Dr. Mirle Kellett-Kim Tierney: Hit the Target Presentation

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


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.


Clinical Equipose CurveClinical Equipose CurvePCI Time Delay and OutcomePCI Time Delay and Outcome

Nallamothu, BK AJC 2003








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.


•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



Demographics


ED Data and Metrics Rebecca Chagrasulis, MD

Data and Metrics


Process Elements

PCI Center

EMS

Transport



Demographics


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


Process Elements

PCI Center

EMS

Transport



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


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


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


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

Documents

Dr. Mirle Kellett-Kim Tierney: Hit the Target Presentation