Acute Myocardial Infarction AMI JCAHO Core Measure Project

Acute Myocardial Infarction (AMI) JCAHO Core Measure Project Team Membership Clinical Departments: Cardiology, Cardiovascular Surgery, Emergency Medical Services Hospital Departments: 3 NEWS, Cardiac Cath Lab, Cardiac Rehab, Emergency Department, Medical Records, Quality and Resource Management, Center for Clinical Effectiveness

Opportunity for Improvement n n n LUHS began reporting AMI core measures to JCAHO beginning in July, 2002 and to the Center for Medicaid and Medicare Services (CMS) in July, 2003. AMI core measures are based on AHA/ACC Coronary Heart Disease guidelines Full FY 05 Medicare reimbursement requires reporting of AMI and other quality measures to CMS Data will be reported on the CMS website and in the media. LUHS performs well on most measures, but our goal is to achieve excellent performance on all measures

Most Likely Causes for the Improvement Opportunity AMI patients are complex and the care is often emergent n Care involves many different units and teams during a patient’s stay n Clinicians lack tools (forms, reminders, order sets) needed to follow guidelines n Hospitals have previously not addressed prevention like smoking cessation n

JCAHO AMI Core Measures n n n Aspirin within 24 hours before or after arrival Aspirin prescribed at discharge Beta blocker within 24 hours after arrival Beta blocker prescribed at discharge Time to PTCA in patients with an ST n n n ACE-Inhibitor prescribed at discharge in patients with left ventricular systolic dysfunction (LVSD) Adult smoking cessation advice to all patients who have smoked within the last 12 months Inpatient mortality

Solutions Implemented n 2002 and 2003 n n n n Formed AMI Core Measure committee Implemented AMI Discharge Progress Note Addendum Educated attendings, residents and nursing staff Developed chart stickers to designate AMI patients Established process with Cath Lab to obtain precise wire cross times for PTCA Developed draft of pre-printed unstable angina/non-ST elevation MI physician order set Implemented hospital-wide smoking cessation program

Solutions Implemented (con’t) n 2004 Implemented pre-printed unstable angina/non. ST elevation MI orders n Revised Nursing Database to accurately collect smoking history n Revised Patient Education Record to include documentation of smoking cessation advice n Formed a sub-committee and began data collection to study the admission process for patients presenting with an ST elevation AMI n

03 Se p- 03 g- Au l-0 3 Ju 03 n- Ju 3 -0 ay M 3 r-0 Ap ar -0 3 100% M Fe b 03 03 2 -0 n- Ja ec D 02 ov - N 2 -0 ct O 02 Se p- 02 g- Au l-0 2 Ju Rate of Eligible AMI Patients Receiving Aspirin within 24 hours of Arrival UCL AMI Core Measure - Aspirin at Arrival LUHS Mean = 97% National Mean = 93% Q 12003 90% LCL 80% 70% 60% 50%

03 Se p- 03 g- Au l-0 3 Ju 03 n- Ju 3 -0 ay M 3 r-0 Ap ar -0 3 M Fe b 03 03 90% n- 2 -0 Mean Ja ec D 02 ov - N 2 -0 ct O 02 Se p- 02 g- Au l-0 2 Ju Rate of Eligible AMI Patients Receiving Aspirin Prescription at Discharge AMI Core Measure - Aspirin at Discharge UCL 100% LUHS Mean = 97% National Mean = 89% Q 12003 LCL 80% 70% 60% 50%

03 p- Se 03 g- Au l-0 3 Ju 03 n- Ju 3 -0 ay M 3 r-0 Ap -0 3 ar M b 03 Fe 03 n- 02 ec - 02 ov - Ja D N 2 -0 ct O 02 p- Se 02 g- Au l-0 2 Ju Percent of AMI Smokers Receiving Smoking Cessation Counseling Acute Myocardial Infarction - Smoking Cessation Advice 100% UCL 100% 80% LUHS Mean = 69% National Mean = 66% Q 12003 60% 40% 20% LCL 0%

Acute Myocardial Infarction Inpatient Mortality 25% UCL 15% National Mean = 13% Q 12003 LUHS Expected Mean 10% LUHS Mean = 7% 5% 0% 3 p 0 Se 3 g 0 Au Ju l-0 3 03 Ju n- 3 M ay -0 3 r-0 Ap -0 3 ar M b 03 Fe 03 Ja n- 2 -0 ec D N ov -0 2 2 ct -0 O 2 p 0 Se Au g 0 2 LCL Ju l-0 2 Percent Mortality of AMI Patients 20%

03 Se p- 03 Au g- l-0 3 Ju 03 Ju n- 3 -0 ay M 3 r-0 Ap -0 3 ar M b 03 Fe 03 2 -0 Ja n- ec D ov N 02 Se p- 02 Au g- Ju l-0 2 Median Time (minutes) to PTCA of Eligible AMI Patients AMI Core Measure - Median Time to PTCA 360 300 240 UCL 180 National Mean = 192 minutes Q 12003 LUHS Mean = 137 minutes 120 60 LCL 0

Next Steps n n Continue with establishing a comprehensive system-wide smoking cessation program Present findings to physician and nurse groups to promote their participation and obtain their input and suggestions Develop and implement AMI care pathway, discharge protocol form and patient education materials Develop and implement ST elevation MI preprinted order set