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Mortality rates from coronary heart disease have declined by 25% since 1999,1 not so much from new designer drugs or improved technology, but through the determined enforcement of basic standards of care that are important enough to be deemed “guidelines” based on “evidence.” Aspirin, patented in 1900, is a medication that is now ubiquitous to the cardiac patient, at least for the last 20 years since we learned it could relieve pain and prevent a heart attack. Statin medications, originally embraced for their cholesterol-lowering effects, also exert substantial benefits through antioxidant, anti-inflammatory, and direct endothelial actions, thus securing their place as a cornerstone of primary and secondary preventive efforts.2 Both medications are now considered so vital to the prevention of cardiac events, that they have been included in virtually every cardiovascular guideline to date.

With over 1000 cardiac-related articles published monthly, the ability to keep pace with new findings while differentiating fact from fancy has become increasingly challenging, even for the most savvy research consumer. Fortunately, the American Heart Association (AHA) has been a leader in disseminating evidence-based cardiovascular practices based on the strength of the literature. Recommendations from the AHA range from Class I (a treatment/procedure that should be used based on current evidence), Class IIa (where it is reasonable to recommend the treatment) or Class IIb (where a treatment may be considered), but additional studies are needed for both, to Class III (where the risks outweigh the benefits and the treatment should not be performed).3 Class I recommendations that are based on multiple randomized controlled trials or a meta-analysis represent the highest level of evidence, and often proceed along a “fast-track” for dissemination by the AHA.

Once such recommendations have been made, it is critically important to then apply the myriad available treatments to a particular patient at a specific point in time. Thus, the concept of evidence-based practice (EBP) comes to fruition. EBP is the integration of the best available evidence with clinical expertise and patient preferences to achieve desired outcomes.4 It does not necessarily mean implementing research studies to answer a question, but indicates use of a systematic method for using available evidence to guide patient care decisions.5 For patients with cardiac disease, the AHA and the American College of Cardiology (ACC) offer systematic reviews, Class I guidelines based on the highest level of evidence, to optimize care management. For example, following acute myocardial infarction (AMI), aspirin on arrival, statins and β blocker therapy, smoking cessation advice and a discharge referral to cardiac rehabilitation (new for 2008) are critical performance measures.6 For the chronic heart failure (CHF) patient, diuretics and salt restriction, angiotensin-converting enzyme (ACE) inhibitors, and β blockers should be standard, as well as educating patients regarding medications, symptom management, and daily weight monitoring.3 Following coronary artery bypass graft surgery (CABG), aspirin, statins, and β blockers (which prevent perioperative atrial fibrillation) are again advised, as are reduced serum glucose levels and attention to the timing (≤60 minutes before skin incision) and duration (<48 hours) of antibiotic use.7 The most recently published ACC/AHA guideline addresses, for the first time, the growing population of adults with congenital heart disease, and includes information regarding treatments, exercise, medications, family planning, insurance, referral to specialized centers, and more.8

In addition to providing the structure of what we should be doing for those with heart disease, the AHA also provides tools that assist in the process of how we can implement these guidelines to achieve the best possible outcomes for cardiac patients. Their Get with the Guidelines program includes a “toolbox” with sample order sets, core measures worksheets, and discharge instructions, as well as tips on overcoming barriers to implementation (http://www.americanheart.org). An excellent starting point for an EBP nursing model is ensuring that written policies, protocols, and care planning documents are based upon current best evidence. In addition to these AHA guidelines that can easily be incorporated into institution-specific tools, the Institute for Healthcare Improvement (IHI) offers evidence-based care “bundles” of activities for the prevention of central line infections, pressure ulcers, pneumonia, deep vein thrombosis, and more (http://www.ihi.org). Unfortunately, many areas exist in nursing where the evidence is not yet well defined. Here, the application of EBP methodologies includes systematic literature searches for available studies, case reports, or expert opinions, followed by a rating of the evidence to determine the best course of action.

