CRUSADE: A National Quality Improvement Initiative CRUSADE: A National Quality Improvement Initiative Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines

AHA/ACC Treatment Recommendations n Aspirin n Aspirin + Clopidogrel n Beta-Blockers n Heparin (UFH or LMWH) n GP IIb/IIIa Inhibitors l For high-risk patients l For early cath/PCI n Aspirin n Aspirin + Clopidogrel n Beta-Blockers n Heparin (UFH or LMWH) n GP IIb/IIIa Inhibitors l For high-risk patients l For early cath/PCI n Aspirin n Aspirin + Clopidogrel n Beta-Blockers n Statins n ACE-Inhibitors n Cardiac Rehab n Smoking Cessation Acute Therapies Discharge Therapies

CRUSADE Objectives n Determine current state of awareness of and adherence to the ACC/AHA Non-ST-Elevation (NSTE) ACS Guidelines n Implement quality improvement initiatives to promote ACC/AHA NSTE ACS recommendations n Improve clinical outcomes for NSTE ACS patients via early risk stratification and implementation of evidence-based care n Determine current state of awareness of and adherence to the ACC/AHA Non-ST-Elevation (NSTE) ACS Guidelines n Implement quality improvement initiatives to promote ACC/AHA NSTE ACS recommendations n Improve clinical outcomes for NSTE ACS patients via early risk stratification and implementation of evidence-based care

Inclusion Criteria: High-Risk NSTE ACS n Ischemic symptoms lasting  10 minutes < 24 hours and at least one of the following: n Positive cardiac markers l CK-MB or TnI / TnT above ULN l Positive bedside troponin assay n Dynamic ST-segment ECG changes: l ST-segment depression  0.5 mm l Transient ST-segment elevation of mm (lasting < 10 mins) n Transfer patients - must arrive at CRUSADE hospital within 24 hrs of symptoms n Ischemic symptoms lasting  10 minutes < 24 hours and at least one of the following: n Positive cardiac markers l CK-MB or TnI / TnT above ULN l Positive bedside troponin assay n Dynamic ST-segment ECG changes: l ST-segment depression  0.5 mm l Transient ST-segment elevation of mm (lasting < 10 mins) n Transfer patients - must arrive at CRUSADE hospital within 24 hrs of symptoms

Study Design n Nationwide quality improvement initiative l 400+ participating hospitals n Collaborative effort between Emergency Medicine, Cardiology, Hospital QI, Academia, and Industry l Optimize risk stratification for NSTE ACS patients l Promote adherence to ACC/AHA treatment guidelines for NSTE ACS l Implement quality improvement interventions n Nationwide quality improvement initiative l 400+ participating hospitals n Collaborative effort between Emergency Medicine, Cardiology, Hospital QI, Academia, and Industry l Optimize risk stratification for NSTE ACS patients l Promote adherence to ACC/AHA treatment guidelines for NSTE ACS l Implement quality improvement interventions

Data Collection n Concise, 3-page data collection form l Retrospective data collection l Payment of $20 per DCF returned n Data collected includes: l Pt risk factors/presenting symptoms l Use of medications/ Use of invasive procedures/In-hospital clinical outcomes n Institutional Review Boards: l Should not require informed consent l Should be viewed by local IRB as QI n Concise, 3-page data collection form l Retrospective data collection l Payment of $20 per DCF returned n Data collected includes: l Pt risk factors/presenting symptoms l Use of medications/ Use of invasive procedures/In-hospital clinical outcomes n Institutional Review Boards: l Should not require informed consent l Should be viewed by local IRB as QI

Quality Improvement Initiative: Primary Endpoints n Effectiveness of QI initiatives measured by changes in adherence to AHA/ACC treatment guidelines l Early / Discharge aspirin and clopidogrel use l Early / Discharge beta-blocker use l Discharge ACE-Inhibitor and statin use l GP IIb/IIIa Inhibitors: Early use and during PCI l Early invasive management - use of cath/PCI/CABG l Appropriate secondary prevention measures Smoking cessation Smoking cessation Cardiac rehabilitation Cardiac rehabilitation n Effectiveness of QI initiatives measured by changes in adherence to AHA/ACC treatment guidelines l Early / Discharge aspirin and clopidogrel use l Early / Discharge beta-blocker use l Discharge ACE-Inhibitor and statin use l GP IIb/IIIa Inhibitors: Early use and during PCI l Early invasive management - use of cath/PCI/CABG l Appropriate secondary prevention measures Smoking cessation Smoking cessation Cardiac rehabilitation Cardiac rehabilitation

Patient Identification Strategies Screening in the Emergency Department n Prospectively identify patients in the ED l Elevated cardiac markers, dynamic ECG changes l Rapid, bedside Troponin I assays in the ED n Review daily ED admission logs l Unstable angina, chest pain, R/O MI, or acute MI n Review admissions to chest pain units n Develop triggers for ED nursing staff to identify patients for CRUSADE n Work with research coordinators who are screening patients for ACS clinical trials n Prospectively identify patients in the ED l Elevated cardiac markers, dynamic ECG changes l Rapid, bedside Troponin I assays in the ED n Review daily ED admission logs l Unstable angina, chest pain, R/O MI, or acute MI n Review admissions to chest pain units n Develop triggers for ED nursing staff to identify patients for CRUSADE n Work with research coordinators who are screening patients for ACS clinical trials

