Acute Myocardial Infarction
      (AMI) Initiative
Putting All the Pieces in Place
About Us

Spartanburg Regional Healthcare System

                                              585 beds – tertiary referr...
About Us

                                        Approximately 800 Chest
      Opened October 2004               Pain Pat...
Chest Pain Core Team
                                    (Meets Monthly)

Physicians:                             Other Di...
Chest Pain Committee
                           (Meets Quarterly)

Physicians:                      Departments Represente...
Reducing Mortality and Morbidity

Treatments are time dependent
and necessitate rapid initiation.
The patient must quickly...
Reperfusion Therapy

        Treatment Delayed is Treatment Denied




 Symptom          Call to           Prehospital    ...
STEMI Time Line
                         (1st Graph Introduced CP Core Team)

                                            ...
Common Factors Identified as Contributing
     to Failure to Provide Prompt Therapy:


Delays in obtaining a 12-Lead ECG

...
Common Factors Identified as Contributing
    to Failure to Provide Prompt Therapy




Delays related to gender biases

De...
% Received Thrombolytic Therapy WI
                                30 Minutes from Arrival to Facility

                  ...
% Received Primary PCI WI 120
                                             Minutes from Arrival to Facility

             ...
% Received Primary PCI WI 90
                                           Minutes from Arrival to Facility

                ...
Cardiac Cath Lab




                   14
STEMI Timeline
                                                                           APRIL-MAY 2006
                 ...
GOAL: Decrease Door-to-PPCI
                     Times < 90 Minutes


GOALS: “CODE STEMI” Timeline:
(Recommended by CP Cor...
GOAL: Decrease Door-to-PPCI
    Times < 90 Minutes



        Coming Attraction:
        Transmission of 12-Lead
         ...
GOAL: Decrease Door-to-Primary
             PCI Times to < 90 Minutes

                                   Cardiologist on ...
Other AMI Indicators
Aspirin Received WI 24H
                                                   ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE
  ...
Beta Blockers WI 24H
                                                   ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE
     ...
Aspirin Prescribed @ Discharge

                                                               ACUTE MYOCARDIAL INFARCTION...
Beta Blocker Prescribed @ Discharge

                                                       ACUTE MYOCARDIAL INFARCTION (A...
ACE Inhibitor or ARB Prescribed @ Discharge


                                                        ACUTE MYOCARDIAL INF...
Action: Encourage Physicians to Use:
               HEO - Cardiac Discharge Template




ACC/AHA
Guidelines




          ...
Smoking Cessation Advice/Counseling

                                                         ACUTE MYOCARDIAL INFARCTION ...
Titles/E-Mail Addresses
♥   Susan Duggar, Interim Executive Director Heart Center/Interim CNO
    (sduggar@srhs.com)

♥   ...
Questions????
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Acute Myocardial Infarction Acute Myocardial Infarction (AMI ...

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Acute Myocardial Infarction Acute Myocardial Infarction (AMI ...

