1. 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

2. 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

3. 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

4. 1.Improve the care, quality of life and survival of Maine patients with AMI 2.Patients will receive the right care at the right time 3.Establish a system of care to be used by all providers 4.Continually monitor sufficient indicators of process and quality to maximize the quality of the process. Mission In a Heartbeat

5. Process Data and Metrics committee formed to develop indicators across the spectrum of care Data and Metrics committee formed to develop indicators across the spectrum of care Treatment guideline subcommittee formed to establish a common treatment guideline Treatment guideline subcommittee formed to establish a common treatment guideline

6. 1.Common treatment guideline report 2.Data and Metrics Framework 3.EMS data processes 4.ED data and process improvement 5.Post-discharge data Treatment Guideline & Data and Metrics

7. 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

8. Subcommittee 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. 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:

9. STEMI CLINICAL PATHWAY 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 YESYES NONO HIGHHIGH LOWLOW 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. **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.

10. *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

12. Clinical Equipose Curve PCI Time Delay and Outcome Nallamothu, BK AJC 2003

13. Clinical Equipose Curve PCI Time Delay and Outcome Nallamothu, BK AJC 2003

14. Clinical Equipose Curve PCI Time Delay and Outcome Nallamothu, BK AJC 2003

15. STEMI CLINICAL PATHWAY 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 YESYES NONO HIGHHIGH LOWLOW 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. **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.

16. *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

17. 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

18. 1.Improve the care, quality of life and survival of Maine patients with AMI 2.Patients will receive the right care at the right time 3.Establish a system of care to be used by all providers 4.Continually monitor sufficient indicators of process and quality to maximize the quality of the process. Mission In a Heartbeat

19. 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

20. Data collection and analysis will: tell us what percent of these patients are not receiving tell us what percent of these patients are not receiving reperfusion therapy and why reperfusion therapy and why show where the delay in treatment lies show where the delay in treatment lies give feedback on performance throughout the give feedback on performance throughout the system of care system of care give the tools for process improvement of care. give the tools for process improvement of care.

21. WHO ECG with ST segment elevation (STEMI) ECG with ST segment elevation (STEMI)or Left bundle branch block (LBBB) and Cardiac Symptoms ( same cohort JACHO/CMS core metrics) ( same cohort as JACHO/CMS core metrics) Patient Cohort for data measures Data and Metrics

22. Patient Eligibility Criteria: STEMI STE/ LBBB ST segment elevation with >1mm/.10mV in two orST segment elevation with >1mm/.10mV in two or more leads. Documentation of ST- segment elevation or left bundleDocumentation 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.Using the 12-lead ECG performed closest to the time of hospital arrival. ECGs done more than one hour prior to hospitalECGs done more than one hour prior to hospital arrival should be repeated. Patient Inclusion Data and Metrics

23. 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

24. Metrics in the Process Process Elements PCI Center EMS Transport Emergency Department Retrospective Discharge Data Demographics WHAT Data and Metrics

25. EMS Data and Metrics Jay Bradshaw Data and Metrics

26. Metrics in the Process Process Elements PCI Center EMS Transport Emergency Department Retrospective Discharge Data Demographics WHAT Data and Metrics

27. ED Data and Metrics Rebecca Chagrasulis, MD Data and Metrics

28. Metrics in the Process Process Elements PCI Center EMS Transport Emergency Department Retrospective Discharge Data Demographics WHAT Data and Metrics

29. 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

30. Documentation 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

31. Metrics in the Process Process Elements PCI Center EMS Transport Emergency Department Retrospective Discharge Data Demographics WHAT Data and Metrics

32. 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 :

33. 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

34. Defining the Elements Limited data points Limited data points Current Data Collection processes Current Data Collection processes e.g. Maine EMS InterfacilityTransport Program e.g. Maine EMS InterfacilityTransport Program JACHO/CMS Core Measures - Same Metrics and Definitions JACHO/CMS Core Measures - Same Metrics and Definitions ACC/AHA Guidelines and definitions ACC/AHA Guidelines and definitions Consensus of State represented committee Consensus of State represented committee Process data / during point of care – incorporated Process data / during point of care – incorporated into current documentation into current documentation Data and Metrics

35. 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 Core metrics same as JACHO/CMS extraction Process improvement metrics Process improvement metrics Data Collection Data and MetricsHOW

36. 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

37. 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

38. 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

39. Data Reporting Maine Quality Forum Critical Analysis APPROPRIATE CARE METRIC # of STEMI patients receiving reperfusion therapy Total # of STEMI patients-#with contraindications 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

40. 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