safer healthcare now! acute myocardial infarction presented by amanda thompson, safer healthcare now...
TRANSCRIPT
Safer Healthcare Now!
Acute Myocardial Infarction
Presented by
Amanda Thompson, Safer Healthcare Now Facilitator
Safer Healthcare Now! Background
Largest patient safety initiative in Canadian history
Adopted form IHI Over 600 teams registered
across Canada Goal to improve health care
delivery through 6 initiatives
Safer Healthcare Now! Initiatives
Acute Myocardial Infarction (AMI) Ventilator Associated Pneumonia
(VAP) Central Line Associated Infection
(CLI) Prevention of adverse drug
events through Medication Reconciliation (Med. Rec)
Prevention of Surgical Site Infection (SSI)
Rapid Response Teams (RRT)
AMI – Goal
• Decrease mortality rate for AMI by 20% by implementing all 6 elements
• NDBMH will have all 6 elements implemented by May 18th 2007
Six Elements of AMI
•Timely initiation of thrombolytics
•Early administration of aspirin
•Smoking cessation counseling/nicotine replacement
•Aspirin at discharge
•ACE or ARB at discharge
•Beta Blocker at discharge
“Canadian Cardiologists & experts who were consulted when developing …this kit agree, that these six care components should be provided to all patients with an AMI. Unless a clear contraindication exists and is documented in the medical record.”
Acute MI
Timely Initiation of Reperfusion with
Thrombolytics Defined as percent of AMI patients
who received thormbolytics within 30 minutes of arrival
A goal of 85% of patients with ST elevation or new LBBB on ECG
ST Elevation LBBB
Statistics on Thrombolytics
TNKase•ST elevation of 1mm or more, in
two or more contiguous standard limb leads
Or…•Elevation of 2 mm or more, in two
or more contiguous precordial leads
•New or presumed new LBBB
Thrombolytics within 30 Minutes
Where we are now…
20%
85%
0%
20%
40%
60%
80%
100%
Percentages
Thrombolytics within 30 Minutes
% Received
Goal
Early Administration of Aspirin
• Defined as percent of AMI patients who received ASA within 24 hours before or after hospital arrival.
• Prompt aspirin administration results in a 15% reduction in vascular events
• A study by the RAND corporation showed 61% of AMI patients received early administration of aspirin
• Goal is 90%
Early Administration of Aspirin cont’d
Where we are now…
87.5% 90%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Percentages
ASA on Arrival
% Received
Goal
Smoking Cessation/Counseling/ Nicotine
Replacement/Pharmacological Therapy
• Percent of AMI patients who received smoking cessation advice or counseling
• Any patient who has smoked in the past year
• Recommended: counseling combined with pharmacological therapy and cessation programs.
• Goal is 100%
Smoking Cessation/Counseling/ Nicotine
Replacement/Pharmacological Therapy cont’d
Where we are now…
0%
67%
100%
0%
20%
40%
60%
80%
100%
Percentages
Smoking Cessation
% Received
% of Smoking Patients
Goal
Beta Blockers at Discharge
Reduces AMI mortality in the first week by 13% and long-term mortality by 23%
IHI 100K Lives Campaign has used early administration of Beta Blockers
May be better to start Beta Blockers when patient is stable & then continue long term
Studies show risk for cardiogenic shock increased by 11 per 1000 on days 0-1 post MI
Goal 90%
Beta Blockers at Discharge cont’d
Where we are…
90% 90%
0%
20%
40%
60%
80%
100%
Percentages
Beta Blocker on Discharge
% Received
Goal
Common Beta Blockers
Timolol Timolol BetaxololBetaxolol
PropranololPropranolol MetoprololMetoprolol
LabetalolLabetalol AtenololAtenolol
Aspirin at Discharge
One study showed that after One study showed that after 5 weeks, patients who had 5 weeks, patients who had aspirin , had a decreased risk aspirin , had a decreased risk of vascular mortality (23%), of vascular mortality (23%), non fatal reinfarction (49%) non fatal reinfarction (49%) and non fatal stroke (46%).and non fatal stroke (46%).
Aspirin at Discharge
Goal 90%Where we are….
90% 90%
0%
20%
40%
60%
80%
100%
Percentages
ASA on Discharge
% Received
Goal
ACE or Angiotension Receptor
Blockers (ARB) at Discharge
ACE = proven to decrease mortality after an MI particularly in PTS with LV dysfunction, heart failure or both.
ARB = can improve heart failure, and is usually used when and ACE can not be tolerated.
Common ACE & ARB
Goal 85%
ACE InhibitorsACE Inhibitors
CaptoprilCaptopril
VasotecVasotec
EnalaprilEnalapril
RamiprilRamipril
MavikMavik
AccuprilAccupril
ZestrilZestril
ARBARB
CozaarCozaar
AvaproAvapro
DiovanDiovan
TevetanTevetan
AtacandAtacand
ACE or Angiotension Receptor
Blockers (ARB) at Discharge cont’d
Where we are….
60%
85%
0%
20%
40%
60%
80%
100%
Percentages
ACE on Discharge
% Received
Goal
“Perfect AMI Care”
Perfect AMI care = patient who receives all six elements within the time frame
30%
95%
0%
20%
40%
60%
80%
100%
Percentages
Perfect AMI Care
% Received
Goal
Admission Standing Orders
AMI Order SetAMI Diagnostic Criteria
ST elevated MI: Y___ N___
New LBBB: Y ___ N ___
Thrombolysis with 30 minutes
Time Administered ________ Contraindication _________
EKG Post TNK ________
4 hrs Post TNK ________
Common LABS ___________
Early Measures
Aspirin within 24 hours
Dose _______ Route _______ Time _______
“How to Improve Care”
Discharge Medication ProgramIncludes key AMI care components Aspirin: Y___ N___ Reason not given
___ Beta Blocker: Y ___ N ___ Reason not given ___ ACE/ARB: Y ___ N ___ Reason not given
___Smoking Counseling Provided
Y ___ N ___ Not Applicable ___ If “Yes”, Zyban Prescribed Y ___ N ___ Reason not
given___
Referral to Cardiac Rehab Program Y ____ N _____
“How to Improve Care” cont’d
This method has contributed to greater than 90% compliance with Aspirin and Beta Blocker guidelines
To be compliant, documentation must exist
Documentation of contraindication must exist
If documentation for any one area is missing patient is not considered as having perfect care
Statins at Discharge
66.66%
90%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
% Received Goal
Statins at Discharge
Mortality Rate
Where we are….
20.83%
16.66%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Percentages
AMI Inpatient Mortality
% Received
Goal
Education on AMI
Posters on AMI care
Education sessions
Increase public awareness
Change in policy and procedures
Questions?
Thank You!
Questions?