1. Acute Myocardial Infarction (Heart Attack) Committee Membership: B. Majcher, APRN, C. Mulhall, APRN, K. McLean, MD, M. Jarotkiewicz RRT, MS, Administrative Director Cardiovascular Service Line, Nursing Staff of 3NEWS, CCU, 3 ITV, and Emergency Room, Cardiac Cath Lab, Medical Records Department, Center for Clinical Effectiveness. Confidential: For Quality Improvement Purposes Only

2. Evidence Angiotensin converting enzyme inhibitor (ACEI) therapy reduces mortality and morbidity in patients with left ventricular systolic dysfunction (LVSD) after AMI. Recent clinical trials have also established angiotensin-II receptor blocker (ARB) therapy as an acceptable alternative to ACEI, especially in patients with heart failure and/or LVSD who are ACEI intolerant. CMS/TJC Core Measure Specification Guidelines Confidential: For Quality Improvement Purposes Only

3. Evidence National guidelines strongly recommend ACEI for patients hospitalized with AMI who have either clinical heart failure or LVSD. Guideline committees have also supported the inclusion of ARBs in performance measures for AMI. Despite these recommendations, ACEIs remain under-utilized in eligible older patients hospitalized with AMI. ACC/AHA Guidelines for the management of patients with STEMI 2004, ACC/AHA Guidelines for the management of patients with UA and NSTEMI 2002. Confidential: For Quality Improvement Purposes Only

4. Opportunity for Improvement Loyola was achieving 100% compliance in most Acute Myocardial Infarction (AMI) Core Measures. Loyola provided ACEI / ARB prescriptions on discharge less consistent than other hospitals (National and UHC). Confidential: For Quality Improvement Purposes Only

5. Solutions Implemented The Core Measures Committee meets monthly to review and reviews the percentage of patients receiving ACEI and/or ARB prescriptions at discharge. On daily basis, each patient’s Medication Administration Record (MAR) is reviewed by cardiac case manager for any changes in patients’ severity, medications and planned discharged date. Confidential: For Quality Improvement Purposes Only

6. Solutions Implemented Patient’s are checked for inpatient ACEI or ARB administration and/or possible contraindications to ACEI or ARB. If a discrepancy is noted, communicative action among the health care providers is taken to improve documentation within the medical record. On discharge each AMI patient’s chart and discharge summary is reviewed and assessed by a cardiac case manager to ensure that appropriate inclusion of an ACEI and/or ARB prescription, or that a contraindication to this medication therapy is documented. Confidential: For Quality Improvement Purposes Only

7. Solutions Implemented during discharge process Confidential: For Quality Improvement Purposes Only

8. Solutions Implemented during discharge process Confidential: For Quality Improvement Purposes Only

9. Percent Acute Myocardial Infarction Patients With Left Ventricular Systolic Dysfunction Receiving ACE Inhibitor or ARB Prescription at Discharge Month UCL = 140.1 Mean = 91.3 LCL = 42.5 Jan 2006 (n=6) Feb 2006 (n=2) Mar 2006 (n=5) May 2006 (n=1) Jun 2006 (n=3) Jul 2006 (n=3) Aug 2006 (n=6) Sep 2006 (n=5) Oct 2006 (n=4) Nov 2006 (n=4) Dec 2006 (n=3) Jan 2007 (n=3) Feb 2007 (n=2) Mar 2007 (n=6) Apr 2007 (n=1) May 2007 (n=2) Jun 2007 (n=2) Aug 2007 (n=1) Sep 2007 (n=1) Oct 2007 (n=1) Nov 2007 (n=2) Dec 2007 (n=4) Feb 2008 (n=2) 0 20 40 60 80 100 120 140 160 180 Confidential: For Quality Improvement Purposes Only

10. Outcomes Significant Improvement! Since December 2006, the observed percentage of ACEI / ARB prescription at discharge at Loyola has been at 100% which is above the national average rate –This improvement appears to be due to improved communication, team work among health care providers and detail processes to ensure that cases are appropriately re-reviewed for medication administration on daily basis and included in this measure. Confidential: For Quality Improvement Purposes Only

11. Next Steps Continue performing case level review of AMI cases at monthly Core Measures Committee meeting. Assess need for other interventions with other AMI Core Measures Confidential: For Quality Improvement Purposes Only