Maine Quality ForumMaine Quality Forum In A HeartbeatIn A Heartbeat
November 9, 2006
Mirle A. Kellett,Jr. MD, FACC, FSCAI
Chief, Department of Cardiac Services
The Maine Heart Center at Maine Medical Center
Mirle Kellett, MD, FACC (Chair), Maine Medical Center Richard Chandler, MD, Penobscot Bay Medical CenterDarlene Glover, RN, MSN, Stephens Memorial HospitalSusan Horton, RN, MSN, Central Maine Heart & Vascular InstituteDoug Libby, RPh, Maine Health Management CoalitionH. Joel Johnson, RN, CCM, ACS, Central & Western Maine Regional PHOKevin Kendall, MD, FACEP, Central Maine Medical CenterSandra Parker, Esq., Maine Hospital AssociationGuy Raymond, MD, Northern Maine Medical CenterKim Tierney, RN, Maine Medical CenterPeter Ver Lee, MD, FACC, Eastern Maine Medical Center Paul vom Eigen, MD, FACC, Northeast Cardiology Associates Dennis Shubert, MD, Maine Quality Forum Christopher McCarthy, Quality Initiatives Administrator, Maine Quality Forum
Committee Members:Committee Members:Data and Metrics
Common Treatment Guideline Subcommittee Members:
Paul vom Eigen, MD, FACC, Northeast Cardiology AssociatesLarry Hopperstead, MD, Central Maine Medical CenterMirle Kellett, MD, FACC, Maine Medical CenterWilliam Phillips, MD, Central Maine Medical Center Peter Ver Lee, MD, FACC, Eastern Maine Medical CenterDennis Shubert, MD, Maine Quality Forum Christopher McCarthy, Quality Initiatives Administrator, Maine Quality ForumKim Tierney, RN, Cardiac Database Coordinator, Maine Medical Center
1.1. Improve the care, quality of life and Improve the care, quality of life and survival of Maine patients with AMIsurvival of Maine patients with AMI
2.2. Patients will receive the right care at the right Patients will receive the right care at the right timetime
3.3. Establish a system of care to be used by all Establish a system of care to be used by all providersproviders
4.4. Continually monitor sufficient indicators of Continually monitor sufficient indicators of process and quality to maximize the quality of process and quality to maximize the quality of the process. the process.
MissionMissionIn a Heartbeat
ProcessProcess
In a Heartbeat
Data and Metrics committeeData and Metrics committee formed to develop formed to develop indicators across the spectrum of care indicators across the spectrum of care
Treatment guideline subcommitteeTreatment guideline subcommittee formed to formed to establish a common treatment guidelineestablish a common treatment guideline
1.1. Common treatment guideline reportCommon treatment guideline report
2.2. Data and Metrics FrameworkData and Metrics Framework
3.3. EMS data processesEMS data processes
4.4. ED data and process improvementED data and process improvement
5.5. Post-discharge dataPost-discharge data
Treatment Guideline
&
Data and Metrics
Common Treatment Guideline Subcommittee Members:
Paul vom Eigen, MD, FACC, Northeast Cardiology AssociatesLarry Hopperstead, MD, Central Maine Medical CenterMirle Kellett, MD, FACC, Maine Medical CenterWilliam Phillips, MD, Central Maine Medical Center Peter Ver Lee, MD, FACC, Eastern Maine Medical CenterDennis Shubert, MD, Maine Quality Forum Christopher McCarthy, Quality Initiatives Administrator, Maine Quality ForumKim Tierney, RN, Cardiac Database Coordinator, Maine Medical Center
Common Treatment Guideline
SubcommitteeSubcommittee
To develop a common treatment To develop a common treatment protocol/pathway that PCI Centers have protocol/pathway that PCI Centers have agreed to use in order to streamline the agreed to use in order to streamline the treatment and transfer process for local treatment and transfer process for local hospitals with patients that need to be hospitals with patients that need to be sent to a heart center.sent to a heart center.