Patient Identification Strategies Screening After Admission n Review daily CCU or telemetry floor admission logs l Unstable angina, chest pain, R/O MI, or acute MI n Review daily cath lab schedule l Unstable angina, acute MI n Develop triggers for CCU / telemetry floor nurses to identify patients for CRUSADE n Screen all patients with elevated cardiac marker levels from local laboratory records n Review daily CCU or telemetry floor admission logs l Unstable angina, chest pain, R/O MI, or acute MI n Review daily cath lab schedule l Unstable angina, acute MI n Develop triggers for CCU / telemetry floor nurses to identify patients for CRUSADE n Screen all patients with elevated cardiac marker levels from local laboratory records

Patient Identification Strategies Screening After Discharge n Review discharge diagnoses for chest pain l Unstable angina, chest pain, R/O MI, or acute MI l New ICD-9 codes for acute MI: + TnT/TnI n Review all patients with elevated cardiac marker levels from local laboratory records n Pull charts after identification of patients to fill out items on the data collection form n Review discharge diagnoses for chest pain l Unstable angina, chest pain, R/O MI, or acute MI l New ICD-9 codes for acute MI: + TnT/TnI n Review all patients with elevated cardiac marker levels from local laboratory records n Pull charts after identification of patients to fill out items on the data collection form

Quality Improvement Initiatives: n Regional educational meetings l ACC/AHA Guidelines recommendations l Review CRUSADE and QI Initiatives n Site Survey l Understand site beliefs and practice environment n Educational / QI materials l ED Risk Stratification Algorithm/ Sample orders l Guidelines Posters/pocket cards l Discharge MD and patient check lists n Quarterly Feedback Reports n Regional educational meetings l ACC/AHA Guidelines recommendations l Review CRUSADE and QI Initiatives n Site Survey l Understand site beliefs and practice environment n Educational / QI materials l ED Risk Stratification Algorithm/ Sample orders l Guidelines Posters/pocket cards l Discharge MD and patient check lists n Quarterly Feedback Reports

Quality Improvement Initiatives: Hospital Survey Component n Baseline understanding of and concurrence with AHA/ACC NSTE ACS treatment guidelines l Is it an education versus adherence issue? n Identify local features which may serve to promote quality improvement initiatives l Survey “structure and culture” of institution l Do institutional characteristics predict improved adherence to guidelines-based care? n Baseline understanding of and concurrence with AHA/ACC NSTE ACS treatment guidelines l Is it an education versus adherence issue? n Identify local features which may serve to promote quality improvement initiatives l Survey “structure and culture” of institution l Do institutional characteristics predict improved adherence to guidelines-based care?

Quality Improvement Initiatives: Data Reporting to Sites n Quarterly feedback reports to sites regarding their adherence to ACC/AHA treatment guidelines l Focused on AHA/ACC Guidelines treatments l Site confidentiality maintained - data supplied back to sites in a secure fashion l Provides sites with benchmark performance data n Quarterly feedback reports to sites regarding their adherence to ACC/AHA treatment guidelines l Focused on AHA/ACC Guidelines treatments l Site confidentiality maintained - data supplied back to sites in a secure fashion l Provides sites with benchmark performance data

Sample Quarterly Report: GP IIb/IIa Inhibitor Use in First 24 Hours

Site Participants and Responsibilities n Emergency Medicine and Cardiology Co-Advocates l Develop strategies to identify high-risk NSTE ACS patients early during hospitalization l Implement QI tools to promote ACC/AHA Guidelines n QI nurse or research coordinator l Completion of case report forms l Assist in local educational/QI efforts to increase adherence to ACC/AHA Guidelines n Emergency Medicine and Cardiology Co-Advocates l Develop strategies to identify high-risk NSTE ACS patients early during hospitalization l Implement QI tools to promote ACC/AHA Guidelines n QI nurse or research coordinator l Completion of case report forms l Assist in local educational/QI efforts to increase adherence to ACC/AHA Guidelines

Promoting a New Paradigm of Evidence-Based Cardiovascular Care n The CRUSADE national quality improvement initiative will teach us much about: l Why current ACC/AHA treatment guidelines for ACS are not followed l What initiatives can improve adherence l How to promote EM-Cardiology collaboration l Will improved early adherence to treatment guidelines lead to better acute outcomes? n The CRUSADE national quality improvement initiative will teach us much about: l Why current ACC/AHA treatment guidelines for ACS are not followed l What initiatives can improve adherence l How to promote EM-Cardiology collaboration l Will improved early adherence to treatment guidelines lead to better acute outcomes?