1. Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative
Feedback
A quality improvement initiative in collaboration with:
NPS: Better choices, Better health

2. Hospital DMACS contacts
Insert hospital
logo here
Local coordinator
Insert name here
Local DMACS team
Insert names here

3. Overview Aims and methods
Best practice in discharge management of patients with Acute Coronary Syndromes (ACS)
Feedback on audit of current practice
Discussion
Education and ongoing monitoring

4. Aims To improve management of ACS at discharge by targeting:
Prescription of guideline-recommended* cardiovascular medicines following an ACS event (antiplatelets, ACE-inhibitor, beta blocker, statin, short-acting nitrate)
Provision of education on lifestyle modifications following an ACS event (incl. smoking cessation, cardiac rehab)
Communication to patient/carer & general practitioner (GP) regarding ACS management post-discharge
*NHF & CSANZ ACS Guidelines working group. National Heart Foundation ACS Guidelines.
Med J Aust 2006:184(Supp):S1-32

5. Methods Quality improvement initiative steps 1. Gain support
2. Collect data (insert month/year here)
Data entered into NPS* DMACS e-DUE audit tool
‘x’ patients (inpatient data)
Patient post-discharge telephone survey (delete if not applicable)
3.Evaluate data (insert month/year here)
Reports generated
4. Feedback data (insert month/year here)
5. Action - Intervention/education
NPS an independent organisation promoting quality use of medicines,
funded by the Commonwealth

6. Best practice for discharge management of patients with ACS*
Initiate long-term management plan for ACS patients
Consider guideline-recommended medicines for all ACS patients
Identify risk factors and refer all ACS patients to secondary prevention programs
Communicate management plan to the patient, carers & the community healthcare providers
*Based on the National Heart Foundation of Australia, Cardiac Society of Australia
and New Zealand Guidelines for the management of acute coronary syndromes 2006,
and Therapeutic Guidelines: Cardiology, Version 5, 2008. 6

7. Inpatient medical record review

8. Demographics and risk factors
Audit 1
(n =)
Audit 2
Median age (years)
Male
Documented cardiac risk factors at admission:
Previous ACS event
Diabetes
Current smokers

9. Discharge diagnosis Audit 1 Audit 2 STEMI* Non-STEMI† Unstable Angina
Unspecified ACS
You may wish to comment of the distribution of ACS diagnoses is different from baseline to follow-up
*STEMI = ST-segment-elevation myocardial Infarction,
†Non-STEMI=non-ST-segment-elevation myocardial infarction

10. Best practice: Consider guideline-recommended
Best practice: Consider guideline-recommended* medicines for all ACS patients
The combination of antiplatelet agents, a beta blocker, a statin and an angiotensin-converting enzyme inhibitor are recommended for most patients.
All 4 drug classes have been proven to reduce subsequent cardiac events and death.
If therapy is not indicated for an individual, document the reason(s) why in the patient’s medical record and management plan.
*NHF & CSANZ ACS Guidelines working group. National Heart Foundation ACS Guidelines.
Med J Aust 2006:184(Supp):S1-32 and Addendum. Heart, Lung and Circulation 2011: Vol 20, 1-16

11. ACS discharge medicines
(adjusted for contraindication, lack of indication & patient refusal)
Audit 1
(n =)
Audit 2
Antiplatelet agents (aspirin and/or clopidogrel/prasugrel/ticagrelor)
Angiotensin blockade
(ACE inhibitor and/or angiotensin ll-receptor antagonist)
Beta blocker
Statin
Short-acting nitrate
Guideline-recommended ACS medicines prescribed at discharge (4 classes)*
*Combination of aspirin and/or clopidogrel/prasugrel/ticagrelor, ACE inhibitor and/or Angiotensin II-receptor antagonist, beta blocker and statin

12. Patients prescribed ACS medicines by discharge diagnosis
(adjusted for contraindication, lack of indication & patient refusal)
STEMI
Non-STEMI
Unstable Angina
Unspecified ACS
Audit 1
Audit 2
Antiplatelet agents (aspirin and/or clopidogrel/ prasugrel/ticagrelor)
Angiotensin blockade
(ACE inhibitor and/or angiotensin II-receptor antagonist)
Beta blocker
Statin
All guideline-recommended ACS medicines

13. Best practice: Identify risk factors
Provide patients with a self-management plan before discharge
Plan should include advice on lifestyle changes such as good nutrition, moderating alcohol intake, regular physical activity and weight management as appropriate.
Patients should be provided with adequate counselling regarding medicines to enable self-management.
Provide smoking-cessation advice and support to all patients who smoke
There is a rapid reduction in the risk of coronary heart disease within one year of quitting smoking.
For patients who would like assistance to quit smoking a combination of pharmacotherapy and support programs are appropriate.
Therapeutic Guidelines: Cardiovascular, Version

14. Patient education - documentation
Audit 1
(n =)
Audit 2
Discharge medicines counselling
Current smokers
Smoking cessation counselling provided to current smokers

15. Best practice: Refer all patients with ACS to secondary prevention programs
Actively refer to, and encourage attendance at secondary prevention and cardiac rehabilitation programs.
Cardiac rehabilitation is a proven effective intervention
Attendance at cardiac rehabilitation outpatient programs reduces risk for further cardiac events
Patients participating in cardiac rehabilitation can achieve improvements in:
Physical activity, weight loss, smoking cessation, blood lipid levels and blood pressure control
NHF and CSANZ ACS Guidelines working group. Med J Aust 2006:184(Supp):S1-32
NHF and CSANZ. Reducing risk in heart disease, Taylor RS, et al. Am J Med 2004;116:
Vale MJ, et al. Arch Intern Med 2003;163: NHF , Australian Cardiac Rehabilitation association.
Recommended framework for cardiac rehabilitation, 2004.

