CRUSADE: A National CRUSADE: A National

Quality Improvement InitiativeQuality Improvement Initiative

CRUSADE: A National CRUSADE: A National

Quality Improvement InitiativeQuality Improvement Initiative

CCan an RRapid Risk Stratification of apid Risk Stratification of UUnstable Angina Patients nstable Angina Patients

SSuppress uppress ADADverse Outcomes with verse Outcomes with EEarly Implementation arly Implementation

of the ACC/AHA Guidelinesof the ACC/AHA Guidelines

CCan an RRapid Risk Stratification of apid Risk Stratification of UUnstable Angina Patients nstable Angina Patients

SSuppress uppress ADADverse Outcomes with verse Outcomes with EEarly Implementation arly Implementation

of the ACC/AHA Guidelinesof the ACC/AHA Guidelines

AHA/ACC Treatment RecommendationsAHA/ACC Treatment Recommendations

Aspirin

Aspirin + Clopidogrel

Beta-Blockers

Heparin (UFH or LMWH)

GP IIb/IIIa Inhibitors For high-risk patients For early cath/PCI

Aspirin

Aspirin + Clopidogrel

Beta-Blockers

Heparin (UFH or LMWH)

GP IIb/IIIa Inhibitors For high-risk patients For early cath/PCI

Aspirin

Aspirin + Clopidogrel

Beta-Blockers

Statins

ACE-Inhibitors

Cardiac Rehab

Smoking Cessation

Aspirin

Aspirin + Clopidogrel

Beta-Blockers

Statins

ACE-Inhibitors

Cardiac Rehab

Smoking Cessation

Acute TherapiesAcute TherapiesAcute TherapiesAcute Therapies Discharge TherapiesDischarge TherapiesDischarge TherapiesDischarge Therapies

CRUSADE ObjectivesCRUSADE ObjectivesCRUSADE ObjectivesCRUSADE Objectives

Determine current state of awareness of and Determine current state of awareness of and adherence to the ACC/AHA Non-ST-Elevation adherence to the ACC/AHA Non-ST-Elevation (NSTE) ACS Guidelines (NSTE) ACS Guidelines

Implement quality improvement initiatives to Implement quality improvement initiatives to promote ACC/AHA NSTE ACS recommendations promote ACC/AHA NSTE ACS recommendations

Improve clinical outcomes for NSTE ACS patients Improve clinical outcomes for NSTE ACS patients via early risk stratification and implementation of via early risk stratification and implementation of evidence-based careevidence-based care

Determine current state of awareness of and Determine current state of awareness of and adherence to the ACC/AHA Non-ST-Elevation adherence to the ACC/AHA Non-ST-Elevation (NSTE) ACS Guidelines (NSTE) ACS Guidelines

Implement quality improvement initiatives to Implement quality improvement initiatives to promote ACC/AHA NSTE ACS recommendations promote ACC/AHA NSTE ACS recommendations

Improve clinical outcomes for NSTE ACS patients Improve clinical outcomes for NSTE ACS patients via early risk stratification and implementation of via early risk stratification and implementation of evidence-based careevidence-based care

Inclusion Criteria: High-Risk NSTE ACSInclusion Criteria: High-Risk NSTE ACSInclusion Criteria: High-Risk NSTE ACSInclusion Criteria: High-Risk NSTE ACS

Ischemic symptoms lasting Ischemic symptoms lasting 10 minutes 10 minutes < 24 hours and at least < 24 hours and at least oneone of the following: of the following:

Positive cardiac markersPositive cardiac markers CK-MB or TnI / TnT above ULNCK-MB or TnI / TnT above ULN Positive bedside troponin assayPositive bedside troponin assay

Dynamic ST-segment ECG changes:Dynamic ST-segment ECG changes: ST-segment depression ST-segment depression 0.5 mm 0.5 mm Transient ST-segment elevation of 0.6-1.0 Transient ST-segment elevation of 0.6-1.0

mm (lasting < 10 mins)mm (lasting < 10 mins)

Transfer patients - must arrive at CRUSADE Transfer patients - must arrive at CRUSADE hospital within 24 hrs of symptomshospital within 24 hrs of symptoms

