Acute Myocardial Infarction February 8, 2006

Factors Leading to Increased Adverse Events  Health-care organizations are high-risk environments  Dramatic advances in the diagnosis and treatment of disease  Advancement in technology and bio technology  Care processes have become much more complex  Aging population  Shortage of qualified physicians, nurses and other professionals  System restructuring  Culture

SHN! Opportunities  Communication of concerns and their investigative outcomes  Learning from the data  Avoidance of repeat errors  Greater openness and disclosure

Safer Healthcare Now!  SHN! is about small tests of change and spread of the Quality Improvement (Q.I.) to other patients and teams

Goal Prevent deaths among patients hospitalized for acute myocardial infarction (AMI) by ensuring reliable delivery of evidence based care. Prevent deaths among patients hospitalized for acute myocardial infarction (AMI) by ensuring reliable delivery of evidence based care.

Components of Reliable Evidence Based Care - AMI Early administration of Aspirin Early administration of Aspirin ASA on discharge ASA on discharge Beta Blockers on discharge Beta Blockers on discharge ACE/ARB on discharge ACE/ARB on discharge Timely initiation of reperfusion (Thrombolysis or percutaneous intervention) Timely initiation of reperfusion (Thrombolysis or percutaneous intervention) Smoking cessation counselling/nicotine replacement /serotonin uptake inhibitor/referral to cardiac rehab Smoking cessation counselling/nicotine replacement /serotonin uptake inhibitor/referral to cardiac rehab Assessment of Perfect Care Assessment of Perfect Care

Retrospective Baseline Results 1.0 ASA at Arrival 1.0 ASA at Arrival Retrospective Denominator 95 Retrospective Denominator 95 Exclusions4 Exclusions4 Sample91 Sample91 Calculation of Numerator Calculation of Numerator ASA 24 hrs prior to arrival40 ASA 24 hrs prior to arrival40 ASA within 24 hours51 ASA within 24 hours51 Final Calculation100% (Goal 90%)

Retrospective Baseline Results 2.0 ASA at Discharge 2.0 ASA at Discharge Retrospective Denominator 95 Retrospective Denominator 95 Exclusions4 Exclusions4 Sample91 Sample91 Calculation of Numerator Calculation of Numerator ASA at discharge91 ASA at discharge91 Final Calculation100% (Goal 90%)

Retrospective Baseline Results 3.0 Beta Blocker at Discharge 3.0 Beta Blocker at Discharge Retrospective Denominator 95 Retrospective Denominator 95 Exclusions9 (Low HR or BP, COPD) Exclusions9 (Low HR or BP, COPD) Sample86 Sample86 Calculation of Numerator Calculation of Numerator Beta Blocker at discharge84 Beta Blocker at discharge84 Final Calculation97.6% (Goal 90%) Improvement OpportunityDocumentation

Retrospective Baseline Results 4.0-A Thrombolytic Agent within 30 minutes 4.0-A Thrombolytic Agent within 30 minutes Retrospective Denominator 95 Retrospective Denominator 95 Pt’s without ST ↑ or LBBB42 Pt’s without ST ↑ or LBBB42 Pt’s who did not receive Thrombolytics24 Pt’s who did not receive Thrombolytics24 Sample29 Sample29 Calculation of Numerator Calculation of Numerator Pt’s who received Thrombolysis 21 within 3o minutes Pt’s who received Thrombolysis 21 within 3o minutes Final Calculation72.4% (Goal 85%) 8 pt’s received lytics greater than 30min (Range of 35 to 48 min with a door to Lytics average of 39 minutes) Improvement Opportunity: Explore why this occurred & initiate PDSA strategies

Retrospective Baseline Results 4.0- B PCI within 90 minutes 4.0- B PCI within 90 minutes Retrospective Denominator 95 Retrospective Denominator 95 Pt’s without ST ↑ or LBBB42 Pt’s without ST ↑ or LBBB42 Pt’s who did not receive PCI31 Pt’s who did not receive PCI31 Pt’s with PCI more than 24 hours after arrival 4 Pt’s with PCI more than 24 hours after arrival 4 Sample18 Sample18 Calculation of Numerator Calculation of Numerator Pt’s who received PCI within 90 minutes 14 from arrival Pt’s who received PCI within 90 minutes 14 from arrival Final Calculation77.8 % (Goal 90%) 4 pt’s received PCI greater than 90min (Range of min with a door to PCI average of 117 min) Improvement Opportunity: Explore why this occurred & initiate PDSA strategies

Retrospective Baseline Results 5.0 ACE/ARB on Discharge 5.0 ACE/ARB on Discharge Retrospective Denominator 95 Retrospective Denominator 95 Exclusions3 (Renal dysfunction) Exclusions3 (Renal dysfunction) Sample92 Sample92 Calculation of Numerator Calculation of Numerator Prescribed ACE on discharge 80 from arrival Prescribed ACE on discharge 80 from arrival Final Calculation86.9 % (Goal 85%) Improvement Opportunity: Documentation LV systolic function not consistently LV systolic function not consistently recorded recorded

Retrospective Baseline Results 6.0 Adult Cigarette Smoking Cessation Advice 6.0 Adult Cigarette Smoking Cessation Advice Retrospective Denominator 95 Retrospective Denominator 95 Exclusions62 (No Hx of smoking within year) Exclusions62 (No Hx of smoking within year) Sample33 (35%) Sample33 (35%) Calculation of Numerator Calculation of Numerator Pt’s who received counselling 26 Pt’s who received counselling 26 Final Calculation78.7 % (Goal 100%) Improvement Opportunity: Cardiac rehab is only source of counselling. Look at other opportunities

