1. Acute Myocardial Infarction (AMI) JCAHO Core Measure Project Loyola University Medical Center Team Members: K. McLean MD, M. Morrow MSN, J. Cochran BSN, M. Cosentino MSN, V. Grant BSN MPH, M. Jarotkiewicz, C. Mazzuca MHA RHIA, S. Oglesby BA RHIT CCSP, A. Porter RN PhD, J. Saulters MSN

2. Opportunity for Improvement JCAHO established a standard set of core measures based on AHA/ACC Coronary Heart Disease guidelines to examine and improve the care of all AMI patients and they mandated that all hospitals use these measures JCAHO established a standard set of core measures based on AHA/ACC Coronary Heart Disease guidelines to examine and improve the care of all AMI patients and they mandated that all hospitals use these measures LUMC needed to establish a process to LUMC needed to establish a process to Meet the JCAHO requirements by 7/1/02 Meet the JCAHO requirements by 7/1/02 Review results from AMI data collection Review results from AMI data collection Initiate quality improvements as needed Initiate quality improvements as needed Data collected in CCU during 2002 indicated Data collected in CCU during 2002 indicated 93.7% of AMI patients were given ASA within 24 hours 93.7% of AMI patients were given ASA within 24 hours 85.4% of AMI patients received Beta blockers 85.4% of AMI patients received Beta blockers 72.5% of AMI patients were given ACE Inhibitors 72.5% of AMI patients were given ACE Inhibitors 59.7% of AMI patients received a lipid-lowering drug 59.7% of AMI patients received a lipid-lowering drug

3. JCAHO AMI Core Measures Aspirin within 24 hours before or after arrival Aspirin within 24 hours before or after arrival Aspirin prescribed at discharge Aspirin prescribed at discharge ACE-Inhibitor prescribed at discharge in patients with left ventricular systolic dysfunction (LVSD) ACE-Inhibitor prescribed at discharge in patients with left ventricular systolic dysfunction (LVSD) Adult smoking cessation advice to all patients who have smoked within the last 12 months Adult smoking cessation advice to all patients who have smoked within the last 12 months Beta blocker prescribed at discharge Beta blocker prescribed at discharge Beta blocker within 24 hours after arrival Time to thrombolysis in patients with an ST elevation AMI Time to PTCA in patients with an ST elevation AMI Lipid profile drawn within 24 hours of arrival Patients with abnormal lipid profile results with documented plan for lipid management Inpatient mortality

4. The hospital stay tends to concentrate on acute problems rather than prevention. The hospital stay tends to concentrate on acute problems rather than prevention. The complexity and emergent nature of the care of AMI patients makes it difficult to implement all aspects of the guidelines. The complexity and emergent nature of the care of AMI patients makes it difficult to implement all aspects of the guidelines. Tools to follow the guidelines, such as standing orders, were not in place. Tools to follow the guidelines, such as standing orders, were not in place. Care of patients may be transitioned to different teams/units during hospital stay. Care of patients may be transitioned to different teams/units during hospital stay. Most Likely Causes for the Improvement Opportunity

5. Solutions Implemented Formed AMI Core Measure committee (5/02) Formed AMI Core Measure committee (5/02) Developed and implemented AMI Discharge Progress Note Addendum (6/02) Developed and implemented AMI Discharge Progress Note Addendum (6/02) Educated cardiology attendings, residents and nursing staff on AMI initiative (6/02) Educated cardiology attendings, residents and nursing staff on AMI initiative (6/02) Began AMI data collection (7/02) Began AMI data collection (7/02) Developed brightly colored sticker for front of chart to designate AMI patients (10/02) Developed brightly colored sticker for front of chart to designate AMI patients (10/02) Added representative from ED to AMI committee (12/02) Added representative from ED to AMI committee (12/02)

6. Solutions Implemented (con’t) Revised AMI Discharge Progress Note Addendum to include contraindications to meds (1/03) Revised AMI Discharge Progress Note Addendum to include contraindications to meds (1/03) Established process with Cath Lab to obtain precise wire cross times for PTCA (1/03) Established process with Cath Lab to obtain precise wire cross times for PTCA (1/03) Developed draft of pre-printed unstable angina/non-ST elevation MI physician order set (2/03) Developed draft of pre-printed unstable angina/non-ST elevation MI physician order set (2/03) Formed Smoking Cessation Task Force to implement hospital-wide smoking cessation program (4/03) Formed Smoking Cessation Task Force to implement hospital-wide smoking cessation program (4/03)

7. Acute Myocardial Infarction - Inpatient Mortality JCAHO Core Measure Data 0% 5% 10% 15% CY02 Q3CY02 Q4 Performance Rate LUMC Obs Rate % LUMC Exp Rate % LUMC Obs Rate % LUMC Exp Rate %

8. Time to Percutaneous Transluminal Coronary Angioplasty JCAHO Core Measure Data - 50 100 150 200 250 300 350 400 450 500 CY02 Q3CY02 Q4 Minutes LUMC Median UHC Median LUMC Median UHC Median

9. AMI Core Measure - Ace Inhibitor for LVSD 80% 82% 84% 86% 88% 90% 92% 94% 96% 98% 100% CY02 Q3CY02 Q4 Performance Rate LUMC Mean UHC Mean LUMC Mean UHC Mean

10. AMI Core Measure - Aspirin 80% 82% 84% 86% 88% 90% 92% 94% 96% 98% 100% CY02 Q3CY02 Q4 Performance Rate Aspirin at Arrival Lumc Aspirin at Disch Lumc Aspirin at Arrival UHC Aspirin at Disch UHC Aspirin at Arrival Lumc Aspirin at Disch Lumc Aspirin at Arrival UHC Aspirin at Disch UHC

11. AMI Core Measure - Beta Blocker 80% 82% 84% 86% 88% 90% 92% 94% 96% 98% 100% CY02 Q3CY02 Q4 Performance Rate Beta Blocker at Arrival Lumc Beta Blocker at Disch Lumc Beta Blocker at Arrival UHC Beta Blocker at Disch UHC Beta Blocker at Arrival Lumc Beta Blocker at Disch Lumc Beta Blocker at Arrival UHC Beta Blocker at Disch UHC

12. AMI – Smoking Cessation Advice JCAHO Core Measure Data Percent of Smokers Receiving Advice

13. Next Steps Complete implementation of pre-printed unstable angina/non-ST elevation MI orders Complete implementation of pre-printed unstable angina/non-ST elevation MI orders Continue with establishing a comprehensive system-wide smoking cessation program Continue with establishing a comprehensive system-wide smoking cessation program Present findings to physician and nurse groups to promote their participation and obtain their input/suggestions Present findings to physician and nurse groups to promote their participation and obtain their input/suggestions Develop and implement AMI care pathway, discharge protocol form and patient education materials. Develop and implement AMI care pathway, discharge protocol form and patient education materials. Develop and implement ST elevation MI pre- printed order set Develop and implement ST elevation MI pre- printed order set