Ischemic symptoms lasting Ischemic symptoms lasting 10 minutes 10 minutes < 24 hours and at least < 24 hours and at least oneone of the following: of the following:

Positive cardiac markersPositive cardiac markers CK-MB or TnI / TnT above ULNCK-MB or TnI / TnT above ULN Positive bedside troponin assayPositive bedside troponin assay

Dynamic ST-segment ECG changes:Dynamic ST-segment ECG changes: ST-segment depression ST-segment depression 0.5 mm 0.5 mm Transient ST-segment elevation of 0.6-1.0 Transient ST-segment elevation of 0.6-1.0

mm (lasting < 10 mins)mm (lasting < 10 mins)

Transfer patients - must arrive at CRUSADE Transfer patients - must arrive at CRUSADE hospital within 24 hrs of symptomshospital within 24 hrs of symptoms

Study DesignStudy DesignStudy DesignStudy Design

Nationwide quality improvement initiativeNationwide quality improvement initiative 400+ participating hospitals400+ participating hospitals

Collaborative effort between Emergency Medicine, Collaborative effort between Emergency Medicine, Cardiology, Hospital QI, Academia, and Industry Cardiology, Hospital QI, Academia, and Industry Optimize risk stratification for NSTE ACS patientsOptimize risk stratification for NSTE ACS patients Promote adherence to ACC/AHA treatment Promote adherence to ACC/AHA treatment

guidelines for NSTE ACSguidelines for NSTE ACS Implement quality improvement interventionsImplement quality improvement interventions

Nationwide quality improvement initiativeNationwide quality improvement initiative 400+ participating hospitals400+ participating hospitals

Collaborative effort between Emergency Medicine, Collaborative effort between Emergency Medicine, Cardiology, Hospital QI, Academia, and Industry Cardiology, Hospital QI, Academia, and Industry Optimize risk stratification for NSTE ACS patientsOptimize risk stratification for NSTE ACS patients Promote adherence to ACC/AHA treatment Promote adherence to ACC/AHA treatment

guidelines for NSTE ACSguidelines for NSTE ACS Implement quality improvement interventionsImplement quality improvement interventions

Data CollectionData CollectionData CollectionData Collection

Concise, 3-page data collection formConcise, 3-page data collection form Retrospective data collectionRetrospective data collection Payment of $20 per DCF returnedPayment of $20 per DCF returned

Data collected includes:Data collected includes: Pt risk factors/presenting symptomsPt risk factors/presenting symptoms Use of medications/ Use of invasive Use of medications/ Use of invasive

procedures/In-hospital clinical outcomesprocedures/In-hospital clinical outcomes

Institutional Review Boards:Institutional Review Boards: Should not require informed consentShould not require informed consent Should be viewed by local IRB as QI Should be viewed by local IRB as QI

Concise, 3-page data collection formConcise, 3-page data collection form Retrospective data collectionRetrospective data collection Payment of $20 per DCF returnedPayment of $20 per DCF returned

Data collected includes:Data collected includes: Pt risk factors/presenting symptomsPt risk factors/presenting symptoms Use of medications/ Use of invasive Use of medications/ Use of invasive

procedures/In-hospital clinical outcomesprocedures/In-hospital clinical outcomes

Institutional Review Boards:Institutional Review Boards: Should not require informed consentShould not require informed consent Should be viewed by local IRB as QI Should be viewed by local IRB as QI

Quality Improvement Initiative:Quality Improvement Initiative:Primary EndpointsPrimary Endpoints

Quality Improvement Initiative:Quality Improvement Initiative:Primary EndpointsPrimary Endpoints

Effectiveness of QI initiatives measured by changes Effectiveness of QI initiatives measured by changes in adherence to AHA/ACC treatment guidelinesin adherence to AHA/ACC treatment guidelines Early / Discharge aspirin and clopidogrel useEarly / Discharge aspirin and clopidogrel use Early / Discharge beta-blocker useEarly / Discharge beta-blocker use Discharge ACE-Inhibitor and statin useDischarge ACE-Inhibitor and statin use GP IIb/IIIa Inhibitors: Early use and during PCIGP IIb/IIIa Inhibitors: Early use and during PCI Early invasive management - use of cath/PCI/CABGEarly invasive management - use of cath/PCI/CABG Appropriate secondary prevention measuresAppropriate secondary prevention measures

