2. Safer Healthcare Now! Acute Myocardial Infarction Presented by Amanda Thompson, Safer Healthcare Now Facilitator

3. Safer Healthcare Now! Background  Largest patient safety initiative in Canadian history  Adopted form IHI  Over 600 teams registered across Canada  Goal to improve health care delivery through 6 initiatives

4. Safer Healthcare Now! Initiatives  Acute Myocardial Infarction (AMI)  Ventilator Associated Pneumonia (VAP)  Central Line Associated Infection (CLI)  Prevention of adverse drug events through Medication Reconciliation (Med. Rec)  Prevention of Surgical Site Infection (SSI)  Rapid Response Teams (RRT)

5. AMI – Goal Decrease mortality rate for AMI by 20% by implementing all 6 elements NDBMH will have all 6 elements implemented by May 18 th 2007

6. Six Elements of AMI Timely initiation of thrombolytics Early administration of aspirin Smoking cessation counseling/nicotine replacement Aspirin at discharge ACE or ARB at discharge Beta Blocker at discharge

7. “Canadian Cardiologists & experts who were consulted when developing …this kit agree, that these six care components should be provided to all patients with an AMI. Unless a clear contraindication exists and is documented in the medical record.” Acute MI

8. Timely Initiation of Reperfusion with Thrombolytics  Defined as percent of AMI patients who received thormbolytics within 30 minutes of arrival  A goal of 85% of patients with ST elevation or new LBBB on ECG ST ElevationLBBB

9. Statistics on Thrombolytics TNKase ST elevation of 1mm or more, in two or more contiguous standard limb leads Or… Elevation of 2 mm or more, in two or more contiguous precordial leads New or presumed new LBBB

10. Thrombolytics within 30 Minutes Where we are now…

11. Early Administration of Aspirin Defined as percent of AMI patients who received ASA within 24 hours before or after hospital arrival. Prompt aspirin administration results in a 15% reduction in vascular events A study by the RAND corporation showed 61% of AMI patients received early administration of aspirin Goal is 90%

12. Early Administration of Aspirin cont’d Where we are now…

13. Smoking Cessation/Counseling/ Nicotine Replacement/Pharmacological Therapy Percent of AMI patients who received smoking cessation advice or counseling Any patient who has smoked in the past year Recommended: counseling combined with pharmacological therapy and cessation programs. Goal is 100%

14. Smoking Cessation/Counseling/ Nicotine Replacement/Pharmacological Therapy cont’d Where we are now…

15. Beta Blockers at Discharge Reduces AMI mortality in the first week by 13% and long-term mortality by 23% IHI 100K Lives Campaign has used early administration of Beta Blockers May be better to start Beta Blockers when patient is stable & then continue long term Studies show risk for cardiogenic shock increased by 11 per 1000 on days 0-1 post MI Goal 90%

16. Beta Blockers at Discharge cont’d Where we are…

17. Common Beta Blockers Timolol Betaxolol PropranololMetoprolol LabetalolAtenolol

18. Aspirin at Discharge One study showed that after 5 weeks, patients who had aspirin, had a decreased risk of vascular mortality (23%), non fatal reinfarction (49%) and non fatal stroke (46%). One study showed that after 5 weeks, patients who had aspirin, had a decreased risk of vascular mortality (23%), non fatal reinfarction (49%) and non fatal stroke (46%).

19. Aspirin at Discharge  Goal 90% Where we are….

20. ACE or Angiotension Receptor Blockers (ARB) at Discharge  ACE = proven to decrease mortality after an MI particularly in PTS with LV dysfunction, heart failure or both.  ARB = can improve heart failure, and is usually used when and ACE can not be tolerated.

21. Common ACE & ARB  Goal 85% ACE Inhibitors CaptoprilVasotecEnalaprilRamiprilMavikAccuprilZestrilARBCozaarAvaproDiovanTevetanAtacand

22. ACE or Angiotension Receptor Blockers (ARB) at Discharge cont’d Where we are….

23. “Perfect AMI Care”  Perfect AMI care = patient who receives all six elements within the time frame

24. Admission Standing Orders AMI Order Set AMI Diagnostic Criteria ST elevated MI: Y___ N___ New LBBB: Y ___ N ___ Thrombolysis with 30 minutes Time Administered ________ Contraindication _________ EKG Post TNK ________ 4 hrs Post TNK ________ Common LABS ___________ Early Measures Aspirin within 24 hours Dose _______ Route _______ Time _______

25. “How to Improve Care”  Discharge Medication Program Includes key AMI care components  Aspirin: Y___ N___ Reason not given ___  Beta Blocker: Y ___ N ___ Reason not given ___  ACE/ARB: Y ___ N ___ Reason not given ___ Smoking Counseling Provided Y ___ N ___ Not Applicable ___  If “Yes”, Zyban Prescribed Y ___ N ___ Reason not given___ Referral to Cardiac Rehab Program Y ____ N _____

26. “How to Improve Care” cont’d  This method has contributed to greater than 90% compliance with Aspirin and Beta Blocker guidelines  To be compliant, documentation must exist  Documentation of contraindication must exist  If documentation for any one area is missing patient is not considered as having perfect care

27. Statins at Discharge

28. Mortality Rate Where we are….

29. Education on AMI  Posters on AMI care  Education sessions  Increase public awareness  Change in policy and procedures

30. Questions?

31. Contact Information Amanda Thompson 709-292-2647 athompson@cwhc.nl.ca www.saferhealthcarenow.ca

32. Thank You!

33. Questions?