Purpose:Purpose:
STEMI CLINICAL PATHWAY
STE/ LBBBSymptoms < 12hours
STE/ LBBBSymptoms < 12hours
Presentation to Cath Lab Door <1hr *Or
Contraindication to Lytic(See table)
Primary PCI Transfer to PCI Center
Goal: Door to Balloon 90”
Lytic Goal: Door to Drug< 30”
TIMI Risk Criteria:Previous MIAnterior InfarctSB/P< 100HR >100A-Flutter or FibAge>75Killip Class>IIPost CPR
Administer MEDS as indicated:ASABeta blockerPlavix 300mgHeparin **
Contraindications to lyticAny prior intracranial hemorrhageKnown structural cerebral vascular lesion (e.g. AVM)Known malignant intracranial neoplasmIschemic stroke within 3 mos (EXC within 3hoursSuspect aortic dissectionActive bleeding or bleeding diathesis (EXC) mensesSignificant closed head traumaUncontrolled HTN (SB/P>175;DB/P>110)Current use of anticoagulants
YES
NO
HIGH
LOW
Transfer toPCI Center
Stay / ObserveOr
Transfer to PCI
*For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policy.
**Heparin bolus only for patients within 1 hour transport to PCI Facility – 60un/kg max 4,000unit Patient transport over 1 hour to PCI Facility continue Heparin with 12un/kg drip.
*For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policies should be developed.
STEMI CLINICAL PATHWAY
Clinical Equipose CurveClinical Equipose CurvePCI Time Delay and OutcomePCI Time Delay and Outcome
Nallamothu, BK AJC 2003
Clinical Equipose CurveClinical Equipose CurvePCI Time Delay and OutcomePCI Time Delay and Outcome
Nallamothu, BK AJC 2003
Clinical Equipose CurveClinical Equipose CurvePCI Time Delay and OutcomePCI Time Delay and Outcome
Nallamothu, BK AJC 2003
STEMI CLINICAL PATHWAY
STE/ LBBBSymptoms < 12hours
STE/ LBBBSymptoms < 12hours
Presentation to Cath Lab Door <1hr *Or
Contraindication to Lytic(See table)
Primary PCI Transfer to PCI Center
Goal: Door to Balloon 90”
Lytic Goal: Door to Drug< 30”
TIMI Risk Criteria:Previous MIAnterior InfarctSB/P< 100HR >100A-Flutter or FibAge>75Killip Class>IIPost CPR
Administer MEDS as indicated:ASABeta blockerPlavix 300mgHeparin **
Contraindications to lyticAny prior intracranial hemorrhageKnown structural cerebral vascular lesion (e.g. AVM)Known malignant intracranial neoplasmIschemic stroke within 3 mos (EXC within 3hoursSuspect aortic dissectionActive bleeding or bleeding diathesis (EXC) mensesSignificant closed head traumaUncontrolled HTN (SB/P>175;DB/P>110)Current use of anticoagulants
YES
NO
HIGH
LOW
Transfer toPCI Center
Stay / ObserveOr
Transfer to PCI
*For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policy.
**Heparin bolus only for patients within 1 hour transport to PCI Facility – 60un/kg max 4,000unit Patient transport over 1 hour to PCI Facility continue Heparin with 12un/kg drip.
*For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policies should be developed.
STEMI CLINICAL PATHWAY
•Why are we measuring this data
• Who are we measuring it on
• What metrics in the process will we measure
• How will we define the elements/metrics
• Data collection
• Data reporting
• Ongoing role
DATA and METRICSDATA and METRICS
1.1. Improve the care, quality of life and Improve the care, quality of life and survival of Maine patients with AMIsurvival of Maine patients with AMI
2.2. Patients will receive the right care at the right Patients will receive the right care at the right timetime
3.3. Establish a system of care to be used by all Establish a system of care to be used by all providersproviders
4.4. Continually monitor sufficient indicators of Continually monitor sufficient indicators of process and quality to maximize the quality of process and quality to maximize the quality of the process. the process.
