Dr. Mirle Kellett-Kim Tierney: Hit the Target Presentation
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Dr. Mirle Kellett-Kim Tierney: Hit the Target Presentation Dr. Mirle Kellett-Kim Tierney: Hit the Target Presentation Presentation Transcript

  • Hit the Target: Data and Metrics Maine Quality Forum In A Heartbeat November 9, 2006 Mirle A. Kellett,Jr. MD, FACC, FSCAI Chief, Department of Cardiac Services The Maine Heart Center at Maine Medical Center
  • Mirle Kellett, MD, FACC (Chair), Maine Medical Center Richard Chandler, MD , Penobscot Bay Medical Center Darlene Glover, RN, MSN , Stephens Memorial Hospital Susan Horton, RN, MSN , Central Maine Heart & Vascular Institute Doug Libby, RPh , Maine Health Management Coalition H. Joel Johnson, RN, CCM, ACS , Central & Western Maine Regional PHO Kevin Kendall, MD, FACEP , Central Maine Medical Center Sandra Parker, Esq. , Maine Hospital Association Guy Raymond, MD , Northern Maine Medical Center Kim Tierney, RN , Maine Medical Center Peter Ver Lee, MD, FACC , Eastern Maine Medical Center Paul vom Eigen, MD, FACC , Northeast Cardiology Associates Dennis Shubert, MD , Maine Quality Forum Christopher McCarthy , Quality Initiatives Administrator, Maine Quality Forum Committee Members: Data and Metrics
  • Common Treatment Guideline Subcommittee Members: Paul vom Eigen, MD, FACC , Northeast Cardiology Associates Larry Hopperstead, MD , Central Maine Medical Center Mirle Kellett, MD, FACC , Maine Medical Center William Phillips, MD , Central Maine Medical Center Peter Ver Lee, MD, FACC , Eastern Maine Medical Center Dennis Shubert, MD , Maine Quality Forum Christopher McCarthy , Quality Initiatives Administrator, Maine Quality Forum Kim Tierney , RN, Cardiac Database Coordinator, Maine Medical Center
    • Improve the care, quality of life and survival of Maine patients with AMI
    • Patients will receive the right care at the right time
    • Establish a system of care to be used by all providers
    • Continually monitor sufficient indicators of process and quality to maximize the quality of the process.
    Mission In a Heartbeat
  • Process In a Heartbeat Data and Metrics committee formed to develop indicators across the spectrum of care Treatment guideline subcommittee formed to establish a common treatment guideline
    • Common treatment guideline report
    • Data and Metrics Framework
    • EMS data processes
    • ED data and process improvement
    • Post-discharge data
    Treatment Guideline & Data and Metrics
  • Common Treatment Guideline Subcommittee Members: Paul vom Eigen, MD, FACC , Northeast Cardiology Associates Larry Hopperstead, MD , Central Maine Medical Center Mirle Kellett, MD, FACC , Maine Medical Center William Phillips, MD , Central Maine Medical Center Peter Ver Lee, MD, FACC , Eastern Maine Medical Center Dennis Shubert, MD , Maine Quality Forum Christopher McCarthy , Quality Initiatives Administrator, Maine Quality Forum Kim Tierney , RN, Cardiac Database Coordinator, Maine Medical Center
  • Common Treatment Guideline Subcommittee To develop a common treatment protocol/pathway that PCI Centers have agreed to use in order to streamline the treatment and transfer process for local hospitals with patients that need to be sent to a heart center. Purpose:
  • STEMI CLINICAL PATHWAY ** Heparin bolus only for patients within 1 hour transport to PCI Facility – 60un/kg max 4,000unit Patient transport over 1 hour to PCI Facility continue Heparin with 12un/kg drip. STE/ LBBB Symptoms < 12hours Presentation to Cath Lab Door <1hr * Or Contraindication to Lytic (See table) Primary PCI Transfer to PCI Center Goal: Door to Balloon 90” Lytic Goal: Door to Drug< 30” TIMI Risk Criteria: Previous MI Anterior Infarct SB/P< 100 HR >100 A-Flutter or Fib Age>75 Killip Class > II Post CPR Administer MEDS as indicated: ASA Beta blocker Plavix 300mg Heparin ** Contraindications to lytic Any prior intracranial hemorrhage Known structural cerebral vascular lesion (e.g. AVM) Known malignant intracranial neoplasm Ischemic stroke within 3 mos (EXC within 3hours Suspect aortic dissection Active bleeding or bleeding diathesis (EXC) menses Significant closed head trauma Uncontrolled HTN (SB/P>175;DB/P>110) Current use of anticoagulants YES NO HIGH LOW Transfer to PCI Center Stay / Observe Or Transfer to PCI *For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policy.
