Change of care for patients with acute myocardial infarctions through algorithm and standardized physician order sets

To determine whether there was a difference in patient care for patients with acute myocardial infarction, when physicians had a choice of using standardized orders or de novo orders for acute coronary syndrome (ACS). In both instances, the physician had available an algorithm developed using the American Heart Association/American College of Cardiology (AHA/ACC) guidelines for ACS.

This was a retrospective study where hospital charts were reviewed that had the primary diagnosis of acute myocardial infarction (including segment elevation myocardial infarction (STEMI) and non-segment elevation myocardial infarction (NSTEMI). Charts were reviewed to assess medications ordered within the first 24 hours of hospitalization. These medications included aspirin, beta-blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors), I.V. unfractionated heparin therapy or subcutaneous low-molecular-weight heparin (enoxaparin or Lovenox), I.V. tenecteplase, or I.V. eptifibatide. Other patient care items were also reviewed: cardiac rehabilitation and cardiovascular medicine consultation. Finally, discharge medications were reviewed.

Patients were more likely to receive aspirin, beta-blockers, and ACE inhibitor therapy when standardized (preprinted) orders were used as opposed to de novo orders constructed by the physicians for that particular admission. For those patients with STEMI, all received I.V. reperfusion therapy (I.V. tenecteplase), when standardized orders were used. This was not nearly the case when de novo orders were written by the physician. The same finding prevailed for the use of I.V. eptifibatide in the NSTEMI patients, when standardized orders were compared with de novo order sheets. Cardiac rehabilitation (phase I) was ordered more frequently in the patient subset that had the initiation of therapy with the standardized orders compared with the de novo orders. A perplexing issue did arise on review of discharge medications. Those patients who had their care initiated with standardized orders were less likely to go home on their hospitalization medications (aspirin, beta-blockers, and ACE inhibitors) than those patient that had their hospital care initiated with the de novo orders.

A higher percentage of patients whose physicians initiated hospital therapy with standardized order sheets, which follow AHA/ACC guidelines, received appropriate medications in a timely fashion. This was not necessarily the case on review of the discharge medications. Without having standardized discharge orders; those patients whose care was initiated by standardized orders were less likely to be discharged on aspirin, beta-blockers, or ACE inhibitors. On further investigation, it was discovered that physicians who used standardized orders assumed the patient was discharged on the same medication they received in the hospital. After realization of this, the order sheet is being revised to include this part of patient care.