MissionMissionIn a Heartbeat
WHYWHY
There is concern that patients with acute myocardial infarct are not receiving the
appropriate care
And
That there are significant delays in the care they receive
Data and Metrics
Data and Metrics
Data collection and analysis will:
• tell us what percent of these patients are not receiving tell us what percent of these patients are not receiving reperfusion therapy and whyreperfusion therapy and why
• show where the delay in treatment liesshow where the delay in treatment lies
• give feedback on performance throughout the give feedback on performance throughout the system of care system of care
• give the tools for process improvement of care.give the tools for process improvement of care.
WHOWHO
ECG with ST segment elevation (STEMI) ECG with ST segment elevation (STEMI)
or or
Left bundle branch block (LBBB)Left bundle branch block (LBBB)
andand
Cardiac SymptomsCardiac Symptoms
((same cohortsame cohort as JACHO/CMS core metrics)JACHO/CMS core metrics)
Patient Cohort for data measures
Data and Metrics
Patient Eligibility Criteria: STEMI
STE/ LBBB •ST segment elevation with ST segment elevation with >>1mm/.10mV in two or 1mm/.10mV in two or more leads.more leads.
•Documentation of ST- segment elevation or left bundle Documentation of ST- segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival. performed closest to hospital arrival. •Using the 12-lead ECG performed closest to the time of Using the 12-lead ECG performed closest to the time of hospital arrival. hospital arrival.
•ECGs done more than one hour prior to hospital ECGs done more than one hour prior to hospital arrival should be repeated. arrival should be repeated.
Patient InclusionPatient InclusionData and Metrics
Symptom OnsetOnset time for patients reporting symptoms initially Onset time for patients reporting symptoms initially intermittent and subsequently constant, the onset time is intermittent and subsequently constant, the onset time is defined as the time of change from intermittent to constant defined as the time of change from intermittent to constant symptoms. Patients reporting symptoms that were initially symptoms. Patients reporting symptoms that were initially mild and subsequently changed to severe, the onset time is mild and subsequently changed to severe, the onset time is defined as the time of change in symptom severity. For defined as the time of change in symptom severity. For patients with both, the change in symptom severity is given patients with both, the change in symptom severity is given preeminence in determining symptom onset time. preeminence in determining symptom onset time. The REACT Trial definition. Am Heart J 138(6):1046-1057The REACT Trial definition. Am Heart J 138(6):1046-1057
Patients with symptom onset >12hours are included in the Patients with symptom onset >12hours are included in the
general study but excluded from time measuresgeneral study but excluded from time measures..
Patient Inclusion for timelinessPatient Inclusion for timeliness
Symptoms <12 hoursSymptoms <12 hours
MetricsMetrics in the Processin the Process
Process Elements
PCI Center
EMS
Transport
Emergency Department
Retrospective Discharge Data
Demographics
WHATWHATData and Metrics
EMS Data and Metrics Jay Bradshaw
Data and Metrics
Metrics in the ProcessMetrics in the Process
Process Elements
PCI Center
EMS
Transport
Emergency Department
Retrospective Discharge Data
Demographics
WHATWHATData and Metrics
ED Data and Metrics Rebecca Chagrasulis, MD
Data and Metrics
Metrics in the ProcessMetrics in the Process
Process Elements
PCI Center
EMS
Transport
Emergency Department
Retrospective Discharge Data
Demographics
WHATWHATData and Metrics
Data and Metrics
PCI Center/Cath Lab DataPCI Center/Cath Lab Data
Balloon Inflation Time (reperfusion) – First documented balloon time or first documented TIMI flow>2
If patient went to CABG (coronary artery bypass grafting)
Mortality (death) in the lab
DocumentationDocumentation
Reasons for delay in any treatment must be documented:•Patient initial refusal in treatment
•Religious reasons
•Waiting for family to arrive
•No urgent need for PCI
Data and Metrics
Metrics in the ProcessMetrics in the Process