  • *For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policies should be developed. STEMI CLINICAL PATHWAY
  •  
  • Clinical Equipose Curve PCI Time Delay and Outcome Nallamothu, BK AJC 2003
  • Clinical Equipose Curve PCI Time Delay and Outcome Nallamothu, BK AJC 2003
  • Clinical Equipose Curve PCI Time Delay and Outcome Nallamothu, BK AJC 2003
  • STEMI CLINICAL PATHWAY ** Heparin bolus only for patients within 1 hour transport to PCI Facility – 60un/kg max 4,000unit Patient transport over 1 hour to PCI Facility continue Heparin with 12un/kg drip. STE/ LBBB Symptoms < 12hours Presentation to Cath Lab Door <1hr * Or Contraindication to Lytic (See table) Primary PCI Transfer to PCI Center Goal: Door to Balloon 90” Lytic Goal: Door to Drug< 30” TIMI Risk Criteria: Previous MI Anterior Infarct SB/P< 100 HR >100 A-Flutter or Fib Age>75 Killip Class > II Post CPR Administer MEDS as indicated: ASA Beta blocker Plavix 300mg Heparin ** Contraindications to lytic Any prior intracranial hemorrhage Known structural cerebral vascular lesion (e.g. AVM) Known malignant intracranial neoplasm Ischemic stroke within 3 mos (EXC within 3hours Suspect aortic dissection Active bleeding or bleeding diathesis (EXC) menses Significant closed head trauma Uncontrolled HTN (SB/P>175;DB/P>110) Current use of anticoagulants YES NO HIGH LOW Transfer to PCI Center Stay / Observe Or Transfer to PCI *For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policy.
  • *For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policies should be developed. STEMI CLINICAL PATHWAY
    • Why are we measuring this data
    • Who are we measuring it on
    • What metrics in the process will we measure
    • How will we define the elements/metrics
    • Data collection
    • Data reporting
    • Ongoing role
    DATA and METRICS
    • Improve the care, quality of life and survival of Maine patients with AMI
    • Patients will receive the right care at the right time
    • Establish a system of care to be used by all providers
    • Continually monitor sufficient indicators of process and quality to maximize the quality of the process.
    Mission In a Heartbeat
  • WHY There is concern that patients with acute myocardial infarct are not receiving the appropriate care And That there are significant delays in the care they receive Data and Metrics
  • Data and Metrics
    • Data collection and analysis will:
    • tell us what percent of these patients are not receiving
    • reperfusion therapy and why
    • show where the delay in treatment lies
    • give feedback on performance throughout the
    • system of care
    • give the tools for process improvement of care.
  • WHO ECG with ST segment elevation (STEMI) or Left bundle branch block (LBBB) and Cardiac Symptoms ( same cohort as JACHO/CMS core metrics) Patient Cohort for data measures Data and Metrics
    • Patient Eligibility Criteria: STEMI
    • STE/ LBBB
    • ST segment elevation with > 1mm/.10mV in two or
    • more leads.
    • Documentation of ST- segment elevation or left bundle
    • branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival.
    • Using the 12-lead ECG performed closest to the time of hospital arrival.
    • ECGs done more than one hour prior to hospital
    • arrival should be repeated.