  1. 1. Acute Myocardial Infarction (AMI) Initiative Putting All the Pieces in Place
  2. 2. About Us Spartanburg Regional Healthcare System 585 beds – tertiary referral center • Top 100 hospital for advances in computer technology • Bariatric Surgery Center of Excellence • JCAHO Certified Primary Stroke Center “South Carolina’s leader in overall heart services. #1 in South Carolina and North Carolina for Heart Surgery” 2 Health Grades (10/16/06)
  3. 3. About Us Approximately 800 Chest Opened October 2004 Pain Patients per month go through our Chest Pain Clinical Decision Unit South Carolina’s 1st Certified Chest Pain Center 2003 Level One Trauma Center: Approximately 100,000 visits annually 3
  4. 4. Chest Pain Core Team (Meets Monthly) Physicians: Other Disciplines: Cardiology: Cardiac Cath Lab: N. Srivastava, Medical Director Chest Pain Center M. Petty, Cath Lab Manager R. MacDonald Emergency Center: Emergency Center: W. Finn, Medical Director E.C. C. O’Hara, E.C. Clinical (previous) Director B. Rody, Medical Director E.C. C. Emmerth, E.C. Clinical (Current) Unit Educator F. Singletary (previous) Heart Center: K. Hanspard (Current) S. Duggar, Interim Executive Director Cardiology/Interim CNO JT Smith, Chest Pain Coordinator B. Hunter, Cardiology Clinical Outcomes Specialist 4
  5. 5. Chest Pain Committee (Meets Quarterly) Physicians: Departments Represented: Cardiology: Emergency Medical Services N. Srivastava, Medical (EMS) Director CP Center Regional One R. MacDonald Emergency Center Emergency Center: Cardiology Administration W. Finn, Medical Cardiac Cath Lab Director E.C. (Previous) Critical Care Inpatient Units B. Rody, Medical Director Cardiac Rehab/Wellness E.C. (Current) Hospitalist: Laboratories A. Koser Nuclear Medicine Nuclear Radiologist: Pharmacy/Drug Information B. Joyce Quality Services Vascular Services 5
  6. 6. Reducing Mortality and Morbidity Treatments are time dependent and necessitate rapid initiation. The patient must quickly recognize the signs and symptoms of an AMI. The physician must quickly diagnose the AMI and initiate treatment. 6
  7. 7. Reperfusion Therapy Treatment Delayed is Treatment Denied Symptom Call to Prehospital ED Cath Lab Recognition Medical System Increasing Loss of Myocytes Delay in Initiation of Reperfusion Therapy 7 (Slide: American College of Cardiology Foundation / American Heart Association) Heart
  8. 8. STEMI Time Line (1st Graph Introduced CP Core Team) JANUARY 2005 ST SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI) TIME LINE FROM ARRIVAL TO FACILITY TO TIME WIRE CROSSES LESION GOAL: Door-to-PCI = < 120 Minutes 400 350 Chest Pain Center 300 (273M) Clinical Decision Unit Opened October 2004 250 (196M) NUMBER OF MINUTES 200 DIRECT ADMIT 150 (123M) (112M) (105M) TO CATH LAB (83M) 100 (73M) (36M) 50 0 PT # 1 PT # 2 PT # 3 PT # 4 PT # 5 PT # 6 PT # 7 PT # 8 BEGIN TIME TO WIRE ACROSS LESION 10 28 17 21 16 13 21 12 CATH LAB ARRIVAL - BEGIN TIME 14 15 6 13 4 23 17 13 CODE STEMI -CATH LAB 37 16 ECG - CODE STEMI CALLED 32 31 ECG - CATH LAB 81 237 154 EC ARRIVAL - CATH LAB 82 58 D-T-ECG 18 0 0 2 6 4 EMS 0 8
  9. 9. Common Factors Identified as Contributing to Failure to Provide Prompt Therapy: Delays in obtaining a 12-Lead ECG Delays in decision-making Delays in consultation of cardiologist Delay or lack of rapidly available serum markers for AMI Society of Chest Pain Centers 9
  10. 10. Common Factors Identified as Contributing to Failure to Provide Prompt Therapy Delays related to gender biases Delays related to staff perception of a patient’s pain as noncardiac Society of Chest Pain Centers 10