• Smoking cessationSmoking cessation

• Cardiac rehabilitationCardiac rehabilitation

Effectiveness of QI initiatives measured by changes Effectiveness of QI initiatives measured by changes in adherence to AHA/ACC treatment guidelinesin adherence to AHA/ACC treatment guidelines Early / Discharge aspirin and clopidogrel useEarly / Discharge aspirin and clopidogrel use Early / Discharge beta-blocker useEarly / Discharge beta-blocker use Discharge ACE-Inhibitor and statin useDischarge ACE-Inhibitor and statin use GP IIb/IIIa Inhibitors: Early use and during PCIGP IIb/IIIa Inhibitors: Early use and during PCI Early invasive management - use of cath/PCI/CABGEarly invasive management - use of cath/PCI/CABG Appropriate secondary prevention measuresAppropriate secondary prevention measures

• Smoking cessationSmoking cessation

• Cardiac rehabilitationCardiac rehabilitation

Patient Identification StrategiesPatient Identification StrategiesScreening in the Emergency DepartmentScreening in the Emergency Department

Patient Identification StrategiesPatient Identification StrategiesScreening in the Emergency DepartmentScreening in the Emergency Department

Prospectively identify patients in the EDProspectively identify patients in the ED Elevated cardiac markers, dynamic ECG changesElevated cardiac markers, dynamic ECG changes Rapid, bedside Troponin I assays in the EDRapid, bedside Troponin I assays in the ED

Review daily ED admission logsReview daily ED admission logs Unstable angina, chest pain, R/O MI, or acute MIUnstable angina, chest pain, R/O MI, or acute MI

Review admissions to chest pain unitsReview admissions to chest pain units

Develop triggers for ED nursing staff to identify Develop triggers for ED nursing staff to identify patients for CRUSADEpatients for CRUSADE

Work with research coordinators who are screening Work with research coordinators who are screening patients for ACS clinical trialspatients for ACS clinical trials

Prospectively identify patients in the EDProspectively identify patients in the ED Elevated cardiac markers, dynamic ECG changesElevated cardiac markers, dynamic ECG changes Rapid, bedside Troponin I assays in the EDRapid, bedside Troponin I assays in the ED

Review daily ED admission logsReview daily ED admission logs Unstable angina, chest pain, R/O MI, or acute MIUnstable angina, chest pain, R/O MI, or acute MI

Review admissions to chest pain unitsReview admissions to chest pain units

Develop triggers for ED nursing staff to identify Develop triggers for ED nursing staff to identify patients for CRUSADEpatients for CRUSADE

Work with research coordinators who are screening Work with research coordinators who are screening patients for ACS clinical trialspatients for ACS clinical trials

Patient Identification StrategiesPatient Identification StrategiesScreening After AdmissionScreening After Admission

Patient Identification StrategiesPatient Identification StrategiesScreening After AdmissionScreening After Admission

Review daily CCU or telemetry floor admission logsReview daily CCU or telemetry floor admission logs Unstable angina, chest pain, R/O MI, or acute MIUnstable angina, chest pain, R/O MI, or acute MI

Review daily cath lab scheduleReview daily cath lab schedule Unstable angina, acute MIUnstable angina, acute MI

Develop triggers for CCU / telemetry floor nurses to Develop triggers for CCU / telemetry floor nurses to identify patients for CRUSADEidentify patients for CRUSADE

Screen all patients with elevated cardiac marker Screen all patients with elevated cardiac marker levels from local laboratory recordslevels from local laboratory records

Review daily CCU or telemetry floor admission logsReview daily CCU or telemetry floor admission logs Unstable angina, chest pain, R/O MI, or acute MIUnstable angina, chest pain, R/O MI, or acute MI

Review daily cath lab scheduleReview daily cath lab schedule Unstable angina, acute MIUnstable angina, acute MI

Develop triggers for CCU / telemetry floor nurses to Develop triggers for CCU / telemetry floor nurses to identify patients for CRUSADEidentify patients for CRUSADE

Screen all patients with elevated cardiac marker Screen all patients with elevated cardiac marker levels from local laboratory recordslevels from local laboratory records

