What are we trying to do?

Acute Phase Driver Diagram

An example from another setting Acute MI Care in US Aspirin at discharge ACEI for LVSD Beta-blocker at arrival Beta-blocker at discharge Door to lytic Door to PCI Smoking cessation advice Composite and all-or-none scores Survival rate/index Aspirin at arrival

Reliability Level errors 90% right Level errors 99% right Level errors 99.9% right

Examples – most are level 2 or 3 but three are level 1 Himalaya mountaineering Fatal iatrogenic adverse events Cardiac surgery (Patient ASA 3-5) Road safety Civil aviation Railways France Nuclear power industry Anaesthesia ASA1 Blood transfusion A and E staff reading X-rays

Examples – most are level 2 or 3 but three are level 1 Himalaya mountaineering Fatal iatrogenic adverse events Cardiac surgery (Patient ASA 3-5) Road safety Civil aviation Railways France Nuclear power industry Anaesthesia ASA1 Blood transfusion A and E staff reading X-rays

Strategies –Level 1 “Intent, vigilance, hard work” Standardized protocols Feedback Training Checklists

What they did at the Mayo Expanded the Chest Pain Center hours to 24/7 with observation area for 23- hour evaluation. Revised criteria for EKG screening in the ED to include atypical presentations (e.g., non-STEMI, female, gastric). Created buy-in to measures by reviewing the inclusion and exclusion criteria for each indicator for CMS/ORYX, thereby accelerated the learning curve on the varying definitions compared to prior/other benchmarks. Overhauled ED and Cath Lab process flow including transmission of EKG results by the EMS, setting time threshold cutoffs, implementing a master clock system, centralizing the Cath Lab call-back system, fast-tracking Cath Lab set- up with ED transport and pre-set equipment/supplies, and availability of non- interventional or interventional cardiologist to start the case. Revised elective Cath Lab schedule to expand blocks, hours of service. Added smoking history to admission assessment for all patients. Trained acute MI care champions in each care area.

Strategies –Level 2 “Redesign the system – don’t rely on checking” Decision aids and reminders built into the system Automation Evidence as the default Scheduling Connection to habits

What they did at the Mayo Activated Chest Pain Center default orders tailored to AMI type, incorporated on ED record, with RN follows up with ER physician if variation. Inserted opportunity for ED MD to give the lytic if door-to-Cath Lab time predicted to exceed 90 minutes. Initiated concurrent redundant review in the Cath Lab to identify and mitigate fallouts (e.g., ASA or beta-blocker within 24 hours of arrival). Created brochure for first- and second-hand smoking cessation, made default care for all patients regardless of diagnosis. Implemented Quality Management review of all admitted patients for evidence-based indicators, with concurrent review with ED, cardiologist if fallout. Reviewed final fallouts routinely with ED, hospitalist and cardiology physicians and nursing staff, with drill-down data for PCI process as well as non-STEMIs, to create enhanced understanding of overall scoring and further PI opportunities. Next changes: Adding to manager/director/VP and hospitalist incentive goals.

We can do this in Wales!

Action plans Local awareness Ownership Agree morbidity outcome measure Ensure data collection Drive for reliability Understand special cases Make hypotheses PDSAs June conference