1. Quality Improvement Programs and Critical Pathways

2. Why Develop Critical Pathways?
“A treatment gap between therapy that is dictated by evidence-based medicine and therapy that occurs in practice is not a deficit of knowledge; rather, it is a deficit of implementation.”
Sidney Smith, MD Director, Center for Cardiovascular Science and Medicine, UNC School of Medicine

3. Critical Pathways
Standardized treatment protocols for the management of specific disorders
Developed to optimize and streamline patient care
Prevent underutilization of medications, time in ICU/hospital, costs
Ensure quality-of-care measures (eg, door-to-drug times)
Optimize patient triage
Facilitate communication with specialists and PCP post-discharge
Enhance patient compliance and outcomes
Minimize potential for medical errors
Improve compliance with national standards (JCAHO)
Adapted from: Cannon CP, O’Gara PT. Critical Pathways in Cardiology. Lippincott Williams & Wilkins; 2001.

4. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
1997: Launched ORYX™ to integrate use of outcomes and other performance measures into accreditation process
2001: Announced 4 initial core measurement areas for hospitals (2 of 4 required):
Acute MI
Heart failure
Community-acquired pneumonia
Pregnancy
2004: New accreditation process (“Shared Visions–New Pathways”) introduced. Hospitals previously collecting 2 of 4 measure sets are now required to collect 3 of 4 measure sets

5. JCAHO Quality Measures in MI
Hospitals graded on:
Antiplatelet therapy in AMI at arrival and discharge
b-blocker therapy at arrival and discharge
ACE inhibitor therapy for LVSD
Time to thrombolysis
Time to PCI
Adult smoking cessation counseling
Inpatient mortality

6. Why a Hospital-Based System?
Patients
Patient capture point
Have patients/family attention: “teachable moment”
Predictor of care in community
Hospital structure
Standardized processes/protocols/orders/teams
JCAHO (ORYX and “Shared Visions – New Pathways”)
Source:

7. Practical Steps to Improve the Use of Evidence-Based Therapies for ACS
Develop critical pathways
Establish a multidisciplinary team approach (cardiology, ED, primary care, nursing, laboratory)
Identify local cardiology and ED “champions”
Track adherence to ACC/AHA guidelines
Develop educational materials to improve physicians’ knowledge of the guidelines
Secure institution’s commitment to improved patient care
Identify areas for continuous QI; provide QI tools
Elicit ongoing quarterly feedback
Cannon CP, et al. Am Heart J. 2002;143:
Cannon CP, Hand MH, Bahr R, et al; National Heart Attack Alert Program (NHAAP) Coordinating Committee Critical Pathways Writing Group. Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program. Am Heart J. 2002;143:

8. Critical Pathways Begin in Ambulance and Extend to Long-term, Office-based Care
EMS ED
Community
Inpatient
Discharge
Adapted from Cannon CP, O’Gara PT. Critical Pathways in Cardiology. Lippincott Williams & Wilkins; Corbelli J, et al. Critical Pathways in Cardiology. 2003;2:71-87.
Cannon CP, O’Gara PT, eds. Critical Pathways in Cardiology. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001.
Corbelli JC, Janicke DM, Corbelli JA, Chow S, Pruski M. Acute Coronary Syndrome Emergency Treatment Strategies: a rationale and road map for critical pathway implementation. Critical Pathways in Cardiology. 2003;2:71-87.