6/04 CRUSADE: A National Quality Improvement Initiative C an R apid Risk Stratification of U nstable Angina Patients S uppress AD verse Outcomes with E arly Implementation of the ACC/AHA Guidelines

6/04 CRUSADE Description CRUSADE is a Quality Improvement Initiative designed to improve the care of high-risk patients with NSTE ACS –by collecting data regarding patient management practice patterns in the U.S. and –using those data to target educational interventions designed to promote adherence to the revised ACC/AHA NSTE ACS guidelines recommendations.

6/04 CRUSADE Objectives n Determine the current state of awareness of and adherence to the ACC/AHA Non-ST-segment Elevation Acute Coronary Syndromes (NSTE ACS) Guidelines. n Implement quality improvement initiatives to promote ACC/AHA NSTE ACS Guidelines recommendations. n Improve clinical outcomes for NSTE ACS patients via early risk stratification and implementation of evidence-based care, both in-hospital and post-discharge.

6/04 ACC/AHA Treatment Recommendations n Aspirin l Clopidogrel/ticlopidine, if contraindicated n Beta blocker l Ca 2+ blocker, if contraindicated n ACE inhibitor (HTN, CHF) n Heparin (UFH or LMWH) n GP IIb-IIIa inhibitor l All high-risk patients l All receiving PCI l Those with recurring ischemia n Aspirin n Clopidogrel n Beta blocker n ACE inhibitor n Lipid-lowering agent n Cardiac rehabilitation n Smoking cessation n Dietary modification Acute Therapy Discharge Therapy

6/04 CRUSADE Design n Nationwide Quality Improvement (QI) initiative l Up to 600 participating hospitals n Collaborative effort between Emergency Medicine, Cardiology, Hospital QI, Academia, and Industry n Focused on improving the care of NSTE ACS patients

6/04 Inclusion Criteria: High-Risk NSTE ACS n Ischemic symptoms lasting  10 minutes within previous 24 hours and at least one of the following: l Positive cardiac markers CK-MB or TnI / TnT above ULN CK-MB or TnI / TnT above ULN Positive bedside troponin assay Positive bedside troponin assay l ST-segment ECG changes: ST-segment depression  0.5 mm ST-segment depression  0.5 mm Transient ST-segment elevation mm (lasting < 10 mins) Transient ST-segment elevation mm (lasting < 10 mins) n Transfer patients (with any of the above) must arrive at CRUSADE hospital within 24 hrs of symptoms

6/04 Data Collection n Web-based Data Collection Form (DCF) l Retrospective data collection l Sites enter data via secure Internet website n Data collected includes: l Patient risk factors/presenting symptoms l Use of medications/use of invasive procedures l In-hospital clinical outcomes n Institutional Review Boards: l May be viewed by hospital as QI l May not require IRB review and/or approval l May not require informed consent l Local hospital decision

6/04 Quality Improvement Initiative: Measuring Change n Effectiveness of QI initiatives measured by changes in adherence to ACC/AHA treatment Guidelines l Early / discharge antiplatelet use (ASA, clopidogrel) l Early / discharge beta blocker use l Early heparin use l Discharge ACE inhibitor and statin use l GP IIb-IIIa inhibitors: early use and use during PCI l Appropriate secondary prevention measures Smoking cessation Smoking cessation Cardiac rehabilitation Cardiac rehabilitation Dietary modification Dietary modification

6/04 Quality Improvement Initiatives: Data Reporting to Sites n Quarterly feedback reports to sites regarding their adherence to ACC/AHA Guidelines l Focused on the ACC/AHA Guidelines treatment & management recommendations l Site confidentiality maintained – data supplied back to sites in a blinded fashion l Provides sites with benchmark performance data

6/04 Sample Quarterly Report: Trend Graphs

6/04 Sample Quarterly Report: Descriptive Tables

6/04 Benefits of Participation n Quality improvement performance feedback l Reports documenting utilization of evidence- based management strategies and therapies l Performance ranking among “like”, national, and “best practice” hospitals l Insight into hospital care and areas for improvement l May be applied to hospital QI monitoring efforts/requirements

6/04 Benefits of Participation n Quality improvement tools to help improve outcomes for high-risk NSTE ACS patients. l Initiatives to help increase understanding of the ACC/AHA Guidelines l Initiatives to improve risk stratification and diagnosis of NSTE ACS patients l Newsletters and website for continuing education

6/04 Promoting a New Paradigm of Evidence-Based Cardiovascular Care n The CRUSADE national quality improvement initiative will teach us much about: l Why current ACC/AHA Guidelines for ACS are not followed l What initiatives can improve adherence l How to promote Emergency Medicine - Cardiology collaboration l Whether improved early adherence to treatment guidelines leads to better acute outcomes

6/04 CRUSADE Implementation n Training of staff and physicians should be conducted by CRUSADE co-advocates and DCRI team prior to the start of CRUSADE n Participating hospitals must complete, sign, and return a CRUSADE Participation Agreement and Data Use Agreement n Data collection personnel must obtain log-in access and training for the data entry website n Quarterly, the site will receive a Feedback Report detailing use of Guidelines- recommended therapies