1. ACUTE MYOCARDIAL INFARCTION Team Membership Clinical Departments: Cardiology, Cardiovascular Surgery, Emergency Medical Services Hospital Departments: 3 NEWS, Cardiac Cath Lab, Cardiac Rehab, Emergency Department, Medical Records, Quality and Resource Management, Center for Clinical Effectiveness

2. Opportunity for Improvement LUHS began reporting Acute Myocardial Infarction (AMI) core measures beginning in July, 2002 AMI core measures are based on AHA/ACC Coronary Heart Disease guidelines Full FY 05 Medicare reimbursement requires reporting of AMI and other quality measures to CMS Data is reported on the JCAHO, CMS, and Loyola Health System websites. LUHS performs well on all measures, but our goal is to achieve excellent performance on all measures

3. Complicated and emergent care is required for most AMI patients Care involves many different units and teams Clinicians lack tools (forms, reminders, order sets) needed to follow guidelines Hospitals have previously not addressed prevention like smoking cessation Causes for the Improvement Opportunity

4. Measures of Focus in 2004 –PCI within 120 minutes for ST elevation AMI patients –ACE-Inhibitor, or ARB, prescribed at discharge in patients with left ventricular systolic dysfunction (LVSD) –Adult smoking cessation advice to all patients who have smoked within the last 12 months Measures with LUHS performance of 97 – 98% –Aspirin within 24 hours before or after arrival –Aspirin prescribed at discharge –Beta blocker within 24 hours after arrival –Beta blocker prescribed at discharge Focus of Interventions

5. Solutions Implemented 2002-2003 Actions –AMI National Hospital Quality Measures (NHQM) committee formed –AMI Discharge Progress Note Addendum implemented –Educated attending physicians, residents, and nursing staff –Hospital-wide smoking cessation program implemented 2004 Actions –Pre-printed unstable angina/non-ST elevation MI orders implemented –Process analysis of ST elevation AMI presentation by AMI NHQM sub-committee –Patient Education Record revised to include documentation of smoking cessation advice –Discharge progress note revised to accept ACE inhibitor or angiotensin receptor blockers for LVSD

6. Definition: AMI patients with time to PCI under 120 minutes in patients with ST segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time. Patients transferred from another hospital are excluded. Patients with PCI time greater than 24 hours are excluded. Data source: LUMC medical records abstracted by RNs. Performance improved with 63% of AMI patients with ST elevation, or LBBB now receiving PCI within 120 minutes

7. Definition: AMI patients who are prescribed an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at hospital discharge / AMI patients with LVSD and without ACEI contraindications. LVSD is defined as chart documentation of a left ventricular ejection fraction less than 40% or a narrative description of left ventricular function consistent with moderate or severe systolic dysfunction. Prior to 2005, ARBs were not recognized in this measure. Data source: Original data extracted from LUMC charts by RNs. Percent National Hospital Quality Measures Acute Myocardial Infarction Patients With Left Ventricular Systolic Dysfunction Receiving ACE Inhibitor or ARB Prescription at Discharge * Preliminary data for quality improvement purposes only Month Jul-02 (n=4) Aug-02 (n=5)Sep-02 (n=3) Oct-02 (n=10) Nov-02 (n=12) Dec-02 (n=4) Jan-03 (n=10) Feb-03 (n=9) Mar-03 (n=7) Apr-03 (n=2) May-03 (n=10) Jun-03 (n=7) Jul-03 (n=8) Aug-03 (n=4) Sep-03 (n=4) Oct-03 (n=8) Nov-03 (n=9)Dec-03 (n=5) Jan-04 (n=6) Feb-04 (n=6) Mar-04 (n=8) Apr-04 (n=6) May-04 (n=7) Jun-04 (n=12) Jul-04 (n=5) Aug-04 (n=2) Sep-04 (n=8) *Oct-04 (n=7) *Nov-04 (n=6)*Dec-04 (n=7) *Jan-05 (n=3) *Feb-05 (n=3) 40 60 80 100 120 140 UCL = 125.19 Mean = 90.34 LCL = 55.49 Ninety percent of AMI patients with LVSD receive ACE-inhibitor at discharge

8. Definition: Smokers receiving smoking cessation counseling / AMI Patients who have smoked cigarettes at any time in the 12 months prior to hospital arrival. Data source: Original data extracted from LUMC charts by RNs. Smoking cessation counseling improved with 90% of patients with AMI now receiving counseling before discharge

9. Next Steps Develop and implement ST elevation MI pre-printed order set Expand comprehensive system-wide smoking cessation program Provide performance reports and charts to departments that are critical for specific measures Develop and implement AMI care pathway, discharge protocol form and patient education materials