Acute Myocardial Infarction (Heart Attack)

1. Acute Myocardial Infarction(Heart Attack) Committee Membership: B. Majcher, APRN, C. Mulhall, APRN, K. McLean, MD, M. Jarotkiewicz MBA, M. Morrow, RN, MSN, PhD, Nursing Staff of 3NEWS, CCU, 3 ITV, and Emergency Room, Cardiac Cath Lab, Medical Records Department, Center for Clinical Effectiveness.

2. Since May 2002 Loyola University Medical Center (LUMC) has been reporting performance on AMI Patients for Core Measures. • These Core Measures, developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Center for Medicare and Medicaid Services (CMS) were established to implement the best practice guidelines for AMI patients. • They are based on the American Heart Association (AHA) and the American College of Cardiology (ACC).

3. Opportunity for Improvement • Review of Acute Myocardial Infarction (AMI) Core Measures data has shown that Loyola is meeting, or exceeding, the University HealthSystem Consortium (UHC) and national rates for most measures. • However, LUMC mortality was above expected rates, according to Core Measures risk adjustment methodology.

4. Solutions Implemented • To understand the Core Measures risk adjustment methodology, the AMI Core Measures cases were analyzed using the UHC risk adjustment methodology, which is unrelated to the Core Measures methods, for severity adjustment. • This algorithm is currently employed at more than 100 Academic Hospitals for clinical quality improvement efforts separate from the Core Measures • This analysis showed a below expected mortality rate (favorable). • The discrepancy between the two risk-adjustment models appeared to be due to cases in which patients with non-cardiac illnesses were not being adequately risk-adjusted within the Core Measures’ limited algorithm.

5. Solutions Implemented • The AMI Core Measures Committee meets monthly to review and to discuss mortality cases in order to understand and improve AMI care. • Following AMI patient discharge, all charts are assessed by a cardiac case manager and a medical records coder for appropriate inclusion in the measure set based on priority of diagnoses. • Physician review is included on all expired patients or when the conclusion is unclear.

6. Solutions Implemented • All AMI patients are seen by cardiac case managers for risk factor reduction. • On daily basis all AMI patients’ charts are being reviewed by a cardiac case manager for any changes in patients’ severity, medications and planned discharged date.

7. Acute Myocardial Infarction Mortality 14 12 10 8 6 Percent Mortality 4 2 0 2003 Q4 (n=79) 2004 Q1 (n=83) 2004 Q2 (n=67) 2004 Q3 (n=67) 2004 Q4 (n=74) 2005 Q1 (n=85) 2005 Q2 (n=60) 2005 Q3 (n=47) 2005 Q4 (n=55) 2006 Q1 (n=46) 2006 Q2 (n=40) 2006 Q3 (n=50) LUMC Observed Mortality Rate LUMC Expected Mortality Rate National Morality Rate (Mean) Quarter

8. Outcomes • From Quarter 3 2005 through Quarter 3 2006, the observed mortality at Loyola has dropped to a level far below the expected levels as calculated by the Core Measures risk-adjustment model. • This appears to be due to improved processes to ensure that cases are appropriately included in these measures.

9. Next Steps • Perform case level review of mortality cases at monthly AMI Core Measures Committee meeting. • Notify JCAHO/CMS of additional diagnoses and co-morbidities absent from the risk-adjustment formula which can influence AMI mortality risk. • Continue to evaluate coding criteria of AMI patients.

10. Next Steps, other AMI Measures • The AMI Core Measures Committee will continue meeting on monthly basis to address additional opportunities for improving the care of AMI patients at Loyola. • Involvement of a clinical pharmacist in order for the AMI patient to receive the most benefit from the right medications during hospital stay and at discharge.