  11. 11. % Received Thrombolytic Therapy WI 30 Minutes from Arrival to Facility ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE % RECEIVED THROMBOLYTIC THERAPY WITHIN 30 MINUTES OF ARRIVAL TO FACILITY (Q3 FY 2006) (HQI - JCAHO - CMS - PREMIER) HQI 100 MEAN TIME Q2 FY 2006 = 24.3 minutes 1 case outlier by 3 minutes 80 HQI: 1st (Top) Decile 66.667 66.67% HQI: Top 2nd Decile (2/3) % COMPLIANCE 60 57.14% MIDAS Com parative JCAHO No Thrombolytic 40 Given 29.41 28.57 25.0% Q1 FY 2006 28.57 HQI: Top 50% Q3 FY 2006 20 14.29 (1/7) (0/5) 0 (0/3) HQI: 8th Decile 0 (0/2) 0% 0 0 Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY FY 2005 Q1 FY Q2 FY Q3 FY Thrombolytic Therapy Rarely Given …Alternative when Cath Lab Unavailable 2003 2003 2003 2003 2004 2004 2004 2004 2005 2005 2005 2006 2006 2006 TIME FRAME 11 SRHS HQI 1st (Top) Decile HQI Top 2nd Decile HQI 50% HQI: 8th Decile MIDAS* JCAHO*
  12. 12. % Received Primary PCI WI 120 Minutes from Arrival to Facility ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE % RECEIVED PRIMARY PCI WITHIN 120 MINUTES FROM ARRIVAL TO FACILITY (Q3 FY 2006) (HQI - JCAHO - CMS - PREMIER) HQI 100 96.296 (26/27) 92.593 HQI 1st (Top) Decile 88.0% 91.176 (25/27) 81.42% 80 HQI Top 2nd Decile HQI Top 50% 67.19% % COMPLIANCE JCAHO 70.83 60 66.67 MIDAS Com parative (58/87) 53.33 53 HQI 8th Decile 42.86 40 42.22% SRHS 31.82 31.58 20 22.22 July 2006 no longer reporting Door-to-PPCI WI 120 Minutes 0 Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY FY 2005 Q1 FY Q2 FY Q3 FY 2003 2003 2003 2003 2004 2004 2004 2004 2005 2005 2005 2006 2006 2006 TIME FRAME 12 SRHS HQI 1st (Top) Decile HQI Top 2nd Decile HQI 50% HQI: 8th Decile MIDAS* JCAHO*
  13. 13. % Received Primary PCI WI 90 Minutes from Arrival to Facility ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE % RECEIVED PRIMARY PCI WITHIN 90 MINUTES FROM ARRIVAL TO FACILITY (Q3 FY 2006) (HQI - JCAHO - CMS - PREMIER) 80 73.529 70 Chest Pain Center Clinical Decision Unit Opened Oct 2004 60 "CODE STEMI" implemented Nov 2004 55.556 (15/27) 50 % COMPLIANCE 48.148 (13/27) 40 MIDAS Com parative 33.333 30 33.33 35.29 (10/30) (5/15) (6/17) 29.17 Mean Times: (7/24) 20 Q1 FY 2006 (84.3) Q2 FY 2006 (79.3) 10 10.53 Q3 FY 2006 (88.3) (2/19) SRHS0 (0/18) 0 Q3 FY 2004 Q4 FY 2004 Q1 FY 2005 Q2 FY 2005 Q3 FY 2005 Q4 FY 2005 Q1 FY 2006 Q2 FY 2006 Q3 FY 2006 TIME FRAME SRHS HQI 1st (Top) Decile HQI Top 2nd Decile HQI 50% HQI: 8th Decile MIDAS* JCAHO* 13
  14. 14. Cardiac Cath Lab 14
  15. 15. STEMI Timeline APRIL-MAY 2006 ST Segment Elevation Myocardial Infarction (STEMI) Time Line From Arrival to Facility to 1st Balloon Inflation 140 120 Goal = < 90 Minutes Number of Minutes 100 80 Cath Lab Def intions: 60 Ready Time = Pt prepped/draped Begin Time = MD present/local given 40 20 0 MA MA MA MA MA MA MA MA MA MA APR APR APR APR APR APR APR APR Y# Y# Y# Y# Y# Y# Y# Y# Y# Y# #1 #2 #3 #4 #5 #6 #7 #8 1 2 3 4 5 6 7 8 9 10 "BEGIN TIME" TO "1st BALLOON INFLATION" 28 30 33 20 28 23 18 34 31 25 20 19 17 19 17 17 21 9 READY TIME - BEGIN TIME 1 4 7 1 5 3 2 5 6 3 2 9 7 2 7 2 18 3 CATH LAB ARRIVAL - READY TIME 10 4 13 11 9 10 10 8 9 1 4 4 6 6 4 5 4 8 CATH LAB ARRIVAL - BEGIN TIME CODE STEMI -CATH LAB 21 12 41 25 36 47 50 22 54 29 33 57 43 52 20 ECG - CODE STEMI CALLED 0 26 30 8 8 12 3 0 0 3 15 0 13 0 ECG - CATH LAB 46 76 51 2 Direct Admit - CATH LAB D-T-ECG 3 0 2 21 4 9 3 9 14 0 1 3 6 31 0 21 0 0 D-T-ECG Direct Adm it - CATH LAB ECG - CATH LAB 15 ECG - CODE STEMI CALLED CODE STEMI -CATH LAB CATH LAB ARRIVAL - BEGIN TIME CATH LAB ARRIVAL - READY TIME READY TIME - BEGIN TIME "BEGIN TIME" TO "1st BALLOON INFLATION"
