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Rapid Response Teams	Pressure Ulcers
Acute Myocardial Infarction	High-Alert Medications
Medication Reconciliation (ADE)	Congestive Heart Failure
Central Line Infections	MRSA
Surgical Site Infections	Surgical Complications
Ventilator-Associated Pneumonia	Boards on Board

Use this table to quickly find a mentor for improving Acute Myocardial Infarction care with demographics similar to your own, or use 'ctrl+f' in your web browser to search for specific key words on this page.

Aiken Regional Medical Centers – Aiken, SC
Availability Status: Available to answer requests
Licensed Beds: 225
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Marilyn Swanson, RN
Mentor Contact Email: marilyn.swanson@uhsinc.com
Mentor Contact Phone: 803-641-5773

Additional Information:

• Key to success has been consistent and enthusiastic support from the Board of Governors and Senior Adminitrative levels
• Aiken Regional has the advantage of having one cardiology group, making physician education and follow-up relatively easy.  This has also allowed us to achieve "one voice" in the expected management of the AMI patient.
• We found that in most cases, patients were receiving evidence based care.  Documentation of that care, however, was missing.  “Physician champions” were identified early who were very responsive to docu-prompters and other reminders.
• Identified “nurse champions” for each of the departments who are critical to the success of these initiatives.  This has promoted the concept of teamwork in achieving success by including those at the bedside in the development of solutions and education. We are quick to recognize departmental improvements by offering various rewards and recognition.
• Increased percent of patients receiving aspirin on arrival from 80% in 2005 to 100% in January 2006.
• Increased percent of patients receiving a beta blocker from 66% in 2005 to 89% in January 2006.
• Reviewed each case of mortality and no quality issues noted.  Many of the patients are DNR or Comfort Measures only.
[6/2/06]

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AnMed Health – Anderson, SC
Availability Status: Available to answer requests
Licensed Beds: 533
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Leigh Miller, Director of Clinical Outcomes
Mentor Contact Email: leigh.miller@anmedhealth.org
Mentor Contact Phone: 864-512-2480

Additional Information:

AnMed Health began a physician-led process improvement initiative in January 2005 to improve rapid diagnosis and treatment of the Acute Myocardial Infarction (AMI) patient.  The Medical Executive Committee endorsed a system-wide approach to improvement of AMI care after AnMed Health dropped to the 8th decile from the 5th in the CMS/Premier Hospital Quality Incentive Demonstration Project. Two physician led teams were formed to improve general care of AMI patients and to improve rapid diagnosis and treatment of STEMI’s (ST elevation myocardial infarctions).

Changes included development of an AMI Alert process in which the ED physician diagnoses the STEMI and pages the cardiologist and cath lab at the same time.  Goals were set around door to ECG ( < 10 minutes), door to cath lab
(< 45 minutes), door to balloon inflation (first < 120 minutes, since July 2006, < 90 minutes).  Order templates were developed in Emstat for the Emergency Department physicians to facilitate ordering quickly and accurately.  New alpha-numeric beepers were obtained for the cardiologists to facilitate Alert paging. 

The cath lab changed many of their processes.  Prep for emergency caths was minimized by leaving the cath lab equipment table ready for an emergency case at the end of the day. Call teams were rearranged to ensure no team included more than one member on any team had more than a 30 minute response time.  One person was designated to go straight to the ED to assist with prep for the cath lab as well as assist with transportation, while the other three team members went to the cath lab to get the equipment ready. 

Preprinted orders were revised to include all AMI indicators as well as other evidence-based guidelines. The orders were built in our CPOE system for those physicians trained on that system.  The electronic template of the paper version was added to the home page of the physician portal to ensure that any physician not using CPOE could easily print a copy.  Plans of care were revised and added to electronic nursing documentation to ensure all AMI patients were receiving needed treatments and education.  Preprinted discharge orders were developed and printed to ensure the physician did not miss any needed discharge medications.

Every AMI alert is reviewed by a multi-disciplinary team from the Emergency Department, the Cath Lab, Clinical Outcomes and Process Improvement. Any patient not meeting established goals is examined carefully for breaks in process. Feedback is given to the individual physician by the CV Services medical director with assistance of the AMI case manager. Reports are given at bimonthly Cardiology Department meeting, as well as Internal Medicine Department.  Outcomes are reviewed monthly at the Quality Coordinating Council, as well as at the Quality Committee of the Board of Trustees.

• At the beginning of the initiative, only 45% of the STEMI patients received PCI in less than 120 minutes and only 37.5% in less than 90 minutes. During the last reported quarter (Q3 2006), 96% of the patients received PCI in less than 90 minutes. We have been below 90% only one quarter since Q2 2005.  AnMed Health’s current performance for door to PCI time is averaging 81 minutes.
• In Q1 2005, only 77% of those patients with left ventricular systolic dysfunction received an ACE-I or ARB. For the past six quarters,100% of patients with left ventricular systolic dysfunction received an ACE-I or ARB.
• In Q1 2005, mortality for AMI patients was 13%. Mortality for AMI patients has run 1.96-5.71% since Q2 2005 with all but one month below 5%.
• The preprinted orders and diligent attention by staff has impacted all AMI indicators. In Q1 2005, 95% of patients received aspirin on admission. Since Q3 2005, only one month has fallen below 100% (99%).  Only 93.26% of the AMI patients received aspirin on discharge in Q1 2005.  When we also changed our CABG discharge orders in Q4 2005, we immediately went to 100% and have sustained that. 
• Beta-blocker use on admission was 93.5% in Q1 2005, but has been 100% since Q4 2005.  On discharge, beta-blockers were given 91.67%, but have been 100% since Q4 2005.
• The Perfect Care Score 67.83% in Q1 2005, but had been consistently between 65 and 70% since Q4 2003.  It has steadily increased since we began the process improvement.  Since Q4 2005, it has been below 97% only once (94.36%).

Our improvements have been possible due to every person involved in the process knowing what has to happen, why it's important, and how that person fits in making it work.  We have celebrated our successes with staff in all involved departments: ED, Cath lab, CCU, telemetry, Clinical Outcomes, and the physicians. The true winners have been the persons in our community who present at AnMed Health with Acute Myocardial Infarctions.

[6/26/07]

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Aurora Sinai Medical Center – Milwaukee, WI
Availability Status: Available to answer requests
Licensed Beds: 386
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: October 2003
Mentor Contact Name: John Whitcomb, MD
Mentor Contact Email: john.whitcomb@aurora.org
Mentor Contact Phone: 414-219-4940

Additional Information:

• Site-based interdisciplinary team with hospitalist and physician champion.
• Staff education on AMI care components.
• Concurrent monitoring of cases.
• Review of case "fall-outs" by a team of physicians, nurses and physician assistants in the Emergency Department with a spirit of exploration of barriers.
• Real time feedback to physicians and nurses which has increased awareness and dialog about performance criteria.
• Door to balloon time process simplified. ED calls cardiologist and then cath lab. No longer have to wait for cardiology fellow to come in and see patient.
• Spirit of healthy competition and desire to be the best among ED staff members.
• Recognition and reward/token of appreciation for best performance through e-mails, posters, announcements at meetings and the "Wall of Fame."
• Repetitive education to attain lasting behavioral change.