Patient Identification StrategiesPatient Identification StrategiesScreening After DischargeScreening After Discharge

Patient Identification StrategiesPatient Identification StrategiesScreening After DischargeScreening After Discharge

Review discharge diagnoses for chest painReview discharge diagnoses for chest pain Unstable angina, chest pain, R/O MI, or acute MIUnstable angina, chest pain, R/O MI, or acute MI New ICD-9 codes for acute MI: + TnT/TnINew ICD-9 codes for acute MI: + TnT/TnI

Review all patients with elevated cardiac marker Review all patients with elevated cardiac marker levels from local laboratory records levels from local laboratory records

Pull charts after identification of patients to fill out Pull charts after identification of patients to fill out items on the data collection formitems on the data collection form

Review discharge diagnoses for chest painReview discharge diagnoses for chest pain Unstable angina, chest pain, R/O MI, or acute MIUnstable angina, chest pain, R/O MI, or acute MI New ICD-9 codes for acute MI: + TnT/TnINew ICD-9 codes for acute MI: + TnT/TnI

Review all patients with elevated cardiac marker Review all patients with elevated cardiac marker levels from local laboratory records levels from local laboratory records

Pull charts after identification of patients to fill out Pull charts after identification of patients to fill out items on the data collection formitems on the data collection form

Quality Improvement Initiatives: Quality Improvement Initiatives: Quality Improvement Initiatives: Quality Improvement Initiatives:

Regional educational meetings Regional educational meetings ACC/AHA Guidelines recommendationsACC/AHA Guidelines recommendations Review CRUSADE and QI InitiativesReview CRUSADE and QI Initiatives

Site Survey Site Survey Understand site beliefs and practice environmentUnderstand site beliefs and practice environment

Educational / QI materials Educational / QI materials ED Risk Stratification Algorithm/ Sample ordersED Risk Stratification Algorithm/ Sample orders Guidelines Posters/pocket cardsGuidelines Posters/pocket cards Discharge MD and patient check listsDischarge MD and patient check lists

Quarterly Feedback ReportsQuarterly Feedback Reports

Regional educational meetings Regional educational meetings ACC/AHA Guidelines recommendationsACC/AHA Guidelines recommendations Review CRUSADE and QI InitiativesReview CRUSADE and QI Initiatives

Site Survey Site Survey Understand site beliefs and practice environmentUnderstand site beliefs and practice environment

Educational / QI materials Educational / QI materials ED Risk Stratification Algorithm/ Sample ordersED Risk Stratification Algorithm/ Sample orders Guidelines Posters/pocket cardsGuidelines Posters/pocket cards Discharge MD and patient check listsDischarge MD and patient check lists

Quarterly Feedback ReportsQuarterly Feedback Reports

Quality Improvement Initiatives:Quality Improvement Initiatives:Hospital Survey ComponentHospital Survey Component

Quality Improvement Initiatives:Quality Improvement Initiatives:Hospital Survey ComponentHospital Survey Component

Baseline understanding of and concurrence with Baseline understanding of and concurrence with AHA/ACC NSTE ACS treatment guidelinesAHA/ACC NSTE ACS treatment guidelines Is it an education versus adherence issue?Is it an education versus adherence issue?

Identify local features which may serve to promote Identify local features which may serve to promote quality improvement initiativesquality improvement initiatives Survey “structure and culture” of institutionSurvey “structure and culture” of institution Do institutional characteristics predict improved Do institutional characteristics predict improved

adherence to guidelines-based care?adherence to guidelines-based care?

Baseline understanding of and concurrence with Baseline understanding of and concurrence with AHA/ACC NSTE ACS treatment guidelinesAHA/ACC NSTE ACS treatment guidelines Is it an education versus adherence issue?Is it an education versus adherence issue?

Identify local features which may serve to promote Identify local features which may serve to promote quality improvement initiativesquality improvement initiatives Survey “structure and culture” of institutionSurvey “structure and culture” of institution Do institutional characteristics predict improved Do institutional characteristics predict improved

adherence to guidelines-based care?adherence to guidelines-based care?

