Effectiveness of implementation of standard clinical pathway Effectiveness of implementation of standard clinical pathway through healthcare professionals among acute myocardial through healthcare professionals among acute myocardial infarction patients undergoing angiography / angioplasty in a infarction patients undergoing angiography / angioplasty in a public tertiary care hospital, Karachi public tertiary care hospital, Karachi

Objective: To assess the eﬀect of acute myocardial infarction standard clinical pathway among acute myocardial infarction patients on length of stay in public tertiary care setting. Methods: The quasi-experimental non-randomised study was conducted at the Department of Cardiology, Dr Ruth Pfau Civil Hospital, Karachi, from September to December 2018, and comprised acute myocardial infarction patients. Those admitted before the implementation of acute myocardial infarction standard clinical pathway formed the control group, while those admitted after the implementation were in the intervention group. Acute myocardial infarction standard clinical pathway was implemented and the interventional clinical practices of healthcare professionals, including cardiologists, postgraduates, residents, nurses and critical care technicians, were assessed using a standard checklist. Data was analysed using SPSS 21. Results: Of the 100 participants, 50(50%) were in the control group; 31(62%) males and 19(38%) females. The intervention group also had 50(50%) patients; 35(70%) males and 15(30%) females. Regarding eﬀectiveness of the implementation of standard clinical pathway, length of hospital stay reduced significantly in the intervention group compared to the control group ( p =0.003). Conclusion: The implementation of acute myocardial infarction standard clinical pathway reduced the length of hospital stay of acute myocardial infarction patients.


Introduction
Acute myocardial infarction (AMI) is one of the leading and common cardiovascular diseases (CVDs), which are composed of heart and blood vessels, including coronary artery disease (CAD).It is also preventable and treatable condition like other chronic diseases, such as stroke, chronic respiratory diseases and diabetes mellitus (DM).The burden of AMI is increasing in developed and underdeveloped countries along with increased length of hospital stay (LOS), resulting in increased financial burden on AMI patients.Globally, 17.5 million people died of CVDs in 2014, which is 31% of all global deaths, whereas 7.4 million deaths occurred due to coronary heart disease (CHD). 1 In fact, now AMI is also one of the leading causes of death and disability in the Asia Pacific region which is half of the global burden. 2 Likely, the highest prevalence of AMI is seen in those aged <45 years in south Asian countries Pakistan, India, Bangladesh and Nepal. 3e management of AMI is divided into three segments; medical, surgical and clinical pathway (CP).4][5][6][7][8][9] Along with medical therapy, CPs is one of the medical approaches to treat AMI patients.Primarily, it was developed in the 1980s and has been implemented in different healthcare settings. 2ndeed, initially it was made for hospital use only, but now it is being used in other healthcare setups as well, such as home-care, etc. 10 CPs are also known as care pathway, critical pathway, integrated care pathway or an integrated care map that is the main tool used for the management of different diseases and also for quality assurance. 10CP is a teamwork and an interdisciplinary goal-oriented care plan that particularly focusses on necessary teamwork approach. 2,10Standard CPs are being used to reduce the patients' stay in hospitals, such as in the United States, 11 the United Kingdom, 12 Australia, 13 China 1,12 and South Korea. 10owever, standard CPs are also used for diseases, such as pneumonia, 10,14 ischaemia stroke, 12,13 cancer 11 as well as for cardiac rehabilitation 1 among AMI patients.There is strong evidence that CPs provide evidence-based practices in healthcare setting. 14e current study was planned to assess the effect of AMI standard CP among AMI patients on LOS in public tertiary care setting.