  16. 16. GOAL: Decrease Door-to-PPCI Times < 90 Minutes GOALS: “CODE STEMI” Timeline: (Recommended by CP Core Team) Door-to-ECG…..5 minutes ECG-to-Call of “CODE STEMI”…..5 minutes “CODE STEMI” –to-Arrival to Cath Lab….. 30 minutes Cath Lab Arrival-to-Begin Time…..15 minutes Begin Time-to-1st Balloon Inflation…..15 minutes TOTAL: 70 Minutes Goals Approved: Cardiology Physician Advisory Council 16
  17. 17. GOAL: Decrease Door-to-PPCI Times < 90 Minutes Coming Attraction: Transmission of 12-Lead ECG from the field (EMS) or from Regional One via an interface from Life Pak 12 to a telephone/radio receiver to a …. 17
  18. 18. GOAL: Decrease Door-to-Primary PCI Times to < 90 Minutes Cardiologist on call’s PDA for rapid decision to Cardiac Cath Lab Receiving station in CP Center CDU, reviewed by E.C. Physician and then beamed to …. 18
  19. 19. Other AMI Indicators
  20. 20. Aspirin Received WI 24H ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE ASPIRIN RECEIVED WITHIN 24 HOURS OF ARRIVAL TO FACILITY (Q3 FY 2006) (JCAHO - HQA - CMS/ Premier HQI - IHI) SRHS GOAL: 100% Com pliance HQI 100 HQI 1st (Top) Decile 99.65% 100 HQI Top 2nd Decile 98.11% (106/109) (99/99) 98.0 97.248 96.7 96.0 96.078 95.08 95.15 95.83% HQI Top 50% 94.93 95 MIDAS Com parative 93.01 (393/314) % COMPLIANCE JCAHO 93.75 93.333 90.28 91.8 90.76% (98/105) 90 HQI 8th Decile SRHS 88.39 85 80 Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY FY 2005 Q1 FY Q2 FY Q3 FY 2003 2003 2003 2003 2004 2004 2004 2004 2005 2005 2005 2006 2006 2006 TIME FRAME Q3 FY 2006 Opportunities Identified: SRHS HQI:YEAR 1 BASELINE: 8th HQI Top 10% MIDAS COMPARATIVE HQI Top 20% JCAHO EXPECTED* HQI: 5TH (MEDIAN) 20 NONE, Met Standard
  21. 21. Beta Blockers WI 24H ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE BETA BLOCKER RECEIVED WITHIN 24 HOURS FROM ARRIVAL TO FACILITY (Q3 FY 2006) (JCAHO HQA - CMS/Premier HQI - IHI) HQI HQI 1st (Top) Decile 99.42% 100 (84/84) 100 97.701 HQI Top 2nd Decile 97.67% 96.05 95.4 94.565 97.85 (85/87) SRHS 92.92 92.22 92.59 92.31 98.649 91.21 92.42 HQI Top 50% 95.2 (73/74) 90 (337/354) 89.69 93.89% JCAHO % COMPLIANCE MIDAS Com parative HQI 8th Decile 80 81.82% 70 60 50 Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY FY 2005 Q1 FY Q2 FY Q3 FY 2003 2003 2003 2003 2004 2004 2004 2004 2005 2005 2005 2006 2006 2006 TIME FRAME Q3 FY 2006 Opportunities Identified: (1 case) SRHS HQI Top 10% HQI Top 20% HQI: 5TH (MEDIAN) 21 Process HQI:YEAR 1where8th “NOW” dose was not transcribed/documented as being given issue BASELINE: the MIDAS COMPARATIVE JCAHO EXPECTED*
  22. 22. Aspirin Prescribed @ Discharge ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE ASPIRIN PRESCRIBED AT DISCHARGE (Q3 FY 2006) (JCAHO - HQA - CMS/Premier HQI - IHI) HQI 99.6% HQI 1st (Top) Decile 99.346 100 99.08% 99.324 HQI Top 2nd Decile 97.727 98.73 97.6 98.551 98.43 97.26 (147/148) 96.73 96.45 (152/153) HQI Top 50% 95.24 (129/132) 94.16 (533/548) 95 94.12 96.21% % COMPLIANCE 94.08 MIDAS Com parative 92.05 SRHS 90 JCAHO 86.84% HQI 8th Decile 85 Q3 FY 2006 Opportunities Identified: (3 cases) 80 ♥ 1 case - Aspirin received day FY discharge; however, notFY Q2 FYin Q3 FY FY 2005 Q1 FY Q2 FY Q3 FY Q1 FY 2003 Q2 FY 2003 Q3 FY 2003 Q4 of Q1 FY Q2 FY Q3 FY Q4 FY Q1 listed Physician Discharge 2006 2003 2004 2004 2004 2004 2005 2005 2005 2006 2006 Summary nor the Universal Medication Form TIME FRAME 22 ♥ 2 cases – Aspirin only ordered 8th “NOW”10% SRHS HQI:YEAR 1 BASELINE: as HQI Top HQI Top 20% HQI: 5TH (MEDIAN) dose on admission; daily dose never ordered MIDAS COMPARATIVE JCAHO EXPECTED*