    Patient Inclusion Data and Metrics
  • Symptom Onset Onset time for patients reporting symptoms initially intermittent and subsequently constant, the onset time is defined as the time of change from intermittent to constant symptoms. Patients reporting symptoms that were initially mild and subsequently changed to severe, the onset time is defined as the time of change in symptom severity. For patients with both, the change in symptom severity is given preeminence in determining symptom onset time. The REACT Trial definition. Am Heart J 138(6):1046-1057 Patients with symptom onset >12hours are included in the general study but excluded from time measures . Patient Inclusion for timeliness Symptoms <12 hours
  • Metrics in the Process Process Elements PCI Center EMS Transport Emergency Department Retrospective Discharge Data Demographics WHAT Data and Metrics
  • EMS Data and Metrics Jay Bradshaw Data and Metrics
  • Metrics in the Process Process Elements PCI Center EMS Transport Emergency Department Retrospective Discharge Data Demographics WHAT Data and Metrics
  • ED Data and Metrics Rebecca Chagrasulis, MD Data and Metrics
  • Metrics in the Process Process Elements PCI Center EMS Transport Emergency Department Retrospective Discharge Data Demographics WHAT Data and Metrics
  • Data and Metrics PCI Center/Cath Lab Data Balloon Inflation Time (reperfusion) – First documented balloon time or first documented TIMI flow > 2 If patient went to CABG (coronary artery bypass grafting) Mortality (death) in the lab
  • Documentation
    • Reasons for delay in any treatment must be documented:
    • Patient initial refusal in treatment
    • Religious reasons
    • Waiting for family to arrive
    • No urgent need for PCI
    Data and Metrics
  • Metrics in the Process Process Elements PCI Center EMS Transport Emergency Department Retrospective Discharge Data Demographics WHAT Data and Metrics
    • JACHO/CMS Core Measures are already collected by hospitals:
    • ASA on Arrival and Discharge
    • Beta blocker on arrival and discharge
    • Ace Inhibitor
    • Statin
    • Smoking cessation
    • Discharge Instructions
    Data and Metrics Discharge Data :
    • Same extraction that is done for JACHO/CMS at all hospitals:
    • Collection of STEMI ICD.9 discharge codes
    • Primary and secondary diagnosis codes (shock and stroke)
    • Primary and secondary procedure codes (cath, PCI, CABG)
    • Disposition at discharge (dead or alive)
    Retrospective Data : Data and Metrics
  • Defining the Elements
    • Limited data points
    • Current Data Collection processes
    • e.g. Maine EMS InterfacilityTransport Program
    • JACHO/CMS Core Measures - Same Metrics and Definitions
    • ACC/AHA Guidelines and definitions
    • Consensus of State represented committee
    • Process data / during point of care – incorporated
    • into current documentation
    Data and Metrics
    • Maine Quality Forum has assumed the responsibility for contracting for data collection and reporting.
    • Collection in the process of care across the spectrum providing tools for adapting into current documentation
    • Core metrics same as JACHO/CMS extraction
    • Process improvement metrics
    Data Collection Data and Metrics HOW
  • Data Reporting Maine Quality Forum is committed to providing meaningful analysis on this data to provide actionable information back to providers across the spectrum of care. Critical analysis points –a statewide snapshot of performance on key process points and clinical outcomes. Reports on : timeliness, treatment and outcomes Data and Metrics
  • Data Reporting Maine Quality Forum Critical Analysis Symptom Onset to medical activation EMS activation To patient arrival EMS to 1 st Hospital arrival Door to Data Data to Drug Transfer to Cath Lab Arrival Lab Arrival to reperfusion Timeliness In median times Door to Drug GOAL: 30 minutes Door to Balloon GOAL: 90 minutes Data and Metrics Door to Cath Lab Arrival GOAL: 60 minutes
  • Maine Quality Forum Critical Analysis Data Reporting Treatment Provided Primary PCI Lytic and PCI Lytic Coronary Artery Bypass grafts (CABG) Medical Treatment or Comfort Measures Only Data and Metrics
  • Data Reporting Maine Quality Forum Critical Analysis APPROPRIATE CARE METRIC # of STEMI patients receiving reperfusion therapy Total # of STEMI patients-#with contraindications TIMELINESS OF CARE METRIC # reperfused patients treated under goal # of reperfused patients - # with clinically appropriate delay Data and Metrics
  • Ongoing role Continue to measure and report the system outcomes to improve the global and process improvement outcomes Continue to address barriers to improvement of care within hospitals and across the state Continuously update the care process and protocols with new evidence base science in the treatment of AMI Data and Metrics