed to providing guidance to nursing personnel that best treats the symptoms, whatever they are, of AMI (Joint Commission, 2011).
The current core measures fail to include all AMI patients, as they do not account for those patients who present with atypical symptoms. There are several ways that the Joint Commission can deal with this current failure. They can: do nothing, make incremental changes to the Core Measures, develop new guidelines incorporating the atypical symptoms, or develop existing healthcare guidelines from elsewhere that already include the atypical symptomology. Looking at the various choices, it is clear that doing…
It is also a population that often has limited resources and one that seeks to find others to help comfort and educate them. Modern technology has certainly improved both the diagnosis and treatment of the illness, but there are so many options that the patient is often left bewildered and frightened (Guadalupe).
A proactive and professional nursing approach to this illness takes Mishel's theory and uses it in four ways: