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CRUSADE: A National Quality Improvement Initiative

CRUSADE: A National Quality Improvement Initiative. C an R apid Risk Stratification of U nstable Angina Patients S uppress AD verse Outcomes with E arly Implementation of the ACC/AHA Guidelines. CRUSADE Description.

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CRUSADE: A National Quality Improvement Initiative

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  1. CRUSADE:A National Quality Improvement Initiative Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines

  2. CRUSADE Description • CRUSADE is a Quality Improvement Initiative designed to improve the care of high-risk patients with NSTE ACS • by collecting data regarding patient management practice patterns in the U.S. and • using those data to target educational interventions designed to promote adherence to the revised ACC/AHA NSTE ACS guidelines recommendations.

  3. CRUSADE Objectives • Determine the current state of awareness of and adherence to the ACC/AHA Non-ST-segment Elevation Acute Coronary Syndromes (NSTE ACS) Guidelines. • Implement quality improvement initiatives to promote ACC/AHA NSTE ACS Guidelines recommendations. • Improve clinical outcomes for NSTE ACS patients via early risk stratification and implementation of evidence-based care, both in-hospital and post-discharge.

  4. Aspirin Clopidogrel/ticlopidine, if contraindicated Beta blocker Ca2+ blocker, if contraindicated ACE inhibitor (HTN, CHF) Heparin (UFH or LMWH) GP IIb-IIIa inhibitor All high-risk patients All receiving PCI Those with recurring ischemia Aspirin Clopidogrel Beta blocker ACE inhibitor Lipid-lowering agent Cardiac rehabilitation Smoking cessation Dietary modification ACC/AHA Treatment Recommendations Acute Therapy Discharge Therapy

  5. CRUSADE Design • Nationwide Quality Improvement (QI) initiative • Up to 600 participating hospitals • Collaborative effort between Emergency Medicine, Cardiology, Hospital QI, Academia, and Industry • Focused on improving the care of NSTE ACS patients

  6. Inclusion Criteria: High-Risk NSTE ACS • Ischemic symptoms lasting  10 minutes within previous 24 hours and at least one of the following: • Positive cardiac markers • CK-MB or TnI / TnT above ULN • Positive bedside troponin assay • ST-segment ECG changes: • ST-segment depression  0.5 mm • Transient ST-segment elevation 0.6 - 1 mm (lasting < 10 mins) • Transfer patients (with any of the above) must arrive at CRUSADE hospital within 24 hrs of symptoms

  7. Data Collection • Web-based Data Collection Form (DCF) • Retrospective data collection • Sites enter data via secure Internet website • Data collected includes: • Patient risk factors/presenting symptoms • Use of medications/use of invasive procedures • In-hospital clinical outcomes • Institutional Review Boards: • May be viewed by hospital as QI • May not require IRB review and/or approval • May not require informed consent • Local hospital decision

  8. Quality Improvement Initiative:Measuring Change • Effectiveness of QI initiatives measured by changes in adherence to ACC/AHA treatment Guidelines • Early / discharge antiplatelet use (ASA, clopidogrel) • Early / discharge beta blocker use • Early heparin use • Discharge ACE inhibitor and statin use • GP IIb-IIIa inhibitors: early use and use during PCI • Appropriate secondary prevention measures • Smoking cessation • Cardiac rehabilitation • Dietary modification

  9. Quality Improvement Initiatives:Data Reporting to Sites • Quarterly feedback reports to sites regarding their adherence to ACC/AHA Guidelines • Focused on the ACC/AHA Guidelines treatment & management recommendations • Site confidentiality maintained – data supplied back to sites in a blinded fashion • Provides sites with benchmark performance data

  10. Sample Quarterly Report:Trend Graphs

  11. Sample Quarterly Report:Descriptive Tables

  12. Benefits of Participation • Quality improvement performance feedback • Reports documenting utilization of evidence-based management strategies and therapies • Performance ranking among “like”, national, and “best practice” hospitals • Insight into hospital care and areas for improvement • May be applied to hospital QI monitoring efforts/requirements

  13. Benefits of Participation • Quality improvement tools to help improve outcomes for high-risk NSTE ACS patients. • Initiatives to help increase understanding of the ACC/AHA Guidelines • Initiatives to improve risk stratification and diagnosis of NSTE ACS patients • Newsletters and website for continuing education

  14. Promoting a New Paradigm of Evidence-Based Cardiovascular Care • The CRUSADE national quality improvement initiative will teach us much about: • Why current ACC/AHA Guidelines for ACS are not followed • What initiatives can improve adherence • How to promote Emergency Medicine -Cardiology collaboration • Whether improved early adherence to treatment guidelines leads to better acute outcomes

  15. CRUSADE Implementation • Training of staff and physicians should be conducted by CRUSADE co-advocates and DCRI team prior to the start of CRUSADE • Participating hospitals must complete, sign, and return a CRUSADE Participation Agreement and Data Use Agreement • Data collection personnel must obtain log-in access and training for the data entry website • Quarterly, the site will receive a Feedback Report detailing use of Guidelines-recommended therapies

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