Process Elements
PCI Center
EMS
Transport
Emergency Department
Retrospective Discharge Data
Demographics
WHATWHAT
Data and Metrics
JACHO/CMS Core Measures are already collected by hospitals:
• ASA on Arrival and Discharge
•Beta blocker on arrival and discharge
•Ace Inhibitor
•Statin
•Smoking cessation
•Discharge Instructions
Data and Metrics
Discharge DataDischarge Data::
Same extraction that is done for JACHO/CMS at all hospitals:
•Collection of STEMI ICD.9 discharge codes
•Primary and secondary diagnosis codes (shock and stroke)
•Primary and secondary procedure codes (cath, PCI, CABG)
•Disposition at discharge (dead or alive)
Retrospective Data:
Data and Metrics
Defining the ElementsDefining the Elements
Limited data pointsLimited data points Current Data Collection processes Current Data Collection processes e.g. Maine EMS InterfacilityTransport Programe.g. Maine EMS InterfacilityTransport Program JACHO/CMS Core Measures - JACHO/CMS Core Measures - Same Metrics and DefinitionsSame Metrics and Definitions
ACC/AHA Guidelines and definitionsACC/AHA Guidelines and definitions Consensus of State represented committeeConsensus of State represented committee Process data / during point of care – incorporated Process data / during point of care – incorporated
into current documentationinto current documentation
Data and Metrics
Maine Quality Forum has assumed the responsibility for contracting for data collection and reporting.
Collection in the process of care across the spectrum providing tools for adapting into current documentation
Core metrics same as JACHO/CMS extractionCore metrics same as JACHO/CMS extraction
Process improvement metricsProcess improvement metrics
Data CollectionData Collection
Data and Metrics
HOWHOW
Data ReportingData Reporting
Maine Quality Forum is committed to providing Maine Quality Forum is committed to providing meaningful analysis on this data to provide meaningful analysis on this data to provide actionable information back to providers across actionable information back to providers across the spectrum of care.the spectrum of care.
Critical analysis points –a statewide snapshot of Critical analysis points –a statewide snapshot of performance on key process points and clinical performance on key process points and clinical outcomes. outcomes.
Reports on : timeliness, treatment and outcomesReports on : timeliness, treatment and outcomes
Data and Metrics
Data ReportingData Reporting
Maine Quality Forum Critical AnalysisMaine Quality Forum Critical Analysis
Symptom Onset tomedical activation
EMS activation To patient arrival
EMS to 1st Hospital arrival
Door to Data
Data to Drug
Transfer to Cath Lab Arrival
Lab Arrival to reperfusion
TimelinessTimelinessIn median timesIn median times
Door to Drug GOAL: 30 minutes
Door to Balloon GOAL: 90 minutes
Data and Metrics
Door to Cath Lab Arrival GOAL: 60 minutes
Maine Quality Forum Maine Quality Forum Critical AnalysisCritical Analysis
Data ReportingData Reporting
Treatment ProvidedTreatment Provided
Primary PCIPrimary PCI
Lytic and PCILytic and PCILyticLytic
Coronary Artery Bypass graftsCoronary Artery Bypass grafts(CABG)(CABG)
Medical Treatment Medical Treatment or or
Comfort Measures OnlyComfort Measures Only
Data and Metrics
Data ReportingData Reporting
Maine Quality Forum Maine Quality Forum Critical AnalysisCritical Analysis
APPROPRIATE CARE METRICAPPROPRIATE CARE METRIC
# of STEMI patients receiving reperfusion therapy# of STEMI patients receiving reperfusion therapy
Total # of STEMI patients-#with contraindicationsTotal # of STEMI patients-#with contraindications
TIMELINESS OF CARE METRIC
# reperfused patients treated under goal# reperfused patients treated under goal
# of reperfused patients - # with clinically appropriate delay# of reperfused patients - # with clinically appropriate delay
Data and Metrics
Ongoing roleOngoing role
Continue to measure and report the system outcomes to improve the global and process improvement outcomes
Continue to address barriers to improvement of care within hospitals and across the state
Continuously update the care process and protocols with new evidence base science in the treatment of AMI
Data and Metrics