• Door to balloon time in the first half of 2005 averaged 100 minutes, falling to an average of 88 minutes in the second half. The shortest time being 29 minutes.
• Smoking cessation education improved from 71.4 % at the beginning of 2004 to a consistent 100% through 2005.
• AMI inpatient mortality remains below national comparative rates.
[5/12/06]

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Avera Heart Hospital of South Dakota – Sioux Falls, SD
Availability Status: Available to answer requests
Staffed Beds: 55
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: July 2002
Mentor Contact Name: Peggy Goos
Mentor Contact Email: peggy.goos@medcath.com
Mentor Contact Phone: 605-977-7025

Additional Information:

Avera Heart Hospital of South Dakota (AHHSD) has been actively working to improve AMI care since July 2002.  In October 2005, AHHSD adopted the IHI 100,000 Lives Campaign initiative related to improved care for acute myocardial infarction patients.

The focus of the improvement process related to the 100,000 Lives Campaign has been to maintain high compliance rates with all measures and specifically to decrease door-to-balloon time.  Our work on this intervention includes:

• Development and implementation of AMI admission order sets, with continual evaluation and modification as needed
• Campaign to increase awareness of intervention among physicians and clinical staff
• Development and implementation of a hospital Code STEMI team
• Collaboration with the local ambulance service and referring hospitals to improve care of the AMI patient prior to
  AHHSD receiving patient 
• The improvement process has led to a much greater awareness of appropriate and timely AMI care among all
  physicians and clinical staff with all working as a team toward a common goal.

Improvement efforts since mid-2002 have resulted in nearly 100% compliance with all measures.  An intensive improvement process focused on door-to-reperfusion time has led to vast improvement in timeliness.

Average Door-to-Reperfusion Times:

Fiscal Year 2005 (October 2004-September 2005)       205 minutes
Fiscal Year 2006 (October 2005-September 2006)       120 minutes
Fiscal Year 2007 (October 2006-September 2007)       52 minutes

Through March 2008:

• Smoking Cessation education 100% compliance for 31 consecutive months
• Aspirin at Arrival 100% compliance for 16 consecutive months
• Beta Blocker at Arrival 100% compliance for 19 consecutive months
• Aspirin Prescribed at Discharge 99.7% for last 12 months
• ACE-I/ARB for LVSD  96% for last 12 months
• Beta Blocker Prescribed at Discharge 99.7% for last 12 months
• Average Door-to-Balloon Time for last 12 months:  64 minutes where 92% of patients (1 fallout) with time < 90
 minutes (compared to 22% in 2005)
According to Thomson Top 100 and HealthGrades, Avera Heart Hospital of South Dakota's risk-adjusted AMI mortality rate is significantly lower (statistically) than the peer and benchmark groups.  AHHSD has been named a Thomson Top 100 Cardiovascular Hospital for two consecutive years and Top 5% in Cardiovascular Services by HealthGrades for five consecutive years.
[5/1/08]

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Ball Memorial Hospital – Muncie, IN
Availability Status: Available to answer requests
Licensed Beds: 350
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: June 2006
Mentor Contact Name: Claire Lee, Director of Quality Management
Mentor Contact Email: clee@chsmail.org
Mentor Contact Phone: 765-747-4284

Additional Information:

The quality structure for Ball Memorial Hospital is comprised of clinical collaborative teams focused on quality/safety measures for a specified patient population.  The Cardiology Collaborative Team is accountable for monitoring and implementing process improvement initiatives surrounding AMI Care.  A physician champion has been identified and co-leads this team with the administrative director for cardiology services.  All data is abstracted through the quality department and educational letters are forwarded to physicians as their cases fall out.  If physician trends are identified, the cases are taken through the peer review process.  All data is included in the quality profile for recredentialing.  A rapid response process was implemented between the ED and Cath Lab to improve Door-to-Balloon Time.

All measures are greater than 95%
AMI Mortality Rate has been well below the ACC benchmark for a number of years and is currently 3.6%.
[2/8/08]

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Baystate Medical Center – Springfield, MA
Availability Status: Available to answer requests
Licensed Beds: 636
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January, 2000
Mentor Contact Name: Jan Fitzgerald, RN
Mentor Contact Email: janice.fitzgerald@bhs.org
Mentor Contact Phone: 413-794-2531

Additional Information:

Baystate Medical Center has been successful in incorporating key AMI evidence based components/interventions into clinical care through use of CPOE (Computerized Physician Order Entry), CPG, real time cue/prompt, standardization of care, ongoing performance monitoring/feedback and engaging clinical champions in leading the process review, change and ownership.

We achieved top 10th decile performance in PY 1 of the HQID (CMS/Premier Hospital Quality Incentive Demonstration). High levels of primary and secondary interventions (such as but not limited to ASA on admission and DC, beta blockers on admit/DC - consistently at > 95%) are consistently in place through use of the 3 tier design system.  Our AMI mortality has consistently been well below the national, state and comparative rates.
[1/31/06]

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Berkshire Medical Center – Pittsfield, MA
Availability Status: Available to answer requests
Licensed Beds: 309
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: 2001
Mentor Contact Name: Rick Glasener
Mentor Contact Email: rglasener@bhs1.org
Mentor Contact Phone: 413 447-2383

Additional Information:

Implementation of the American Heart Association's Get With The Guidelines program at Berkshire Medical Center using a multifaceted approach including multidisciplinary rounds was associated with improved treatment rates.
Patient centered multidisciplinary rounds occur 4 times per week in 1 hour sessions provide concurrent feedback using realtime data. Multifaceted approach also includes CPOE order set, cardiovascular disease checklist, documentation tool, and physician reminders. System of Care is adaptable to changing and new measures. Significant increase in treatment utilization compared to pre-intervention which has been sustained for over 4 years.

Smoking cessation advice counseling has improved from 43% baseline to 100% (Q1 03 – Q2 05) sustained performance.
Aspirin at discharge has improved from 96% baseline to 100% sustained performance (Q3 03 – Q2 05).
Beta-blocker at discharge has sustained 100% performance (Q1 03 – Q2 05).
ACEI at discharge has sustained performance (Q3 04 – Q2 05) at 97%
Lipid lowering medication in eligible patients has improved from 59% baseline to 100% (Q3 04 – Q2 05)
Cardiac Rehab referral rates have increased from 14% baseline to 98% (Q3 04 – Q2 05).
[2/14/06]

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Centra Health – Lynchburg, VA
Availability Status: Available to answer requests
Licensed Beds: 403
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: 2002
Mentor Contact Name: Kathy Traylor
Mentor Contact Email: Kathy.Traylor@Centrahealth.com
Mentor Contact Phone: 434-947-3465

Additional Information:

Centra Health has led the way in door to device time since they started tracking it in NRMI in 2002.  The guideline for discharge therapy showed its most remarkable improvement in 2004 with the initiation of discharge contracts. Strong physician champions and teamwork with emergency department have also helped to make the improvements.

• We went from an 83.3% discharge on aspirin to a 96.2% discharge on aspirin.
• Beta Blocker on discharge improved with the contracts from 82.5% to 95.3%.
• Ace on discharge went from 75% to 81.6% compliance on discharge.
• Smoking cessation education went from 92.8% to 93.3% compliance.
• Door to device time changed from 83.5% to 88% within 120 minutes and within 90 minutes from 80.6% in 2004 to 85.1% in 2005.
[3/30/06]

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Charleston Area Medical Center – Charleston, WV
Availability Status: Available to answer requests
Licensed Beds: 913
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: July 2003
Mentor Contact Name: Kim Kendrick, Six Sigma Black Belt
Mentor Contact Email: kim.kendrick@camc.org
Mentor Contact Phone: 304-388-4310

Additional Information:

Focused on high volume indicators initially including ASA and Beta Blocker at Discharge
Developed a process to randomly audit 10 patients per week for defects
Simplified the AMI order set to increase utilization and compliance- added check box for contraindications for discharging medications
Created a physician and unit monthly report to communicate performance and progress toward goal
Worked with the physician group to improve individual compliance with best practice recommendations
Developed a ‘Cardiac Alert’ call for ED similar to the Trauma Call plan and improved door to PCI time by heightening awareness and focus on patient on admission.

We have moved from 88% compliance with Smoking Cessation to maintaining 100% over the last 5 months
Aspirin at Arrival increased from a low of 90% to 93-100% compliance
Aspirin at Discharge increased from a low of 93% to consistent 99-100% for the last nine months
Beta Blocker on arrival increased from 83% to a consistent 100% for the previous 4 months
Beta Blocker at discharge has increased from a low of 91% to >97% for the last 8 months
Perfect Care for AMI has increased from 96% to 98.98%.
[1/31/06]

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Christiana Care Health Systems – Newark, DE
Availability Status: Available to answer requests
Licensed Beds: 675
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: Before 2003
Mentor Contact Name: Maria Albert RN, PI Program Manager
Mentor Contact Email: malbert@christianacare.org
Mentor Contact Phone: 302-733-5417

Additional Information:

The American Heart Association’s “Get With The Guidelines” program is a quality-improvement program that helps hospitals insure that patients consistently receive cardiac care in accordance with best practice guidelines and recommendations.

In June 2007, an interdisciplinary team at Christiana Care recognized the importance of engaging and stimulating conversation between our staff and patients on best practice guidelines for myocardial infarction (MI).  A team of nurses and physicians assessed direct care nurses' current knowledge of best practice interventions for patients with acute MI using a pre-test/post-test method and focus groups. Innovative educational tools developed included:

•  Creative acronym “BLAAST” for best practice interventions
B = Beta blocker
L = Lipid lowering therapy
A = Aspirin
A = ACE/ARB
S = Smoking cessation
T = Talk to your doctor or health care provider

• “ASK ME ABOUT BLAAST” button to encourage dialogue among the health care team as well as between staff and  patients/families

•  Standardized  'BLAAST' script card

Christiana Care was able to roll out the initiative on the pilot unit very quickly and with great results. We are now expanding to a hospital-wide rollout.

The BLAAST those MI's team is now viewed as a very positive resource in the hospital, as the medical staff/cardiology fellows have joined in providing education sessions.  This project has won an award for clinical excellence at our hospital's annual "Focus on Excellence" awards.

Results show that the BLAAST button provided engagement of staff and stimulation of conversation between staff and patients.   Publicly reported core measures for acute MI in the cardiac step down pilot unit were less than 100% at base line for 4 out of 5 measures with a range of 91.5% to 97%.  Post data showed 100% for all 5 measures.  The “BLAAST THOSE MI’S” initiative may have influenced staff knowledge resulting in 100% compliance in core measures on the pilot unit.

[12/6/07]

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Cleveland Regional Medical Center – Shelby, NC
Availability Status: Available to answer requests
Licensed Beds: 241
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: 2005
Mentor Contact Name: Liz Popwell, CHE
Mentor Contact Email: elizabeth.popwell@carolinashealthcare.org
Mentor Contact Phone: 704-487-3690

Additional Information:

CRMC implemented a concurrent chart review and intervention process.  This process includes active intervention and follow up among the Quality Management staff and direct care givers.  Weekly monitoring of our processes as well as "All-or-none/perfect process" indicators have improved mortality as well as process indicator compliance.

Mortality reduction from 8.74% to 6.9%
Perfect process compliance is greater than 95% for 1 year and 6 months
Process compliance for all indicators is 95% or higher.  ASA on arrival and DC, beta blocker on arrival and discharge, ACEI or ARB and Smoking Cessation have been 100% for over a year.
[2/7/07]

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Community Hospital Anderson – Anderson, IN
Availability Status: Available to answer requests
Licensed Beds: 207
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: ?
Mentor Contact Name: Cleo Ann Burgard
Mentor Contact Email: cburgard@ecommunity.com
Mentor Contact Phone: (317) 621 5329

Additional Information:

This intervention is spread throughout our five (5) Network hospitals:  Community Hospital Anderson, Community Hospital East, Community Hospital North, Community Hospital South, and the Indiana Heart Hospital

• The Community Health Network utilized the National Registry for Myocardial Infarction (NRMI) as a means to collect our data
• Best practices were identified and implementation of these quality improvement measures have been undertaken
• Development of standard order sets, pathways and discharge instructions sheets occurred to facilitate best practice
• Education regarding best practice standards to all staffing members
• Development of Code STEMI team to facilitate process improvement

• Process redesign has resulted in a significant reduction of lytic administration to an average of 18.4 minutes for 2005
• Process redesign has resulted with an overall improvement of medication administration with >90% compliance for all of our patients admitted with a primary diagnosis of AMI
• 100% of patients within the Community Health Network receive smoking cessation information
• Overall mortality reduction of >1%
• Decreased door to balloon times by 20% since initiation of Code STEMI
[2/14/06]

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Doylestown Hospital – Doylestown, PA
Availability Status: Available to answer requests
Staffed Beds: 196
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: February 2005
Mentor Contact Name: Michele Clugston, RCIS
Mentor Contact Email: mclugston@dh.org
Mentor Contact Phone: (215) 345-2554

Additional Information:

Following a review of the hospital processes related to acute myocardial infarction (AMI) care, Doylestown Hospital felt we had an opportunity to improve the care provided and to have the various hospital departments work more cohesively as a team to ensure that all AMI patients for which PCI was indicated received the intervention in 90 minutes or less upon arrival.

LESSONS LEARNED
The development of a team philosophy among the members of the ED and cardiac cath lab (CCL) staffs (including strong interdepartmental and interdisciplinary communication and problem-solving) was critical to our success. This team came up with a number of enhancements, including development of an ACS form, physician champions, case management prompts to improve documentation, and utilizing real-time chart review. 

Simple solutions helped save time, such as utilizing pacer pads instead of the traditional 3-lead system for patient transport, ensuring a 500 mL bag of normal saline was running on all patients, and taking time to remove trousers on the front end.  ED staff would also stay in the CCL to ensure that the CCL staff had time to set up the room, supplies and other activities, especially in the off hours, and CCL staff would come to the ED to pick up patients during increased census and acuity times in the ED.

One of the things our team is most proud of is an innovative and simple solution that helped keep this initiative in the forefront of all health care team members' minds.  Bulletin boards (in both the CCL and ED) provide a simple pictorial depiction of the AMI process so staff can better visualize the process, identify where there are delays, and suggest changes. Physicians, nurses, patients, families, administrators, and many others find this spurs discussion.  Pictures illustrate the steps in the process including a door to indicate time of arrival, an EKG strip to depict time of first EKG, a phone to indicate time the CCL was notified, and, finally, a whimsical balloon to indicate successful reperfusion.  At the end, a football referee indicates "GOAL" at the 90-minute mark.  A change identified early on was to have the ED physician alert the CCL of the AMI patient in the ED.  This has cut 10 minutes off of our mean D2B times.

Recently, we performed a mock STEMI drill with our EMS, ED and cath lab in which a real patient and his wife participated. We had a separate team critique all those participating in order to be objective and we met afterward to review processes. (The D2B time was 38 minutes.) One of the key things we learned was the need to increase communication to the patient and family during treatment. We are working to enhance our relationship with all EMS squads by meeting with them quarterly to review MI cases and by having them observe in the ED and the cath lab so that we can incorporate them in the team goals.

There is still room for improvement by capitalizing on use of pre-hospital EKGs and utilizing in-house cardiothoracic physician assistants to set up the Cardiac Catheterization Laboratory during off hours.

- The baseline door-to-balloon time at the start of the project (July 2004 - June 2006) was 84.3 minutes, but only 70 percent of the patients eligible for PCI were receiving the intervention in 90 minutes or less.
- Current door-to-balloon time (July 2007 - March 2008) averages 62.5 minutes, an approximately 22 minute improvement in mean time to PCI.
- For the period July 2007 - June 2008, remeasurement demonstrated that 93.9 percent of all AMI patients eligible for PCI received the intervention in 90 minutes or less.
- Permitting the Emergency Department physicians to call the Cardiac Catheterization Laboratory team reduced on average 10 minutes of the mean door-to-balloon time.

Here is the data (mean, median, %):

Phase                              Mean time to PCI             Median time to PCI     % < 90 min.
Baseline (Jul 04–Jun 06)    84.3 min.                        79.2 min.                  70.3
After improvements          65.6 minutes                   60.5 minutes             91.7
(July 06– Mar 08)

Most recent performance measures (July 2007 - March 2008):

Percent AMI patients who received ASA within 24 hours before or after hospital arrival:  99.4%
Percent AMI patients prescribed ASA at discharge:  99.2%
Percent of AMI patients who received beta-blockers within 24 hours after hospital arrival:  99.3%
Percent of AMI patients prescribed beta-blocker at discharge:  100%
Percent of AMI who were prescribed for ACEI or ARB at discharge:  100%
Percent of AMI patients (cigarette smokers) who received smoking cessation advice or counseling during hospital stay:  100%

Percent of AMI Patients with "Perfect Care":  97.8%

AMI Inpatient Mortality
2005: 1.8%
2006: 1.5%
2007 & 1Q 2008: 0.6%

[8/15/08]

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DuBois Regional Medical Center – DuBois, PA
Availability Status: Available to answer requests
Licensed Beds: 239
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: May 2004
Mentor Contact Name: Carole Berger, RN, BSN, Performance Improvement Manager
Mentor Contact Email: cvberger@drmc.org
Mentor Contact Phone: (814) 375-3329

Additional Information:

•Educating staff on the evidenced-based components of care of AMI patients with emphasis on door to balloon inflation times of less than 120 minutes (“Time is Muscle”).
•Developing standard AMI admission and discharge order sets, listing essential medications and check boxes to indicate reason if medications were not administered/ordered.
•Developing an accompanying ED/cath lab tracking sheet, listing essential steps and times. All sheets are reviewed and help pinpoint system delays in need of correction.
•Improved access to medications stored in the cath lab by installing a keyless, secure entry system to prevent lost minutes while retrieving keys.
•Provided staff and physicians with regular reports featuring door to EKG times, door to balloon inflation times, and AMI core measure component and composite data. (Aggregate and physician-specific AMI core measure reports provided quarterly.)
•Developed a Cardiovascular Morbidity/Mortality Committee to provide in-depth review of any complications/deaths and input on improving care delivery processes.
•Drove change through providing frequent measurement and feedback, including practitioner-specific data (timely, objective, useful, and relevant).
•Involved medical staff, senior management, and board of directors.
•Identifying physician champions.
•Increasing motivation of staff, leaders, and board members by presenting success stories (using actual cases).
•Assured that changes were well thought out and communicated - reducing rework later - by investing time during the planning phase of the PDSA cycle.

We improved the acute myocardial infarction (AMI) composite score from 89.4 to 91.7, and 100 percent of patients with an ST elevated myocardial infarction (STEMI) had a door to balloon inflation time within 120 minutes (an increase from 62 percent in FY04).
[1/31/06]

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Evergreen Hospital Medical Center – Kirkland, WA
Availability Status: Available to answer requests
Licensed Beds: 244
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: Core Measures Team formed in January 2005
Mentor Contact Name: Kathy Schoenrock
Mentor Contact Email: kmschoenrock@evergreenhealthcare.org
Mentor Contact Phone: 425-899-2495

Additional Information:

Contributing to our success: (1) a committed Core Measures Team that provides strong physician leadership and facilitates collaboration among physicians and nursing to educate and to expect best practice; (2) development of the Core Measure Checklist that prompts caregivers on their role in addressing core measure requirements.  This tool has been shared across the country through our participation in the CMS Discharge Initiative Project in summer 2005; (3) concurrent chart review by the Quality Management staff; (4) Physician and nursing unit quarterly report cards; particularly physician report cards that provide individual performance compared with peers; (5) Door to Balloon Team that brings ED and Cath Lab together to improve performance.

At least 90% compliance on all AMI interventions; steady, incremental improvements since 2004.
[6/10/06]

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Fauquier Hospital – Warrenton, VA
Availability Status: Available to answer requests
Licensed Beds: 86
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: January 2006
Mentor Contact Name: Catherine Walsh
Mentor Contact Email: walshc@fauquierhospital.org
Mentor Contact Phone: 540 349 0584

Additional Information:

To comply with the seven interventions that are a part of an improved AMI care plan initiative, Fauquier Hospital has successfully implemented: standing orders; revision of discharge summary forms to include smoking cessation counseling; revision of admission assessment to include questions related to smoking cessation; development of quality indicator dashboard that is presented to Utilization Management Steering Committee and Board of Trustees on a monthly basis; participation in Virginia Collaborative.

Fauquier Hospital has achieved 100% with indicator related to patient's receiving aspirin within 24 hours of arrival; 88% with aspirin prescribed at discharge; 100% ACEI for LVSD; 88% beta blocker at discharge and 94% beta blocker at arrival.  We have also made great strides in patients receiving smoking cessation advice/counseling.
[8/19/06]

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Kaiser Foundation Hospital - Fremont-Hayward Medical Centers – Fremont, CA
Availability Status: Available to answer requests
Licensed Beds: 316
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: July 2003
Mentor Contact Name: Lorelle Poropat
Mentor Contact Email: Lorelle.Poropat@kp.org
Mentor Contact Phone: (510) 300-5964

Additional Information:

For almost two years, the Kaiser Foundation Hospital - Fremont/Hayward Medical Centers has had a multidisciplinary core measure teams that meet regularly and are committed to the success of all of the core measure interventions.  We review AMI patients concurrently, while they are still hospitalized and we are able to make improvements in care. 

We have taken unique, innovative approaches to encouraging our patients to not smoke.  We developed a smoking cessation brochure called "Freedom From Tobacco For You and Your Family."  The brochure is unique because it gives advice for those who smoke as well as advice on how to encourage others to quit smoking.  Another approach we have taken is to identify smokers while they are hospitalized by affixing an ambiguous identifier on the spine of the patient's chart alerting nurses that the patient needs smoking counseling.  The nurse removes the identifier from the chart once the counseling has been done, gives the identifier to their manager who rewards and recognizes the nurse.

Kaiser Foundation Hospital - Fremont/Hayward Medical Centers has developed a standard of practice for all chest pain patients who immediately get an EKG upon arrival as well as aspirin and beta blockers.

Kaiser Foundation Hospital - Fremont/Hayward Medical Centers has demonstrated 95% or higher for perfect care for AMI patients in the last 5 months.  We have demonstrated success in giving our patients aspirin within 24 hours of arrival with 100% compliance for almost a year.  Patients receiving aspirin on discharge has been at 100% compliance for 6 months.  Patients receive beta blockers on arrival to our hospital 100% of the time for 12 of the last 15 months.  Beta blockers on discharge are given 100% of the time over the last 2 years.
[10/28/06]

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Kapiolani Medical Center at Pali Momi – Aiea, HI
Availability Status: Available to answer requests
Licensed Beds: 116
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: June 2005
Mentor Contact Name: Kellé Payne
Mentor Contact Email: kpayne@kapiolani.org
Mentor Contact Phone: 808-485-4374

Additional Information:

• Within first 6 months physician education
• Hand written cards of thanks and public recognition of compliance rates occurred
• Individual physicians were shown their compliance rates when they were under achieving
• Joint chart review between Quality Dept and physician began at 6 months and continue to present
• Nursing education and buy in to audit for compliance
• Physician to physician accountability of bundle elements began at 12 months
• 100% chart audit is ongoing
• New physician orientation to process and expectations began at 18 months

• Pre-intervention (retrospective) measurement:  January to October 2004 gave value of 35% compliance.  Our AMI mean composite score at this time was only 26%.
• After 1st six months:  reduction in mortality of 47%
• After 18 months:  reduction in mortality of 87%
• 1st six months: < 50% compliance by physicians involved in care of the AMI patient
• After 12 months: 100% compliance
• Pali Momi has now achieved 17 months of 100% compliance to bundle for all AMI patients
[2/7/07]

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McLeod Regional Medical Center – Florence, SC
Availability Status: Available to answer requests
Licensed Beds: 371
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: October 2004
Mentor Contact Name: Daphne Heffler
Mentor Contact Email: dheffler@McLeod.org
Mentor Contact Phone: (843) 777-2548

Additional Information:

The following Quality Indicators have been utilized to improve care: Aspirin on arrival and at discharge. Beta Blockers on arrival and at discharge. ACE/ARB for EF<40%. Smoking Cessation Counseling. PCI within 90 Minutes. Thrombolysis within 30 Minutes.

We have utilized evidence-based practice and physician-led teams to accomplish a composite score of 96.99% from Oct 04 to June 05.
[2/14/06]

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Medical Center of Plano – Plano, TX
Availability Status: Available to answer requests
Licensed Beds: 350
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2006
Mentor Contact Name: Julia Campbell RN, MBA, CPHQ
Mentor Contact Email: julia.campbell1@hcahealthcare.com
Mentor Contact Phone: 972-519-1347

Additional Information:

• Regular monthly interdisciplinary meetings with all team members were started.
• AMI cases that fell outside of desired outcomes for process measures were reviewed by the interdisciplinary team.
• Atomic clocks were implemented in the ED and Cath Lab to facilitate accurate data collection.
• Obtaining EKGs in triage was implemented.
• Chest Pain Order sets were developed and implemented.
• Point-Of-Care Testing for cardiac markers was implemented.
• “Cross-training” between AMI and Cath Lab staff was done.
• EMS faxing of EKGs from the field to the ER was implemented.
• Dedicated Interventional Cardiology call for Acute MI with contracted physicians implemented.
• Extensive collaboration and feedback to EMS on individual cases and times was implemented.

• We have achieved 100% compliance with all AMI Core Measures for over 6 months, including PCI within 90 minutes, use of aspirin, beta blockers, ACE Inhibitors or ARBs and smoking cessation counseling.
• We have achieved 100% compliance with PCI within 90 minutes for all cases in 2007.
• We have lowered our Median Door-to-Balloon Time to under 60 minutes for all quarters in 2007.
• We have achieved 67% compliance with patients receiving Primary PCI within 60 minutes of arrival.
[2/8/08]

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Mercy Medical Center – Cedar Rapids, IA
Availability Status: Available to answer requests
Licensed Beds: 445
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: January 2004
Mentor Contact Name: Sue Dawson, MA, RN, CCRP
Mentor Contact Email: sdawson@mercycare.org
Mentor Contact Phone: 319-221-8536 or 319-533-8869

Additional Information:

Mercy developed the "ABCDs of Care” concept as a quick and easy way to highlight all Class I recommendations for the care of the AMI patient:

A - Aspirin on admission and discharge AND ACE- I or ARB for an EF < 40%
B - Beta- Blockers on admission and discharge
C - Cholesterol assessment and treatment
D - Dysphagia screening on admission to the unit
S - Smoking cessation education (if the patient has smoked within the previous year)

Additionally, all cardiac order sets highlight the Class I recommendations for the care of the AMI patient.

Developed the "Evidence-Based Risk Stratification Tool" for any patient that presents as a potential acute coronary syndrome patient.

In June 2005, convened the first STAT (STEMI Time to PTCA Action Team) meeting. This is a multidisciplinary team approach to improving the care of the ST-Segment Elevation MI (STEMI) patients.

• Hospital-wide mortality reduction of 5.29%.
• In June 2005, Mercy's average door-to-balloon time was 125 minutes and by March 2006 our average time had decreased to 80 minutes.
• In the 4th Q 2005, Mercy had 100% compliance in ASA on admission and discharge, Beta-blockers on admission and discharge, ACE-I/ARB for LVSD, and smoking cessation education.
• STEMI mortality decrease from 2004 to 2006: 82%
• STEMI mortality decrease from 2005 to 2006: 77%

[3/17/07]

*                *                  *

Mercy Medical Center – Des Moines, IA
Availability Status: Available to answer requests
Licensed Beds: 629
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: July 2004
Mentor Contact Name: Sister Maurita Soukup, RN, DNSc
Mentor Contact Email: msoukup@mercydesmoines.org
Mentor Contact Phone: (515) 643-3535

Additional Information:

Empowered to improve organizational JCAHO core measure performance for 100% of AMI patients, Mercy Medical Center-The Iowa Heart Hospital's multidisciplinary teams engaged in evidence-based practice leadership with performance targets established at 100% for each of the AMI seven core measures.  Patients not meeting AMI JCAHO core standards were examined through case reviews and 1:1 physician/nurse coaching.  Key processes contributing to success included:  physician and nurse education, standardized physician order sets, reference cards, multidisciplinary team rounds, Level 1 Heart Attack Protocol for improving Time to PCI, and monthly monitoring/reporting of AMI Perfect Care  performance to 100% target, with 1:1 coaching/mentoring of physicians/nurses when a standard was not achieved.  Outcomes, including state and national comparisons and Mercy's contribution to the national 100,000 Lives Campaign, were recognized and celebrated. The Level 1 Heart Attack Protocol initiative for improving Time to PCI was expanded to 21+ rural and network communities and hospitals with proven success.

From July 2004 through June 2006, 99.08% (N=1187/1198) of our AMI patients received Perfect Care.  During these 24-months, 11 patients missed only 1 core measure.  (Perfect Care is operationally defined as 100% of our AMI patients received 100% or all 7 of the AMI core measures.)  AMI Mortality was reduced 1% in FY '05.   The Level 1 Heart Attack Protocol initiative clearly improved Time to PCI, (Mean = <60 minutes for Mercy-DM), and is recognized as a Best Practice initiative.
[2/7/07]

*                *                  *

North Suburban Medical Center – Thornton, CO
Availability Status: Available to answer requests
Licensed Beds: 157
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: July 2004
Mentor Contact Name: Eileen Caden
Mentor Contact Email: eileen.caden@healthonecares.com
Mentor Contact Phone: 303-450-4559

Additional Information:

Initiated North Metro Cardiac Alert involving 5 EMS agencies. EMS interpret 12 lead EKG in field and notify ED physician of acute MI. Cardiac alert is called in house. The cardiac alert team consists of cardiologists and cardiovascular lab staff.
Implemented new order sets for early administration of aspirin and beta blocker and added documentation area for contraindications.
Constant feedback to physicians on compliance with the bundle through congratulatory certificates, letters, graphics, posters and department meetings.

Current PCI time of 61 minutes and and overall 97% compliance with the bundle.
[5/12/06]

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Northwestern Memorial Hospital – Chicago, IL
Availability Status: Available to answer requests
Licensed Beds: 811
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: December 2003
Mentor Contact Name: Bob Costello
Mentor Contact Email: rcostell@nmh.org
Mentor Contact Phone: (312) 926-4714

Additional Information:

Successful Implementation Strategies
(1) Collaboration of ED, Cardiology and Cath Lab clinicians
(2) Dedicated EKG room in the ED
(3) Algorithm for patients with signs and symptons of AMI based on AHA guidelines
(4) Standardized protocol for care
(5) Continuous review of outliers

Performance continues to exceed 95% compliance with AMI guidelines.
[1/31/06]

*                *                  *

Our Lady of Lourdes Memorial Hospital – Binghamton, NY
Availability Status: Available to answer requests
Licensed Beds: 267
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: March 2004
Mentor Contact Name: Jill Patak, RN, Quality Engineering Specialist
Mentor Contact Email: jpatak@lourdes.com
Mentor Contact Phone: 607-798-5881

Additional Information:

The AMI team developed and tested pre-printed physician orders. The orders were tested in the Emergency Department and on the telemetry unit. The team also added the indicators to the patient care path; patient teaching guide and the discharge instructions.
Our hospital does not have a cardiac cath lab. We worked collaboratively with the other hospital in town, to transfer our AMI patients in need of an urgent cardiac cath within 60 - 90 minutes, so the patient can have the PCI within the 120 minutes as recommended by JCAHO and CMS for facilities that perform PCI.

January through November	2004	2005
ASA @ Arrival:	94%	96%
ASA @ Discharge:	94%	95%
ACEI / ARB LVSD:	82%	94%
Smoking Cessation Advice:	62%	100%
Beta Blocker @ Arrival:	95%	95%
Beta Blocker @ Discharge:	93%	96%
Inpatient Mortality:	8.4%	7.4%

[1/31/06]

*                *                  *

Parkview Medical Center – Pueblo, CO
Availability Status: Available to answer requests
Licensed Beds: 305
Teaching / Non-Teaching Status: Non-teaching
Setting: Urban
Start Date of Intervention Work: July 2003
Mentor Contact Name: Judy Sikes, PhD, CPHQ
Mentor Contact Email: jsikes@parkviewmc.com
Mentor Contact Phone: 719-584-4650

Additional Information:

Parkview Medical Center has chosen to participate in all of the AMI measures and we believe the overall process has contributed to the lowering of our AMI mortality rate.

The AMI team developed and tested pre-printed physician orders. The orders were first tested in the Emergency Department using the indicators as a development guide. Getting the ER physicians on board helped to make immense improvement.  We are now working on PCI timing and we have established an interdisciplinary team with the ER physicians, Cardiologists and staff.  All of our other AMI indicators are scoring as follows:

ACE-I on D/C for LVSD:	100% for the past 22 months
ASA on Arrival:	100% for the past 26 months
ASA on D/C:	100% for the past 26 months
Beta Blocker on Arrival:	100% for 20 of the last 22 months, each other month missed one patient
Beta Blocker on D/C:	100% for the past 16 months
Mortalities:	2 inpatient mortalities in the past 18 months (101 pts)
Perfect care:	96% average for the past 18 months
JCAHO AMI mortality rate between July 2005 and June 2006:	11.4%
Parkview Medical Center AMI mortality           rate for same period:	2.2%

[3/13/07]

*                *                  *

Ridgeview Medical Center – Waconia, MN
Availability Status: Available to answer requests
Licensed Beds: 129
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2003
Mentor Contact Name: Melissa Pitts
Mentor Contact Email: melissa.pitts@ridgeviewmedical.org
Mentor Contact Phone: 952-442-2191 x5142

Additional Information:

Ridgeview implemented an acute cardiac care program in partnership with a tertiary care facility in 2003, utilizing evidence-based protocols.  The protocols have become the standard of care for all cardiac patients in the ED, regardless of disposition.  Current work is underway to build the principles of reliability into the AMI order set.

Ridgeview has achieved seven months of ‘perfect care’ for the AMI patients.
[2/14/06]

*                *                  *

Saint Agnes Medical Center – Fresno, CA
Availability Status: Available to answer requests
Licensed Beds: 434
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: October 2004
Mentor Contact Name: Carolyn Okamoto RN
Mentor Contact Email: carolyn.okamoto@samc.com
Mentor Contact Phone: 559-450-3381

Additional Information:

• Saint Agnes has an active multi-disciplinary performance improvement team for AMI care, with a specific focus on the STEMI / PCI process starting with EMS to when the patient reaches the cath lab for intervention.
• Excellent times have been achieved as a result of the collaborative efforts between EMS, Emergency Department staff and physicians, EKG technicians,  cath lab staff and Cardiologists.
• Use of a simultaneous paging system to activate the Cath lab team and Cardiologist has helped to cut down on unnecessary phonecalls.
• Valuable time has been saved by empowering our Emergency Department physicians to activate the Cath Lab team and Cardiologist as soon as a STEMI patient is identified in the ED, or when EMS call in a positive ST elevation EKG performed in the field. 
• Concurrent data is collected on all STEMI patients and reviewed monthly with the AMI performance improvement team.  Outlying cases (cases lasting > 90 minutes) are reviewed immediately by our Outcomes Physician and feedback is provided to the appropriate department or physician.  Unblinded data on all cases is reviewed regularly at the Cardiology Committees.
• Early identification of AMI patients in the Emergency Department, use of standardized order sets, and concurrent data collection to feedback real-time performance to clinical staff has consistently resulted in meeting the core measures for ASA, Beta-blocker and ACEi / ARB therapy for AMI patients.
• The process for ensuring patients receive Smoking Cessation Counseling has been hardwired in to our system. Process changes started in 2006 included the patient being asked questions regarding their smoking history at the time of registration, appropriate smoking cessation counseling literature being provided at that time, and subsequent follow-up being done by the respiratory therapy department for specific patient needs. 

