The following article is a part of conference coverage from the 2021 American Association of Nurse Practitioners National Conference (AANP 2021), held virtually from June 15 to June 20, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading NPs. Check back for more from AANP 2021.


A newly developed evidence-based protocol increased appropriate referrals to a post-myocardial infarction (MI) clinic, according to a poster presentation at the 2021 American Association of Nurse Practitioners National Conference (AANP 2021).

Multiple studies have found a lower rate of unscheduled readmissions among patients who had prompt follow-ups (within 30 days) after a MI. Motivated by these studies, The Johns Hopkins Hospital created a clinic focused on post-MI care. After its launch, clinicians observed a lower referral rate than expected. In order to stimulate appropriate referrals, a new referral protocol was implemented, and a quality improvement study was conducted.

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The new referral protocol comprised evaluating patients using the AMI READMITS (acute myocardial infarction: renal function, elevated brain natriuretic peptide, age, diabetes mellitus, nonmale sex, intervention with timely percutaneous coronary intervention, and low systolic blood pressure) assessment tool. Patient records were reviewed to determine whether or not referral rates were improved. Clinicians were surveyed about their experiences with and opinions of the new protocol.

Patients who were treated preintervention (n=29) and postintervention  (n=28) were aged 41 to 60 years (61.4%), 61 to 80 years (43.9%), or 81 years or older (12.3%), and 61.4% were men. Readmission risk was determined to be extremely low or low (57.9%) or moderate, high, or extremely high (42.1%).

The percentage of patients referred for post-MI care increased from 66% preintervention to 89% after the new protocol was implemented. Use of the screening protocol significantly increased referral rates (P =.033), however, total appointments scheduled within the recommended time frame were not significantly changed (P =.169). (Table)

Table. Referral and Appointment Rates at a Post-MI Clinic

ReferralsReferred, %No Referral, %Total, %
AppointmentsNot Documented, %Scheduled, %Scheduled but Delayed, %
MI, myocardial infarction

When surveyed about the AMI READMITS tool, clinicians had mixed opinions: 10.5% and 36.8% were strongly against or against implementing the tool in clinical practice compared with 5.3% and 15.8% who strongly agreed or agreed the tool should be used, respectively. A third (31.6%) of clinicians had a neutral opinion about incorporating AMI READMITS into routine clinical practice.

The clinicians who were against the incorporation of the tool cited the fact that the efficacy has not been validated. It remains unclear whether unscheduled readmissions within 30 days were reduced.

Despite the mixed feelings, 94.8% of practitioners thought AMI READMITS was helpful in making decisions about referrals, 79.0% reported it was easy to use, 68.4% thought it improved the referral process, and 100% thought they should have the option to include the results in the clinical notes.

This study was conducted at a single center and the results may not be generalizable to other care settings.

These data indicated the evidence-based referral protocol using the AMI READMITS score increased referrals to a post-MI clinic. However, clinicians had mixed feelings about using the tool, as it remains unclear whether unscheduled 30-day readmissions for MI are in fact reduced by AMI READMITS. Additional studies are needed to validate the efficacy of the tool.

Visit Clinical Advisor’s meetings section for complete coverage of AANP 2021. All conference sessions are available to registered attendees through August 31, 2021.


Muganlinskaya N, Posey L, Skojec DV, Resar JR. Implementing the AMI READMITS risk assessment score within a referral protocol to increase referrals for follow-up among patients with type I myocardial infarction. Poster presented at: 2021 American Association of Nurse Practitioners National Conference; June 15-June 20, 2021. Abstract 25.