Influence of a critical path management tool in the treatment of acute myocardial infarction. Clinical Quality Improvement Network Investigators.
OBJECTIVE
The primary objective of this study was to determine the effect of implementing a critical path on use of proven efficacious therapies and outcomes in patients admitted to a hospital with acute myocardial infarction (AMI). The secondary objectives were to evaluate the use of unproven medications and to develop an understanding of the factors associated with adverse in-hospital outcomes in these patients.


METHODS
A nonrandomized before-after study design was used to evaluate the efficacy of a critical path instrument in patients admitted to hospital with AMI.


METHODS
Consecutive patients admitted with AMI in nine participating hospitals were enrolled in the study. The critical path instrument consisted of a locally developed, preprinted physician order form. Practice patterns were determined before (n = 2305) and after (n = 2349) implementation of the critical path by primary chart review. Multivariate analysis of risk factors for mortality was performed on a combined database of 6088 AMI patients.


RESULTS
The use of acetylsalicylic acid (ASA), nitrates, and beta blockers increased significantly by 3%, 2%, and 9%, respectively, after implementation of the critical path. Use of thrombolytics remained stable at 41%, and calcium channel blocker use decreased significantly by 8%. In-hospital mortality decreased by 1%. There was less use of ASA, nitrates, beta blockers, and thrombolytic therapy in women and the elderly. Multivariate analysis showed that advanced age was associated with increased mortality risk, whereas ASA, beta blockers, nitrates, and calcium channel blockers were associated with reduced mortality risk.


CONCLUSIONS
Implementation of a critical path resulted in increased use of proven efficacious therapies, reduced use of noneffective therapy, and a trend toward reduced mortality.
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D001241:Aspirin / Q000627:therapeutic use; D002170:Canada; D019091:Critical Pathways; D005260:Female; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000188:drug therapy / Q000628:therapy*; D009566:Nitrates / Q000627:therapeutic use; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D012307:Risk Factors
D000319:Adrenergic beta-Antagonists; D009566:Nitrates; D001241:Aspirin