  23. 23. Beta Blocker Prescribed @ Discharge ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE BETA BLOCKER PRESCRIBED AT DISCHARGE (Q3 FY 2006) (JCAHO- HQA - CMS/ Premier HQI- IHI) HQI HQI 1st (Top) Decile 100% 100 98.84% 98.56 98.0 98.63 HQI Top 2nd Decile 99.24 99.398 97.89 98.78 98.571 HQI Top 50% 95.71 (558/570)(162/164) (165/166) 94.3 93.29 95.98 95.48 93.79 (138/140) 95.56% 90 SRHS 89.62 JCAHO HQI 8th Decile 82.76% MIDAS Com parative % COMPLIANCE 80 70 60 50 Q3 FY 2006 Opportunities Identified: (2 cases) Q1 FY 2003 Q2 FY 2003 Q3 FY 2003 Q4 FY 2003 Q1 FY 2004 Q2 FY 2004 Q3 FY 2004 Q4 FY 2004 Q1 FY 2005 Q2 FY 2005 Q3 FY 2005 FY 2005 Q1 FY 2006 Q2 FY 2006 Q3 FY 2006 TIME FRAME ♥ Both cases patient received Beta blocker morning of discharge; however, not listed SRHS HQI Top 10% HQI Top 20% HQI: 5TH (MEDIAN) 23 in physician’s discharge summary nor JCAHO EXPECTED* Medication Form HQI:YEAR 1 BASELINE: 8th MIDAS COMPARATIVE Universal
  24. 24. ACE Inhibitor or ARB Prescribed @ Discharge ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE ACE INHIBITOR OR ARB PRESCRIBED AT DISCHARGE (Q3 FY 2006) (JCAHO - HQA - CMS/Premier HQI- IHI) HQI HQI 1st (Top) Decile 100% 100 HQI Top 2nd Decile 95% 95 92.31 91.667 (113/129) 90 (44/48) 87.6 91.429 (32/35) HQI Top 50% 85 82.61 86.11 85.51% % COMPLIANCE 80 83.721 80 SRHS JCAHO 75 73.58 (32/40) 75.0 72.97 72.55 70 72.0 MIDAS Com parative 68.29 66.67% 65 HQI 8th Decile 64.52 60 55 50 Q3 FY 2006 Opportunities Identified: (4 cases) Q1 FY 2003 Q2 FY 2003 Q3 FY 2003 Q4 FY 2003 Q1 FY 2004 Q2 FY 2004 Q3 FY 2004 Q4 FY 2004 Q1 FY 2005 Q2 FY 2005 Q3 FY 2005 FY 2005 Q1 FY 2006 Q2 FY 2006 Q3 FY 2006 TIME FRAME ♥ Addressing reason for not prescribing an ACEI; however, not addressing SRHS HQI Top 10% HQI Top 20% HQI: 5TH (MEDIAN) 24 reason for not prescribing an ARB in renal patients HQI:YEAR 1 BASELINE: 8th MIDAS COMPARATIVE JCAHO EXPECTED*
  25. 25. Action: Encourage Physicians to Use: HEO - Cardiac Discharge Template ACC/AHA Guidelines 25
  26. 26. Smoking Cessation Advice/Counseling ACUTE MYOCARDIAL INFARCTION (AMI) INITIATIVE SMOKING CESSATION ADVICE/COUNSELING (Q3 FY 2006) (JCAHO - HQA - CMS/PremierHQI - IHI) HQI 100 100 100 100 100 100 100 HQI 1st (Top) Decile 100% 100 HQI Top 2nd Decile HQI Top 50% 98.46 99.17 (77/77) 98.36 95.59 96.552 90 96.72 97.1 (239/241) (86/86) 94.74 (78/78) 95.42% 80 SRHS 70 61.11% % COMPLIANCE MIDAS Com parative 60 HQI 8th Decile 50 JCAHO 40 30 20 10 0 Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY Q4 FY Q1 FY Q2 FY Q3 FY FY 2005 Q1 FY Q2 FY Q3 FY Q3 FY 2006 Opportunities Identified: 2003 2003 2003 2003 2004 2004 2004 2004 TIME FRAME 2005 2005 2005 2006 2006 2006 NONE, Met the Standard SRHS HQI:YEAR 1 BASELINE: 8th HQI Top 10% MIDAS COMPARATIVE HQI Top 20% JCAHO EXPECTED* HQI: 5TH (MEDIAN) 26
  27. 27. Titles/E-Mail Addresses ♥ Susan Duggar, Interim Executive Director Heart Center/Interim CNO (sduggar@srhs.com) ♥ Cheryl O’Hara, Clinical Director Emergency Center (cohara@ srhs.com) ♥ Bonnie Hunter, Cardiology Clinical Outcomes Specialist (bhunter@srhs.com) ♥ JT Smith, Chest Pain Coordinator, (jtsmith@srhs.com) ♥ Margie Petty, Cath Lab Manager, (mlpetty@srhs.com) ♥ Karen Newton, Director of Quality Services, (knewton@srhs.com) 27
  28. 28. Questions????

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