Retrospective Baseline Results 7.0 Perfect Care 7.0 Perfect Care Retrospective Denominator 47 Retrospective Denominator 47 Calculation of Numerator Calculation of Numerator Pt’s who received all 6 elements 35 or had documented contraindications Pt’s who received all 6 elements 35 or had documented contraindications Final Calculation74.5% (Goal 95%) Element Breakdown: 4/4 = 3 5/5 = 18 6/6 = 14

Retrospective Baseline Results 8.0 AMI Inpatient Mortality (July 2005) 8.0 AMI Inpatient Mortality (July 2005) Retrospective Denominator 19 Retrospective Denominator 19 Transferred in 1 Transferred in 1 Died in ER 0 Died in ER 0 Sample18 Sample18 Calculation of Numerator Calculation of Numerator Died during hospital stay 1 Died during hospital stay 1 Final Calculation5.5%

Retrospective Baseline Results Other Data Collected Cardiac Rehab Referrals 60% (n= 95) LDL ≤ 2.5on D/C44.4% (n=81) TC/HDL ≤ 4 on D/C45.6% (n= 81) Cholesterol Med on D/C86.5% (n=82)

Opportunities for Improvement Documentation improvements Documentation improvements If Beta Blockers, ASA and ACE/ARB not prescribed why not? If Beta Blockers, ASA and ACE/ARB not prescribed why not? Record LV systolic function consistently Record LV systolic function consistently ~50% of pt’s who present with ICD codings for MI have ST elevation MI’s Door to Lytic & PCI time Door to Lytic & PCI time Smoking Cessation Counselling Opportunities Smoking Cessation Counselling Opportunities Ask, Advise & Assist Program Ask, Advise & Assist Program Pharmaceutical aids on formulary Pharmaceutical aids on formulary Initiate Ottawa Heart Institute Program opportunities Initiate Ottawa Heart Institute Program opportunities

More Data From STEMI Charts 36 charts reviewed 36 charts reviewed 14 arrived by ambulance (39%) 14 arrived by ambulance (39%) 5/14 (36%) > 30 min door to lytic time with average of 10 minutes to first ECG 5/14 (36%) > 30 min door to lytic time with average of 10 minutes to first ECG 7/14 (50%) door to lytics < 30 min 7/14 (50%) door to lytics < 30 min 2/14 (14%) to cath lab < 90min 2/14 (14%) to cath lab < 90min Average of 57 minutes from pick-up to lytics (n=4) Average of 57 minutes from pick-up to lytics (n=4) Of those 4 only one was off door to lytic time (39min) Of those 4 only one was off door to lytic time (39min)

More Data From STEMI Charts 22 Walk – in patients (61%) 22 Walk – in patients (61%) 16/22 (73%) had lytics < 30min 16/22 (73%) had lytics < 30min 2/22 (9%) > 30 min door to lytic time with average of 10 minutes to first ECG 2/22 (9%) > 30 min door to lytic time with average of 10 minutes to first ECG 9% had PTCA < 90 min 9% had PTCA < 90 min 9% had PTCA > 90 min with door to ECG time at 19 min. 9% had PTCA > 90 min with door to ECG time at 19 min.

Notables Those who arrive by ambulance have better door to PCI time but not better lytics time (opportunity exists to have ECG’s done in Ambulance) Those who arrive by ambulance have better door to PCI time but not better lytics time (opportunity exists to have ECG’s done in Ambulance) Time of day not a factor for combined lytics & PCI therapies Time of day not a factor for combined lytics & PCI therapies 12/20 (60%) ECG’s not signed or numbered 12/20 (60%) ECG’s not signed or numbered Documentation discrepancies exist between exact times of ECG’s, physician notification and treatment Documentation discrepancies exist between exact times of ECG’s, physician notification and treatment

Goals Determine our Specific Intervention Goals Determine our Specific Intervention Goals 1. 90% of AMI patients will have the AMI bundle implemented within one year. 2. Special project datasets will be implemented in Discharge Abstract Database within 2 months. 3. A collaborative relationship with other NB hospitals involved in the AMI SHN bundle will occur immediately. Develop Strategies to attain the goals Develop Strategies to attain the goals

OUTCOMES Improve Door to Lytic Time Improve Door to Lytic Time Improve Door to PCI Time Improve Door to PCI Time Improve Smoking Cessation Counselling Improve Smoking Cessation Counselling Improve documentation for all elements i.e. “If not why Not” Improve documentation for all elements i.e. “If not why Not” Incorporate OHI discharge ‘GAP’ tool Incorporate OHI discharge ‘GAP’ tool Incorporate LTG form Incorporate LTG form

Next Steps Engage Plan-Do-Study-Act (PDSA) Cycle Engage Plan-Do-Study-Act (PDSA) Cycle Team 1: Develop form for Lytics and PCI engaging ER and Cath Lab in process Team 1: Develop form for Lytics and PCI engaging ER and Cath Lab in process Team 2: Develop form that combines patient teaching strategies with performance related to ASA, ACE/ARB, Beta Blockers, Lipids, Smoking which will ultimately replace two current forms being used. Team 2: Develop form that combines patient teaching strategies with performance related to ASA, ACE/ARB, Beta Blockers, Lipids, Smoking which will ultimately replace two current forms being used.

An Integrated Approach to Patient Safety Measurement and Evaluation Legal/Regulatory System Changes to Create a Culture of Safety Information and Communication Education and Professional Development