Institute for Healthcare Improvement: Evidence-Based Best Practice Model for AMI

Mission Hospitals, Inc. Owen Heart Center
Asheville, North Carolina, USA

Team
Dr. William Maddox, Cardiologist Team Champion
Jennifer Arledge, RN, Cardiology Case Manager, Team Leader
Dr. Jason Hunt, ED Physician
Dr. David Mouw, Family Practice
Dr. Margaret Coyle, Prime Doc
Kathy Hefner, RN, Director of Medical Cardiology Service Line
Karen Jackson, RN, ED Clinician
June Harvey, RN, Cardiology Case Manager
Valorie Speegle-Snell, RN, Cardiology Case Manager
Angela Gruebmeyer, RN, Cardiology Case Manager
Cathy Trimby, Performance Improvement, Heart Service Line Consultant
Amy Buckner, RN, Performance Improvement Analyst
Jan Renau, RN, CICU Unit Manager
Diane Klotz, RN, CICU Nursing Unit Supervisor
Connie Cogdill, RN, CVPC Unit Manager
Nancy Kapler, RN, Heart Path/MI Educator
Teresa Reed, RN, Adult Medicine Case Manager
Sandra Johnston, RN, Unit Manager, Medical Cardiology Step-down
Matt McNeil, Pharmacist, Heart Service Line
Susan Maley, Decision Support
Wendy Westling, Statistician, Heart Service Line

Aim
To improve care and cost-effectiveness for the acute coronary syndrome and acute myocardial infarction (AMI) patients by implementing evidence-based quality standards as demonstrated by improving our standings in the Centers for Medicare and Medicaid Services (CMS) Hospital Quality Incentive (HQI) project. Our goal is to achieve a quality score of 2nd decile or above with improvements shown in each of the listed quality indicators.

Measures

Hospital Quality Incentive Demonstration Project Incentives:

Aspirin at arrival
Aspirin prescribed at discharge
ACEI for LVSD
Beta-Blocker at arrival
Beta-Blocker prescribed at discharge
PCI received within 120 minutes of hospital arrival
[Mission's goal is to decrease PCI times to less than 90 minutes from ED door to crossing of guide wire in vessel]

Changes

Mission Hospitals developed a CMS initiative task team to identify current delivery of care standards for project diagnosis; AMI was part of this team.
Educational opportunities were identified and pursued.
Clinical pathways were revised to incorporate most recent American College of Cardiology (ACC) recommendations which were linked to our Unstable Angina/Myocardial Infarction (USA/MI) order set to assure adherence to evidence-based best practice guidelines, leading to decreased length of stay, decreased cost, and better patient outcomes.
Added specific nicotine cessation statement to Consent for Treatment and all computerized Discharge Instructions to improve compliance with CMS requirements.
Implemented concurrent coding by Medical Records with physician and Case Management collaboration.
STEMI and Non-STEMI Process Flow algorithms were developed from Emergency Medical Services (EMS) activation to discharge emphasizing early determination of reperfusion strategy.
Collaborated with Regional Transport Director and EMS personnel to assure adherence to CMS quality indicators for AMI.
Emergency Department AMI packets were revised to include a time tracking sheet for physician/Catheterization lab responsiveness with appropriate feedback to those involved.
All nursing staff and support personnel in the Emergency Department (ED) were trained to administer Electrocardiograms (ECG).
The need for an ED specific ECG machine was identified and purchased.
An Excel spreadsheet was developed to track triage time, ECG response time, physician contact and response time, ED to Cath lab time, door-to-balloon time. The Cardiologist Team champion and Nurse Team Leader of the Acute Coronary Syndrome Team and the ED Nurse Clinician receives this data and provides appropriate feedback to those involved with outlier cases.

Results

Summary of Results / Lessons Learned / Next Steps

Implementation of the AMI Quality Indicator Forms with Case Manager efforts to assure compliance, and the utilization of evidence-based order sets that default to best practice, have been instrumental in allowing us to achieve quality standard care for the AMI population.
Better patient outcomes have been achieved as indicated by decreased Percutaneous Coronary Intervention (PCI) times, decreased average length of stay (ALOS), and decreased cost per case.
The CMS Quality Indicators for AMI have been improved:
The development of the STEMI and NSTEMI Process Flow algorithms allowed us to identify areas to improve our responsiveness of care delivery from the initial triage by emergency personal at the scene to patient discharge.

Lessons Learned:

Communication with and education of key players is essential for improved patient outcomes.
Physician and interdisciplinary “buy-in” is crucial to improving care of the AMI patients.
The utilization of Case Managers, their experience and clinical leadership, play a crucial role in the development of order sets, oversight of the process and the collaboration of care with physicians.
Supportive direction and leadership from Senior Administration allows changes to be implemented in a timely and cost-effective manner.
Concurrent coding by Medical Record personnel with collaboration from Case Management assures accurate and complete documentation.
Electronically relaying CMS updates allows key personnel to make changes in a timely manner.
The return on investment (ROI) of buying needed equipment is realized almost immediately with decreased wait times, this in turn improves patient safety and outcomes.
Order sets that default to best practice improve patient safety and insure adherence to ACC guidelines.
Celebrate accomplishments with bedside clinicians to reinforce the need for continued compliance with best practice guidelines for AMI.

Contact Information

Cathy Trimby, PI Consultant
Heart Service Line
jrcccr@msj.org

[Storyboard presentation at IHI's National Forum, December 2005]

	Home > Topics > Reliability > Reliability: General > Improvement Stories