Core measures for atypical acute myocardial infarction presentations

Mr. Medicare's Myocardia

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.

Policy Analysis

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 nothing is not a viable option because it limits the opportunities for effective diagnoses and is not favorable in a cost-benefit analysis. Making incremental changes could prove burdensome to the system without providing immediate positive changes. Adopting foreign standards is counterintuitive, given that the best quality of medical care in the world is found in the U.S. The best policy choice is for the Joint Commission to adopt new guidelines for AMI that build upon the established guidelines and include atypical symptom presentation. This would not only provide a better standard of patient care, but would also reduce the likelihood of malpractice litigation based on a missed AMI diagnosis.

Personal Position

My personal position on how this policy issue should be resolved is that the core measures should be expanded to include patients presenting with atypical AMI symptoms. Heart attacks are a leading cause of death and all of the research suggests that the earlier intervention is received, the better the patient's prospects, not just for surviving the heart attack, but for a post-incident healthful recovery. Of course, the problem with diagnosing AMI based on atypical symptomatic presentation is that it will result in some wrongful diagnosis, so that some patients get more care than necessary. However, the possible consequences of providing excess care are not comparable to the consequences of failing to provide adequate care. Therefore, it seems important to err on the side of caution and include astypical AMI presentation in the core measures.

Moreover, from a personal perspective, I feel as if the education and training that nurses receive are more than adequate to allow nurses to help establish a diagnosis based on even atypical symptoms. Looking at the current core measures, it becomes clear that they can be modified to include guidelines for other symptoms. For example, the current core measures contain a number of vital steps that are part of diagnosis, even for a patient that presents with typical symptoms. These include, the performance of an ECG, immediate interpretation of the ECG, a blood draw to evaluate heart enzyme levels, and the administration of aspirin.

Tasks that are required to be performed include administering 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. What is interesting to note about each of these tasks is that they are very low risk to the patient, but can help confirm a diagnosis. Even the administration of a single aspirin, unless contraindicated by the patient's other medical conditions, provides little risk to the patient with a large possible reward. Nothing in these tests seems as if it would prevent the diagnosis of the patient's underlying medical issues if the atypical symptomatology is not actually linked to an AMI. Therefore, from a health professional standpoint, there seems to be no valid downside to expanding those core measures. My personal conclusions seem to support the positions of the other stakeholders.

Real and Potential Conflicts

There are two possible sources of conflict with the implementation of expanded core measures. The first possible conflict is with a patient who does not recognize the atypical AMI symptoms as a potential heart attack. Those patients may resist the idea that they are having a heart attack and, therefore, be suspicious of treatment regimes that are clearly focused on heart health and issues. This may be particularly true in those instances when patients are self-payers, and the same core measures that would streamline the protocol for atypical AMI may also result in treatment beginning before a patient's insurance can be verified.

The larger, and more detrimental, source of conflict in the workplace is between professionals. Specific to this scenario, the new core measures would be largely dependent upon a nurse's professional judgment of when a patient's atypical symptoms indicate that the patient is experiencing AMI. This may bring the nurse into conflict with other nurses, who may not reach the same conclusion based on the patient's symptoms. It may also bring the nurse into conflict with doctors who may not agree with the nurse's professional position. These conflicts between hospital staff can be quite significant to the patient, because they can result in delayed care and reduce confidence in the care that is being received.

Conflict Resolution Strategies

From a general perspective, there are a number of conflict resolution strategies that can be employed to tackle conflict in the workplace. The first thing to do is to train staff to attempt to avoid conflict when possible, by participating in active listening and communication that resolves many of the underlying disputes that can lead to conflict. This can also involve establishing protocols that help avoid conflict. For this scenario, having a policy of communication with the patient can help avoid conflict with the patient, because the nurse could have, as part of protocol, the responsibility of explaining to the patient that their symptoms are indicative of a heart attack, that timely care can make a significant difference in treatment outcome, and that the core measures require the care that is being administered. While patients may resist the idea of the treatment, most patients will become more accommodating when presented with the idea that the care is being administered to save their lives.

Conflict between different hospital staff members is more insidious and may be more difficult to control because those relationships are longer-lasting than patient interactions. In an emergency room setting, while patient conflict can be detrimental to the workplace environment, the reality is that interaction with each individual patient will be finite; as a patient's care progresses, the patient will be moved from the emergency room facilities to more appropriate facilities. However, conflicts between employees can fester and spoil the work environment. By making clear-cut guidelines about who is in charge of making the AMI determination for each presenting patient, the hospital can reduce the potential for conflict during treatment. Moreover, by establishing regular review and training sessions, with the goal of addressing diagnosis mistakes or errors as they occur and develop, the hospital can ensure that all of its staff are working from the same perspective.

Of course, even the most well-established policies will not wholly eliminate conflict in the workplace. In the instance of individual conflict, a nurse has several options available for dealing with that conflict: competition, accommodation, avoidance, compromise, and collaboration. Not all of those approaches will be appropriate in a scenario in which the patient's health is at risk. "Accommodation is a lose-win strategy that you can use to preserve relationships. This strategy tries to resolve conflict by giving in to the other person, neglecting your own needs" (Lippincott, Williams & Wilkins, Inc., 2013). Clearly, accommodation would be inappropriate in a scenario where one party was advocating for patient care standards that did not meet the new core measures for care. "Avoidance is a lose-lose strategy that sometimes is appropriate, such as when you back away from a heated argument" (Lippincott, Williams & Wilkins, Inc., 2013). Although avoidance has low long-term success rates, avoiding conflict in the moment while continuing to provide the correct standard of patient care may help increase patient confidence in treatment and preserve work relationships, but should only be used as a part of a strategy that aims to handle the underlying disagreements. To handle the bigger-picture issues that lead to conflict, the best approaches are compromise and collaboration. "Compromise is a win-lose/lose-win technique, a give-and-take style of conflict management. It satisfies each person's objectives and is a good way to gain a temporary settlement. Collaboration is a win-win approach. This is the strategy to use to maintain objectives that are agreeable to everyone" (Lippincott, Williams & Wilkins, Inc., 2013).

Happy Ending

Mr. Medicare's symptom, although they did not match the typical symptoms of an AMI were sufficient to trigger the suspicion that he was having a heart attack. Therefore, the staff responded by following the protocol for a heart attack patient. This meant that an ECG was performed within 5 minutes of Mr. Medicare's triage, though not his arrival, and a blood draw was done within 25 minutes of his arrival. Both of these tests confirmed staff suspicions that Mr. Medicare was experiencing an AMI, which triggered the staff to administer a thrombolytic drug, a PCI, and administer a beta blocker and aspirin. These early interventions proved successful, as Mr. Medicare survived his heart attack and was able to make a full recovery. He was discharged with prescriptions for a statin drug and a beta blocker, and advised to begin an aspirin regime and follow up with a cardiologist for routine monitoring and ongoing care.