Despite the existence of valid evidence-based guidelines for cardiac disease, Havranik et al.,9 documented poor compliance and wide variations in their use for elders with heart failure; ejection fraction assessment occurred in only 30.1% to 67.2% of patients, with 55.8% to 87.1% receiving ACE inhibitors. Noncompliance with EBP guidelines has a significant impact on patient outcomes: Peterson10 found that for every 10% increase in AMI guideline adherence, mortality fell by 10% when AHA/ACC guidelines were used, with a standardized discharge tool conferring particular benefit. With the adoption of objective and measurable nationwide standards, a system of performance measurement across facilities becomes feasible. The Joint Commission has adopted sets of “core measures” that evaluate how well hospitals adhere to recommended guidelines for specific populations like AMI, CHF, and CABG.11 Scrutiny of compliance with core measures for these patients is an important quality rubric for patients and payers alike, and is now included in hospital accreditation by The Joint Commission. The trend toward performance measurement is growing rapidly, with new and expanded measures being applied every year for a wide variety of patients. While some measures are not within the scope of nursing practice, nurses can make a significant impact on compliance with many guidelines. In particular, acute care nurses are in a critical position to ensure that patients with AMI, CHF, and CABG receive appropriate discharge education regarding their disease process, medications, symptom monitoring, and follow-up care. Through committed multidisciplinary teams, compliance with these measures can be optimized and patients are more likely to achieve their desired outcomes.10

Clearly, patients deserve care that is based on the most current and valid available evidence, without random variability from provider to provider, or following practices simply “because we've always done it this way.” Cardiac nurses have the tremendous advantage of a large body of evidence that has been shown to improve outcomes for their patients. Embracing systems of care delivery that move our practice from tradition to science are long overdue. Although a fundamental change in patient care delivery is certainly a daunting task, the initial steps have already begun. A critical element of closing the gap between research and practice can begin with something as simple as, “a spirit of inquiry.”12 A committed group of clinicians who repeatedly question why we deliver care in a certain fashion is an important first step toward culture change. The benefits of an institutional culture where, “nursing practice is based on the best available evidence and clinicians are fully engaged in the process,” are clearer than ever.12 It is time to join the charge and it begins with you, asking questions and implementing EBP, one patient at a time.

REFERENCES

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  2. REFERENCES
  • 1
    American Heart Association News. American Heart Association web site. Available from: http://www.americanheart.org/presenter.jhtml?identifier=3053235. Accessed January 22, 2008.
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    Jasinska M, Owczarek J, Orszulak-Michalak D. Statins: a new insight into their mechanisms of action and consequent pleiotropic effects. Pharmacol Rep. 2007;59 (5):483499.
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    Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. American College of Cardiology web site. Available from: http://www.acc.org/clinical/guidelines/failure/index.pdf. Accessed November 24, 2008.
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    Newhouse R, Dearholt S, Poe S, et al. Evidence-based practice: a practical approach to implementation. J Nurs Adm. 2005;35 (1):3540.
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    Schulman CS. Strategies for starting a successful evidence-based practice program. AACN Adv Crit Care. 2008;19 (3):301311.
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    Krumholz HM, Anderson JL, Bachelder BL, et al. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on performance measures. Circulation. 2008;118:153.
  • 7
    Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. American College of Cardiology web site. Available from: http://www.acc.org/clinical/guidelines/cabg/cabg.pdf. Accessed November 3, 2008.
  • 8
    Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2008;118:e714e833.
  • 9
    Havranik EP, Wolfe P, Masoudi FA, et al. Provider and hospital characteristics associated with geographic variation in the evaluation and management of elderly patients with heart failure. Arch Int Med. 2004;164:11861191.
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    Peterson ED, Roe MT, Mulgand J, et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA. 2006;295 (16):19121920.
  • 11
    Joint Commission. Performance measurement initiatives. Available from: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/. Accessed December 1, 2008.
  • 12
    Gawlinski A. The power of clinical nursing research: engage clinicians, improve patients' lives, and forge a professional legacy. Am J Crit Care. 2008;17 (4):315326.