16. Patient referral to cardiac rehabilitation
Audit 1
(n =)
Audit 2
Referral to cardiac rehab (total)
Referral by discharge diagnosis: 
STEMI
Non-STEMI
Unstable Angina
Unspecified ACS
Referral to cardiac rehab (total) = number of patients referred to cardiac rehab
total number of patients in audit
Referral by discharge diagnosis = number of patients referred to cardiac rehab with a particular diagnosis (eg STEMI)
number of patients with a particular diagnosis (eg STEMI)

17. Best practice: Communicate management plan to the patient, carers and community healthcare providers
Communicate the long-term management plan, including treatment goals, to the community healthcare providers
Adherence to long-term therapy improves patient survival
Discontinuation of medicines after MI is common and occurs soon after discharge
Ho PM, et al. Arch Intern Med 2006;166:1842-7

18. Documented ACS management plan
Audit 1
(n =)
Audit 2
Documented ACS management plan:
% of plans that included:
a list of current medicines
a chest pain action plan
risk factor modification
all of the above

19. Best practice: Provide a discharge letter/summary
Include:
Complete list of all medicines
Any changes to pre-admission medicines
Plan for any dose titration
Recommendations for monitoring
Treatment goals
Recommendation for attendance at cardiac rehabilitation
Advice regarding lifestyle modifications

20. Documented ACS management plan communicated to GP
Audit 1
(n =)
Audit 2
ACS management plans communicated to GP:
% of GPs where a plan was communicated that included:
a list of current medicines
a chest pain action plan
risk factor modification
all of the above

21. Documented ACS management plan communicated to patient
Audit 1
(n =)
Audit 2
ACS management plans communicated to patient
% of patients where a plan was communicated that included:
a list of current medicines
a chest pain action plan
risk factor modification
all of the above

22. Communication of documented ACS plans
Audit 1
(n =)
Audit 2
 ACS management plans communicated to:
General practitioner
patient
both GP and patient
neither GP and patient

23. Patient telephone survey at ‘x’ days post-discharge

24. Survey response rates
Audit 1
(n =)
Audit 2
Survey Participation (%)

25. Patient report usage of ACS medicines at time of survey
(% of patients completing telephone survey)
Audit 1
(n =)
Audit 2
Antiplatelet agents*
Angiotensin blockade
(ACE inhibitor and/or angiotensin ll-receptor antagonist)
Beta blocker
Statin
Short-acting nitrate
Guideline-recommended ACS medicines available at time of survey (4 classes)†
*Includes aspirin and/or clopidogrel / prasugrel / ticagrelor plus those on warfarin
†combination of aspirin and/or clopidogrel / prasugrel / ticagrelor, ACE inhibitor and / or angiotensin II-receptor antagonist, beta blocker & statin

26. Patient report of adherence
Audit 1
(n =)
Audit 2
All of the time
Most of the time
Some of the time
None of the time

27. Cardiac rehabilitation
Audit 1
(n =)
Audit 2
Inpatient documentation of referral
Patient-reported advice to attend
Of those who were advised:
Patients reporting completion
Patients reporting still attending or scheduled to attend
Patients who did not attend or complete :

28. Patient reported reasons for non-attendance at follow-up
(% of patients who did not attend/complete cardiac rehab)
You may wish to create a graph like the one opposite or insert a table

29. Patients’ report on type of cardiac rehabilitation / education sessions attended
Audit 1
(n =)
Audit 2
Group, outpatient at hospital (centre-based program)
One-on-one with a nurse at the hospital (centre-based program)
Private cardiac rehabilitation clinic
(centre-based program not attached to hospital)
One-on-one telephone follow-up
(home-based program supported by telephone)
Other

30. Preferred times for cardiac rehabilitation / education sessions
Reported by those patients who were unable to attend due to time / work commitments or session availability
Audit 1
(n =)
Audit 2
Weekday morning
Weekday afternoon
Weekday evening
Weekend

31. Patient’s report on smoking status
Audit 1
(n =)
Audit 2
Patients who reported being smokers at the time of admission*
Patients who smoked at admission who continued to smoke at time of survey
Patients who were smokers at the time of survey who are using a program to help quit smoking
*As a percentage of patients who answered this question.

32. Discussion: Areas where we did well
Customise this slide for your hospital by adding bullet points on areas where your hospital is doing well
An example could be the % of patients with all guideline-recommended medicines prescribed at discharge

33. Discussion: Areas we can build upon
Customise this slide for your hospital by adding bullet points on areas that your hospital project team has identified as an area of interest/focus of education
An example could be: current level of communication at discharge

34. Action: the next step
Strategies to raise awareness of best practice in discharge
management of patients with ACS
Customise this slide for your hospital by adding bullet points on how you will implement
some change.
Examples of educational resources include:
Bookmark reminder
Discharge ACS management plan reminder
Discharge templates/checklists
Group education sessions on current practice and comparison to ‘best practice’
Educational visits (academic detailing using the DMACS information summary card)

35. After the educational intervention
Collect data on ‘x’ ACS cases (similar to Audit 1):
Evaluate post-intervention (Audit 2) data
Feedback data and compare with baseline and ‘best practice’
Highlights of achievements in the post-intervention presentation

36. Acknowledgements
Congratulations and thanks to the team involved in this DUE:
Insert name
NPS together with QLD, VIC, NSW, TAS & SA state DUE groups and state DMACS project committees

37. Questions?
Contact your DMACS coordinator for further information if required
Hospital contact person (insert name)
Ph: (insert contact number)
(insert address)
THANK YOU 37