Quality Improvement Initiatives:Quality Improvement Initiatives:Data Reporting to SitesData Reporting to Sites

Quality Improvement Initiatives:Quality Improvement Initiatives:Data Reporting to SitesData Reporting to Sites

Quarterly feedback reports to sites regarding their Quarterly feedback reports to sites regarding their adherence to ACC/AHA treatment guidelinesadherence to ACC/AHA treatment guidelines Focused on AHA/ACC Guidelines treatmentsFocused on AHA/ACC Guidelines treatments Site confidentiality maintained - data supplied back Site confidentiality maintained - data supplied back

to sites in a secure fashionto sites in a secure fashion Provides sites with benchmark performance dataProvides sites with benchmark performance data

Quarterly feedback reports to sites regarding their Quarterly feedback reports to sites regarding their adherence to ACC/AHA treatment guidelinesadherence to ACC/AHA treatment guidelines Focused on AHA/ACC Guidelines treatmentsFocused on AHA/ACC Guidelines treatments Site confidentiality maintained - data supplied back Site confidentiality maintained - data supplied back

to sites in a secure fashionto sites in a secure fashion Provides sites with benchmark performance dataProvides sites with benchmark performance data

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

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

5.4%

60.3%

10.1%14.0%

59.2%

15.3%10.9%

4.9%

0%

25%

50%

75%

100%

LocalHospital

SimilarHospitals

National BestPractice

GP

IIb

/III

a In

hib

ito

r U

se

Q2 2000YTD 2000

Site Participants and ResponsibilitiesSite Participants and ResponsibilitiesSite Participants and ResponsibilitiesSite Participants and Responsibilities

Emergency Medicine and Cardiology Co-AdvocatesEmergency Medicine and Cardiology Co-Advocates Develop strategies to identify high-risk NSTE ACS Develop strategies to identify high-risk NSTE ACS

patients early during hospitalizationpatients early during hospitalization Implement QI tools to promote ACC/AHA GuidelinesImplement QI tools to promote ACC/AHA Guidelines

QI nurse or research coordinatorQI nurse or research coordinator Completion of case report formsCompletion of case report forms Assist in local educational/QI efforts to increase Assist in local educational/QI efforts to increase

adherence to ACC/AHA Guidelinesadherence to ACC/AHA Guidelines

Emergency Medicine and Cardiology Co-AdvocatesEmergency Medicine and Cardiology Co-Advocates Develop strategies to identify high-risk NSTE ACS Develop strategies to identify high-risk NSTE ACS

patients early during hospitalizationpatients early during hospitalization Implement QI tools to promote ACC/AHA GuidelinesImplement QI tools to promote ACC/AHA Guidelines

QI nurse or research coordinatorQI nurse or research coordinator Completion of case report formsCompletion of case report forms Assist in local educational/QI efforts to increase Assist in local educational/QI efforts to increase

adherence to ACC/AHA Guidelinesadherence to ACC/AHA Guidelines

Promoting a New Paradigm Promoting a New Paradigm

of Evidence-Based Cardiovascular Careof Evidence-Based Cardiovascular Care

Promoting a New Paradigm Promoting a New Paradigm

of Evidence-Based Cardiovascular Careof Evidence-Based Cardiovascular Care

The CRUSADE national quality improvement The CRUSADE national quality improvement initiative will teach us much about:initiative will teach us much about: Why current ACC/AHA treatment guidelines for Why current ACC/AHA treatment guidelines for

ACS are not followedACS are not followed What initiatives can improve adherenceWhat initiatives can improve adherence How to promote EM-Cardiology collaborationHow to promote EM-Cardiology collaboration Will improved early adherence to treatment Will improved early adherence to treatment

guidelines lead to better acute outcomes?guidelines lead to better acute outcomes?

The CRUSADE national quality improvement The CRUSADE national quality improvement initiative will teach us much about:initiative will teach us much about: Why current ACC/AHA treatment guidelines for Why current ACC/AHA treatment guidelines for

ACS are not followedACS are not followed What initiatives can improve adherenceWhat initiatives can improve adherence How to promote EM-Cardiology collaborationHow to promote EM-Cardiology collaboration Will improved early adherence to treatment Will improved early adherence to treatment

guidelines lead to better acute outcomes?guidelines lead to better acute outcomes?