Patients and Methods
The quasi-experimental non-randomised study was conducted at the Department of Cardiology, Dr Ruth Pfau Civil Hospital, Karachi (CHK), from September to December 2018.After approval from the Institutional Review Board (IRB) [IRB-1094/DUHS/Approval/2018, 18th August, 2018] of Dow University of Health Sciences (DUHS), Karachi, the sample size was calculated for intervention and control group using Power Analysis and Sample Size System NCSS Statistical software.Sample size and power; Power Analysis and Sample Size System (PASS) version 11. 15 With 92% power to detect a difference of -2.6 between the null hypothesis that both group means are 5.5 and the alternative hypothesis that the mean of group 2 is 8.2 with estimated group standard deviations of 1.4 and 2.3 and with a significance level (alpha) of 0.01000 using a twosided two-sample t-test. 16ter permission from the CHK administration [MS/CHK/18/7855, 26th, May: 2018], the sample was raised using non-probability consecutive sampling technique.AMI Patients admitted pre-implementation of AMI standard CP were pre-assessed in September 2018, and were included in the control group.Others were included in the intervention group on which AMI standard CP was applied in October-2018.Intervention group was postassessed in November and December 2018 (Figure).A group of healthcare practitioners (HCPs) comprising cardiologists, post-graduates (PGs) / residents, nurses and critical care technicians (CCTs) were recruited using purposive sampling technique for skill evaluation through the AMI standard CP checklist.
The Data were collected after taking written informed consent from the study participants.Assessment and intervention were carried out in three phases Using AMI standard CP tool 17 whose language was modified according to the contextual need of the study setting.AMI standard CP is composed of eight components: investigations; pre-angiography care; post-angiography care; medications; observation and continuation of treatments vital signs and other parameters; nutritional status; mobility, elimination hygiene; and expected outcomes.Permission for use of AMI CP was obtained through email.The content validity index (CVI) of the tool was computed to be 0.9266 for relevancy and 0.9333 for clarity based on feedback from the experts in the field, like cardiologists and cardiac nurses.Cronbach's alpha coefficient was 0.83.
Phase-I comprised pre-assessment of the control group using questionnaires regarding AMI management comprising 15 questions related to their timely (immediately, within 10 minutes, 11-15 minutes, 16-30 minutes) management on different components, such as electrocardiogram (ECG), vital sign, medications prescription and administration etc. HCP's conventional clinical practices were monitored within the same duration through the AMI standard CP checklist.
Phase-II was meant for intervention.For planning the intervention, a meeting was arranged with HCPs and clinical supervisors for establishing effective comfortable  environment for interaction and data collection.The HCPs were gathered from morning, evening and night shifts in the seminar room of the study setting after permission from the department head.Flyer and pamphlets were also prepared and displayed in the relevant departments for the HCPs, resulting in positive outcome during the interactive session for an overview and easy understanding of AMI standard CP.
A power point presentation was shared with the HCPs about the implementation and importance of the AMI standard CP.After discussion, pocket guides were made and distributed among the HCPs for use as guidelines for the management of AMI standard CP protocol.A hard copy was kept in the emergency room (ER) and coronary care intensive care unit (CCICU), and was handed over to clinical supervisor and his team members, charge nurse, CCTs and others senior HCPs.
During the third week of the implementation month, discussion was held with individual HCPs and in small groups for effective implementation of AMI standard CP.In addition, facilitation and consultation was sought from the clinical supervisor regarding having a good understanding about the implementation of CP.In the last week of the intervention, another formal interactive teaching session was held for thorough discussion about the systematic implementation of the AMI standard CP.A proforma was attached to all newly-diagnosed AMI patients' files, which was filled up by the Primary Investigator or Primary author.
During the implementation phase, Primary Investigator or Primary author were present in all the shifts for observing the implementation process and answered all the queries raised by the participants.
In Phase-III, post-implementation data were collected from AMI discharge patients using the same structured questionnaire.In addition, post assessment was done through hard copy of AMI Standard CP attached with each patient's file separately for both groups, which were filled and checked by the HCPs for effective implementation of AMI Standard CP.
Data was analysed using SPSS 21.Frequencies with percentages were used for sociodemographic data and paired sample t-test was used to compare the mean differences in LOS.Chi-square test was used for AMI standard CP between the two groups and among the HCPs.P<0.05 was considered statistically significant.
Mean LOS reduced significantly in the intervention group compared to the control group (Table 2).
Significant differences were found in 24 components in all the eight categories of AMI standard CP post-intervention (Table 3).
documentation of cardiac biomarkers, monitoring of glucose level, angiography / angioplasty procedure, door to balloon procedure within 90 minutes respectively in the current study.A study conducted in Egypt showed significant result only in blood glucose level. 22The current study found non-significant outcomes related to continuous cardiac monitoring, glycosylated haemoglobin (HbA1c), complete blood count, serum urea creatinine and electrolytes, serum magnesium, prothrombin time, activated partial thromboplastin time, and international normalised ratio, door to needle time for fibrinolysis within 30 minutes, and echocardiography.The Egyptian study 22 reported non-significant result in lipid profile, cardiac enzymes, and electrolytes in study and control groups.
Only two AMI standard CP components showed nonsignificant findings; written consent prior to procedure, and post-angiography monitor vital sign.No study was found that evaluated these components.
A similar study conducted in China promoting and implementing different treatment strategies in this regard has given a blue print for other countries to follow. 23 the basis of the findings, it is strongly suggested that the HCPs, particularly the doctors, nurses and CCTs, should follow the systematic approaches of AMI standard CP during care of AMI patients.

Conclusion
The intervention group managed by AMI standard CP had a significantly reduced LOS compared to the control group.

Figure :
Figure: Flow diagram of data collection and intervention plan.