Quality Improvement Proposal:

Prevent Patients from Missing Critical Cardiac Medications

Bon Secours Memorial College of Nursing

NUR 3241: Quality Safety and Nursing Practice

Jamie Driggs, RN

July 20, 2021

“I pledge…”
Quality Improvement Proposal 2

As a nurse in the stress lab at St. Francis Medical Center, I have come to notice a

disturbing pattern in our outpatient population. An alarming number of patients present to their

scheduled stress testing appointments and report that they were instructed to hold their

medications for up to 48 hours prior to their test. Some patients stated they were instructed to

hold all their medications, while others report they were instructed to hold only their ‘cardiac’

medications; but what does that really mean to the patient?

Cardiac medications can include anything from antihypertensive medications to

anticoagulants for irregular heart rhythms. There are great dangers in abruptly stopping, or even

simply pausing treatment with these medications (Elliott, 2019); especially when our patients are

holding medications unnecessarily. This is clearly an issue that needs to be addressed before one

of our patients suffers an adverse reaction as a result of not taking their medications as

prescribed.

Why is this problem occurring? We need to take a deeper look at where our patients are

receiving this information from, and why.

Upon further review, it was discovered that patients are receiving one or more sets of

instructions for pre-procedure testing preparation. Some patients reported receiving instructions

from their primary care physicians who ordered the stress test, while others were reporting that

they received instructions from the schedulers who booked their appointments. Only a handful of

patients have reported receiving no instructions at all. Even still, many patients revealed that they

had received conflicting instructions from their physicians, schedulers, and automated reminder

calls, ultimately leaving the patient to decide which medications to hold.

There's really only two main types of medications that should be held prior to stress

testing. Those are beta blockers and caffeine; depending on the type of testing ordered. One way
Quality Improvement Proposal 3

that beta blockers work is by reducing the heart rate. However, stress testing involving exertion

or the use of an intravenous (IV) dobutamine infusion has a minimum heart rate requirement that

the patient must reach for their test to be considered reliable.

For patients who are unable to participate in physical activity or cannot achieve the

minimum heart rate necessary for stress testing with exertion, we can perform a chemical stress

test with the use of an IV injection called Lexiscan. Lexiscan is a vasodilator, which increases

the size of the arteries surrounding the heart, allowing blood flow to the heart to increase

(Daniels, 2019). However, for patients needing a chemical stress test with Lexiscan, they must

avoid any caffeine intake for at least 12 hours prior to their test, which includes decaffeinated

beverages, coffee, soda, tea, chocolate, and medications containing caffeine (Daniels, 2019). The

science behind this is that caffeine binds to the same receptors as the Lexiscan and inhibits the

desired effect of the medication. In the stress lab, we use caffeine to reverse the medications side

effects once the procedure is complete 100% of the time, either in oral or IV form with caffeine

citrate.

Now that we know patients are becoming confused by their preparation instructions, we

can begin the planning phase of the PDSA cycle to identify areas we can improve. Askew et al.

(2019) recommends that the patient’s current medications should be reviewed and the decision to

hold certain medications prior to testing should be determined on an individual basis, however,

this is seldom the case. Especially when stress tests are ordered by non-cardiology physicians,

they may not know the appropriate requirements for each individual test or understand their

significance.

What can we do to change this process? I believe that we could start by sharing our

knowledge with the primary care and non-cardiac practices that most frequently refer patients to
Quality Improvement Proposal 4

the stress lab. As the procedural nurses for stress testing, we have the most knowledge about the

process, including pre and post procedure instructions. Because of our expertise, we can begin to

gather data to create an informational sheet to share with our referring practices. The sheet

should include the types of testing we offer, the indications for each test, and the specific pre-

procedure instructions for each type of test.

The second improvement process I would like to suggest is collaboration with the

scheduling department to assess the accuracy of the most recent pre-procedure instruction sets

that they are providing for our patients. Perhaps they are outdated, or they have more than one

set to refer to when scheduling tests. Clarification of the most recent and evidence-based

guidelines should streamline pre-procedure instructions that correlate with instructions provided

by the physician’s office. The updated pre-procedure guidelines should also include specific

medication names (both generic and brand names) to review with the patient. I would also

recommend adding direct contact information for the stress lab nurses to all updated guidelines

and informational sheets so that both physicians and patients can reach out to the department

with any additional questions that may arise. While this may require a small amount of additional

time and attention from the stress lab nurses, it could greatly reduce the patient’s risk of adverse

reactions from unnecessarily holding medications and even prevent the need to reschedule stress

testing if certain requirements are not followed.

The third improvement process I believe would be beneficial in reducing confusion for

our patients is to work with the IT department to investigate the number of appointment reminder

calls that each patient receives. When a patient is scheduled for a nuclear stress test, it creates 4

separate appointments in the system: one for the resting isotope injection, one for the nuclear

medicine camera time for ‘resting’ images of the heart, one for the stress portion of the test
Quality Improvement Proposal 5

(Lexiscan or exercise), and one for the nuclear medicine camera time for ‘stress’ images of the

heart. Are our patients receiving appointment reminder calls for all 4 appointments even though

it’s technically one stress test? Further investigation is needed here.

Based on my learning throughout this course, I believe that a successful timeline for this

project should be roughly six months long. We are well positioned to begin collecting real-time

data to determine the specific degree of this occurrence over the next three months. After that

data is collected, we can review the appropriateness of my quality improvement proposals. If

those proposals are in line with our goals, we can implement these interventions and measure

their effectiveness over the following three months.

On the day of testing, the stress nurses will assess each patient for what pre-procedural

instructions that they received, and from whom. We will know these changes have made an

improvement by seeing a reduction in the number of patients who hold more than the necessary

medications prior to their stress test after the three month trial period.

I believe that this quality improvement proposal addresses each of the six concepts I have

learned throughout this course. By preventing patients from holding critical cardiac medications,

we are greatly improving patient safety and focusing our efforts on patient centered care. We will

actively engage in teamwork with the physician offices, IT support, and the scheduling

department to accomplish a collaborative goal. Our research and observations will contribute to

our current informatics, and updating our current practices guided by evidence-based research

will result in quality improvement for the benefit of our patients.

Quality Improvement Proposal 6

References

Askew, J. W., Chareonthaitawee, P., & Arruda-Olson, A. M. (2019). Selecting the

optimal cardiac stress test (W. J. Manning & T. F. Dardas, Eds.). UpToDate. Retrieved

July 19, 2021, from https://www.uptodate.com/contents/selecting-the-optimal-cardiac-

stress-test

Daniels, K. J. (2019). Cardiac stress testing review for the primary care provider. The Nurse

Practitioner, 44(6), 48–55. https://doi.org/10.1097/01.NPR.0000558158.84219.A3

Elliott, W. J. (2019). Withdrawal syndromes with antihypertensive drug therapy (G. L. Bakris &

J. P. Forman, Eds.). UpToDate. Retrieved June 10, 2021, from

https://www.uptodate.com/contents/withdrawal-syndromes-with-antihypertensive-

drugtherapy