• Mean "door-to-balloon" time improved at Saint Agnes from 100 minutes in 2006 to 61 minutes in 2007.
• STEMI cases at Saint Agnes meeting the "door-to-balloon" standard of < 90 minutes improved from 66% in 2006, to 94% in 2007.
• Remarkable "door-to-balloon" times of < 40 minutes (fastest time 24 minutes) have been achieved by many of our community-based cardiologists.
• AMI core measures for ASA & Beta-blocker w/in 24 hrs and at discharge have consistently been met 97-100% of the time in the last 2 years.
• AMI patients needing ACEi / ARB therapy at discharge have received it 100% of the time for the last year.
• In 2005, compliance with the smoking cessation measure for our AMI patients was at 88%.  Process changes resulted in our compliance improving to 100% for 2006 and 2007.

As process improvements have been implemented for AMI care at Saint Agnes, this has been reflected in our in-patient mortality rates.  In 2005, when our mean door-to-balloon time was 163 minutes and "perfect care" for our AMI patients was at 78%, our in-patient mortality rate was at 11.6%.  In 2006, mean door-to-balloon time improved to 99.7 minutes, "perfect care" was provided for AMI patients 96% of the time, and mortality was 7.4%.  We are excited that during 2007, as our mean door-to-balloon times have dropped significantly to 63 minutes, "perfect care" is at 97%, and in-patient mortality is down to 3.4%.
(Note: this is raw mortality data, not risk-adjusted.)
[3/24/08]

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St. Elizabeth Medical Center – Edgewood, KY
Availability Status: Available to answer requests
Licensed Beds: 639
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: April 2002
Mentor Contact Name: Jean Smith
Mentor Contact Email: jsmith@stelizabeth.com
Mentor Contact Phone: 859 301-3858

Additional Information:

St. Elizabeth strives to be one of the top heart hospitals in the nation. Administration and the Medical Staff have worked closely with the quality improvement team to accomplish this goal. Through monitoring, analyzing and changing the patterns of care we have successfully implemented best practices by improving processes and outcomes.

Smoking cessation education improvement was accomplished by taking the approach that all patients - not only AMI patients - should be educated. Smoking cessation packets are now placed in all admission packets and education begins at that time.  It has also been included on the discharge instruction form to reiterate the importance of smoking cessation prior to discharge.

ACEI/ARB at discharge improved through continual communication with the Medical Staff. Stickers were developed to remind staff of the need for ACEI/ARB, standing orders were revised, educational sessions were held outside the medical staff lounge and informational letters were sent to physicians not following the protocol.

A multidisciplinary team was developed and multiple improvement initiatives were developed, including but not limited to: data collection tool that would look at every measurable time frame, EKG's given directly to physician for reading, education provided to ED physicians and staff, procedure for notifiying on call staff changed, and reinservicing was done when variances were identified.

Through process changes and continual feedback to staff St. Elizabeth has been successful in improving care in several areas:
Smoking cessation education has improved from 77% in the 3rd quarter of 02 to 100%.
ACEI/ARB at discharge for EF < 40% has improved from 67% to 100%. This was accomplished through continual communication with the Medical Staff.

Mean time to PCI has improved from 92.9 minutes to 82.4 minutes.
[6/2/06]

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St. Luke’s Hospital – Cedar Rapids, IA
Availability Status: Available to answer requests
Licensed Beds: 560
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: January 2005
Mentor Contact Name: Sherrie Justice
Mentor Contact Email: justicsl@crstlukes.com
Mentor Contact Phone: 319-369-8367 or 1-800-369-7217 ext. 8367

Additional Information:

Interdepartmental team used Six Sigma to elevate the process.  Significant data collection drove the process.

Pre-implementation door-to-dilatation median time = 109 minutes
2005 door to dilatation median time = 91 minutes
2006 door to dilatation median time = 75 minutes

2006 year to date: 80% of the acute STEMI patients have door to dilatation times < 90 minutes.

During the first quarter 2006, 60 of 66 acute MI patients received optimal care (91%) for those acute MI indicators in the original CMS ten starter set.  At present we have a small group from the ED, cath lab and CCU that is working on a communication/handoff tool for these patients to ensure that all of the indicators are met reliably 100% of the time.

Acute MI mortality = 4.5% compared to JCAHO benchmark at 8.96%.
[8/31/06]

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Saint Luke's Hospital – Kansas City, MO
Availability Status: Available to answer requests
Licensed Beds: 576
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: February 2005
Mentor Contact Name: Geri Seavey
Mentor Contact Email: gseavey@saint-lukes.org
Mentor Contact Phone: 816-932-5692

Additional Information:

Patients presenting to SLH ED with ST-elevation MI receive reperfusion in less than 120 minutes. Goal shifts to 90 minutes in 2006 and process will be extended to ST-elevation patients received in transfer.

% of patients who presented with ST-elevation MI who received reperfusion in less than 120 minutes went from 55% in 2004 to 100% in 2nd quarter 2005
[1/31/06]

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St. Peter Community Hospital – St. Peter, MN
Availability Status: Available to answer requests
Licensed Beds: 22
Teaching / Non-Teaching Status: Non-teaching
Setting: Rural
Start Date of Intervention Work: March 2005
Mentor Contact Name: Benjamin W. Chaska, MD, MBA, CPE, Medical Director and Patient Safety Officer
Mentor Contact Email: bchaska@stpeterhealth.org
Mentor Contact Phone: 507-934-8416

Additional Information:

Adaptation: Reliable and timely treatment, stabilization and transfer for acute MI patients seen in the Emergency Department.

Actions Taken:
• Standardized chest pain protocol
• Incorporated into order set
• Adopted Mayo Clinic Fast Track for ST elevation MI
• Communicated expectations for time and process

Results: Reliable AMI care provided for all patients with AMI.

Beta Blockers administered 100% of the time.
ASA administered within 10 minutes 100% of the time.
Patients transferred in 30 to 60 minutes to definitive AMI care.
[1/31/06]

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Southwestern Vermont Medical Center – Bennington, VT
Availability Status: Available to answer requests
Licensed Beds: 99
Teaching / Non-Teaching Status: Non-Teaching
Setting: Rural
Start Date of Intervention Work: January 2001
Mentor Contact Name: Mark Novotny, MD
Mentor Contact Email: mnn@phin.org
Mentor Contact Phone: (802) 447-5006

Additional Information:

• We have imbedded triggers for medications on the CCU order set. If physicians do not order these medications, they have to state why in their documentation
• We have two cardiologists who end up seeing the majority of our AMI patients – either as the admitting physician or consulting (cardiology consult is a part of everyone’s care)
• The cardiologists know the guidelines and help to ensure patients are on the appropriate meds
• We provide consistent communication (via clinical nurse specialist responsible for following AMI patient population) back to all disciplines through outcomes reports that look at compliance with interventions and outcomes of care
• AMI care is discussed in many different arenas including: nursing meetings, ICU daily rounds, physician team meetings, ICU Committee, etc. such that everyone collectively is working on it.

