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

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

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

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

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

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

Inpatient medical record review

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

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

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 2011 Addendum. Heart, Lung and Circulation 2011: Vol 20, 1-16

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

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

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 5. 2008.

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

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, 2007. Taylor RS, et al. Am J Med 2004;116:882-92. Vale MJ, et al. Arch Intern Med 2003;163:2775-83. NHF , Australian Cardiac Rehabilitation association. Recommended framework for cardiac rehabilitation, 2004.

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)

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

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

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

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

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

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

Patient telephone survey at ‘x’ days post-discharge

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

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

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

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 :

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

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

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

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.

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

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

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)

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

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

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