In FY 2005, 97% of patients diagnosed with MI received ‘perfect care’ – meaning that they received all key interventions for treatment of MI.

AMI in-patient risk-adjusted mortality index (Delta Data) has dropped 60% since 2000
 [2/14/06]

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Tacoma General/Allenmore Hospital – Tacoma, WA
Availability Status: Available to answer requests
Licensed Beds: 521
Teaching / Non-Teaching Status: Non-Teaching
Setting: Urban
Start Date of Intervention Work: July 2005
Mentor Contact Name: Christi McCarren, RN, MBA, Administrator, Cardiovascular Services
Mentor Contact Email: christi.mccarren@multicare.org
Mentor Contact Phone: 253-403-1617

Additional Information:

On July 5, 2005, Tacoma General and Allenmore hospitals implemented an improvement process to provide rapid diagnosis and treatment of patients presenting with a myocardial infarction (heart attack)  The redesigned process was dubbed “Code STEMI” (ST-elevation myocardial infarction) and provides the means for all necessary healthcare professional to converge in the emergency department, facilitate consistent adherence to published clinical guidelines, while decreasing the time to treatment and saving precious heart muscle.

Through the Cardiology Clinical Practice Committee and the Ad Hoc Code STEMI working sub-group, all necessary team members were identified.  Part of our success was due to the development of a very specific treatment algorithm where roles, duties and expectations were delineated, and treatments and timeframes were established.

Prior to the process redesign, our time to treatment was consistently greater than 110 minutes – well above the ACC/AHA 90 minute target.  The best heart centers around the country have been able to achieve time to treatment of 60 minutes.  Our entire team felt our community deserved nothing but the best, so we established the same 60 minute goal.  The most significant change to our process was having the emergency department physicians activate the cardiac call team if it was determined a heart attack was underway.  This single process change shaved a minimum of 30 minutes off the total time to treatment.  Our team approach and the adoption of the ACC/AHA clinical guidelines have dramatically improved the care provided to these critically ill patients.  We are proud to report that our mean time to treatment at the end of 2005 was 73 minutes, a 33% improvement in the first six months of this important process redesign.

Overall 2005 year end interval averages are as follows:

Door to ECG:	5.0 minutes	(target=5)
Door to Transport:	39.5 minutes	(target=40)
Door to Stick:	58.0 minutes	(target=50)
Stick to Balloon:	16.6 minutes	(target=10)
Door to Balloon/Flow:	73.8 minutes	(target=60)

Relative to state averages:
Under 90 minutes 81% of the time  (state average = 51%)
Under 60 minutes 26% of the time (state average = 21%)

Time to Treatment by shift:

Days	62.4 minutes
Evenings	75.4 minutes
Nights	85.8 minutes

Focus for 2006:
Increase percentage of patients receiving treatment under 60 minutes to 35%.
Increase percentage of patients receiving treatment under 90 minutes to 90%.
Implement in-house Code STEMI process by March 1, 2006
[3/30/07]

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United Hospital Center – Clarksburg, WV
Availability Status: Available to answer requests
Licensed Beds: 318
Teaching / Non-Teaching Status: Teaching
Setting: Rural
Start Date of Intervention Work: July 2003
Mentor Contact Name:  Mark Povroznik, PharmD – Director, Quality Initiatives
Mentor Contact Email: povroznikm@uhcwv.org
Mentor Contact Phone: 304-624-2088

Additional Information:

Over the past four years, UHC has gone from a predominantly manual process to a more streamlined electronic abstraction process.  The first step in our success was the implementation of Horizon Patient Folder.  This system allows abstractors to review charts that are electronically triggered for review seven days after discharge.  This allows official data to be available quicker and provide more timely feedback to providers on specific cases that have missed opportunities.

UHC's success specifically related with AMI is largely attributed to building redundancies into the patient care processes.  Smoking cessation is incorporated both on the admission assessment, as well as on the Respiratory Therapy assessment.   The Patient Discharge Instructions were also revised to include ACEI/ARB, Aspirin, Beta Blockers, and Smoking Cessation.  Recent implementation of a computerized nursing documentation system has also greatly increased compliance by building the required data elements into the system.

Since January 2007, there has been an increased focus on PCI throughput times.  The Emergency Department and Cardiovascular Department have teamed with local EMS personnel to trigger the call initiation while the patient is still enroute to the hospital.  UHC is in a rural area and it can take 30 to 60 minutes to even transport a patient to this facility.  Despite this obstacle, UHC has been able to reduce median PCI time to 59 minutes in the 1st  Quarter of 2007, with 100% being less than 90 minutes.

UHC has had great success with the AMI process and outcomes measures over the past several years:

	2003	2004	2005	2006
Aspirin at Arrival	85.4%	91.4%	99.2%	100%
Aspirin at Discharge	77.9%	90.6%	97.9%	100%
Beta Blocker at Arrival	83.0%	100%	99.1%	100%
Beta Blocker at Discharge	86.2%	100%	97.9%	100%
Smoking Cessation/Counseling	54.8%	75.0%	100%	100%
Mortality	14.9%	12.1%	6.8%	7.9%
% PCI < 120 minutes	40.0%	84.6%	88.6%	1st Half 2006 - 88.9%

% PCI < 90 minutes (measure changed to 90 minutes 7/1/2006)
2nd Half 2006 - 84.2%, 1Q2007 - 100%

Median PCI Times over the past 5 quarters has improved dramatically:
1Q06 = 85 minutes, 2Q06 = 72 minutes, 3Q06 = 78 minutes, 4Q06 = 71 minutes, 1Q07 = 59 minutes

[12/3/07]

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University of California, San Diego Medical Center – San Diego, CA
Availability Status: Available to answer requests
Licensed Beds: 505
Teaching / Non-Teaching Status: Teaching
Setting: Urban
Start Date of Intervention Work: July 2002
Mentor Contact Name: Andrea Snyder
Mentor Contact Email: agsnyder@ucsd.edu
Mentor Contact Phone: 619-543-6475

Additional Information:

We have implemented standardized order sets, including admission and discharge orders and patient education. We've gotten Respiratory Therapy involved in smoking cessation and provided physician/staff education and feedback.  We're also participating in a county-wide STEMI project, involving 12-lead EKGs in the field.  This valuable information gives us time to prepare our cath lab before the heart attack patient ever reaches our door. We also have a STEMI kit with all the necessary equipment, so that staff are ready to provide care when the patient arrives. In the end, great physician leadership and staff participation have been the key to our success.

Our most current data (Q4 2005) shows that we've reached all time highs in key indicators. Aspirin at arrival, beta blockers at arrival, aspirin at discharge, beta blockers at discharge, lipid lowering therapy and smoking cessation counseling were all 100%! We're also excited about our time to PTCA. Our median time to PTCA for this fiscal year (July-December 2005) is 91 minutes, and we've had cases as quick as 24 minutes. Our inpatient mortality is consistently below expected (based on UHC risk adjustment).
[6/10/06]