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D ischarge M anagement of patients with A cute C oronary S yndromes (DMACS) – a quality improvement initiative. Feedback. A quality improvement initiative in collaboration with: NPS: Better choices, Better health. Hospital DMACS contacts. Insert hospital logo here. Local coordinator

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  1. Discharge Management of patients with Acute Coronary Syndromes (DMACS) – a quality improvement initiative Feedback A quality improvement initiative in collaboration with: NPS: Better choices, Better health

  2. Hospital DMACS contacts Insert hospital logo here • Local coordinator • Insert name here • Local DMACS team • Insert names here

  3. Overview • Aims and methods • Best practice in discharge management of patients with Acute Coronary Syndromes (ACS) • Feedback on audit of current practice • Discussion • Education and ongoing monitoring

  4. Aims To improve management of ACS at discharge by targeting: • Prescription of guideline-recommended* cardiovascular medicines following an ACS event (antiplatelets, ACE-inhibitor, beta blocker, statin, short-acting nitrate) • Provision of education on lifestyle modifications following an ACS event (incl. smoking cessation, cardiac rehab) • Communication to patient/carer & general practitioner (GP) regarding ACS management post-discharge *NHF & CSANZ ACS Guidelines working group. National Heart Foundation ACS Guidelines. Med J Aust 2006:184(Supp):S1-32

  5. Methods Quality improvement initiative steps 1. Gain support 2. Collect data (insert month/year here) Data entered into NPS* DMACS e-DUE audit tool • ‘x’ patients (inpatient data) • Patient post-discharge telephone survey (delete if not applicable) 3.Evaluate data(insert month/year here) • Reports generated 4. Feedback data (insert month/year here) 5. Action - Intervention/education NPS an independent organisation promoting quality use of medicines, funded by the Commonwealth

  6. Best practice for discharge management of patients with ACS* • Initiate long-term management plan for ACS patients • Consider guideline-recommended medicines for all ACS patients • Identify risk factors and refer all ACS patients to secondary prevention programs • Communicate management plan to the patient, carers & the community healthcare providers *Based on the National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes 2006, and Therapeutic Guidelines: Cardiology, Version 5, 2008.

  7. Inpatient medical record review

  8. Demographics and risk factors

  9. Discharge diagnosis

  10. Best practice: Consider guideline-recommended* medicines for all ACS patients • The combination of antiplatelet agents, a beta blocker, a statin and an angiotensin-converting enzyme inhibitor are recommended for most patients. • All 4 drug classes have been proven to reduce subsequent cardiac events and death. • If therapy is not indicated for an individual, document the reason(s) why in the patient’s medical record and management plan. *NHF & CSANZ ACS Guidelines working group. National Heart Foundation ACS Guidelines. Med J Aust 2006:184(Supp):S1-32 and 2011 Addendum. Heart, Lung and Circulation 2011: Vol 20, 1-16

  11. ACS discharge medicines (adjusted for contraindication, lack of indication & patient refusal) *Combination of aspirin and/or clopidogrel/prasugrel/ticagrelor, ACE inhibitor and/or Angiotensin II-receptor antagonist, beta blocker and statin

  12. Patients prescribed ACS medicines by discharge diagnosis (adjusted for contraindication, lack of indication & patient refusal)

  13. Best practice: Identify risk factors • Provide patients with a self-management plan before discharge • Plan should include advice on lifestyle changes such as good nutrition, moderating alcohol intake, regular physical activity and weight management as appropriate. • Patients should be provided with adequate counselling regarding medicines to enable self-management. • Provide smoking-cessation advice and support to all patients who smoke • There is a rapid reduction in the risk of coronary heart disease within one year of quitting smoking. • For patients who would like assistance to quit smoking a combination of pharmacotherapy and support programs are appropriate. Therapeutic Guidelines: Cardiovascular, Version 5. 2008.

  14. Patient education - documentation

  15. Best practice: Refer all patients with ACS to secondary prevention programs • Actively refer to, and encourage attendance at secondary prevention and cardiac rehabilitation programs. • Cardiac rehabilitation is a proven effective intervention • Attendance at cardiac rehabilitation outpatient programs reduces risk for further cardiac events • Patients participating in cardiac rehabilitation can achieve improvements in: • Physical activity, weight loss, smoking cessation, blood lipid levels and blood pressure control NHF and CSANZ ACS Guidelines working group. Med J Aust 2006:184(Supp):S1-32 NHF and CSANZ. Reducing risk in heart disease, 2007. Taylor RS, et al. Am J Med 2004;116:882-92. Vale MJ, et al. Arch Intern Med 2003;163:2775-83. NHF , Australian Cardiac Rehabilitation association. Recommended framework for cardiac rehabilitation, 2004.

  16. Patient referral to cardiac rehabilitation

  17. Best practice: Communicate management plan to the patient, carers and community healthcare providers • Communicate the long-term management plan, including treatment goals, to the community healthcare providers • Adherence to long-term therapy improves patient survival • Discontinuation of medicines after MI is common and occurs soon after discharge Ho PM, et al. Arch Intern Med 2006;166:1842-7

  18. Documented ACS management plan

  19. Best practice: Provide a discharge letter/summary Include: • Complete list of all medicines • Any changes to pre-admission medicines • Plan for any dose titration • Recommendations for monitoring • Treatment goals • Recommendation for attendance at cardiac rehabilitation • Advice regarding lifestyle modifications

  20. Documented ACS management plan communicated to GP

  21. Documented ACS management plan communicated to patient

  22. Communication of documented ACS plans

  23. Patient telephone survey at ‘x’ days post-discharge

  24. Survey response rates

  25. Patient report usage of ACS medicines at time of survey (% of patients completing telephone survey) *Includes aspirin and/or clopidogrel / prasugrel / ticagrelor plus those on warfarin †combination of aspirin and/or clopidogrel / prasugrel / ticagrelor, ACE inhibitor and / or angiotensin II-receptor antagonist, beta blocker & statin

  26. Patient report of adherence

  27. Cardiac rehabilitation :

  28. Patient reported reasons for non-attendance at follow-up (% of patients who did not attend/complete cardiac rehab) • You may wish to create a • graph like the one opposite or • insert a table

  29. Patients’ report on type of cardiac rehabilitation / education sessions attended

  30. Preferred times for cardiac rehabilitation / education sessions Reported by those patients who were unable to attend due to time / work commitments or session availability

  31. Patient’s report on smoking status *As a percentage of patients who answered this question.

  32. Discussion: Areas where we did well • Customise this slide for your hospital by adding bullet points on areas where your hospital is doing well • An example could be the % of patients with all guideline-recommended medicines prescribed at discharge

  33. Discussion: Areas we can build upon • Customise this slide for your hospital by adding bullet points on areas that your hospital project team has identified as an area of interest/focus of education • An example could be: current level of communication at discharge

  34. Action: the next step Strategies to raise awareness of best practice in discharge management of patients with ACS Customise this slide for your hospital by adding bullet points on how you will implement some change. Examples of educational resources include: • Bookmark reminder • Discharge ACS management plan reminder • Discharge templates/checklists • Group education sessions on current practice and comparison to ‘best practice’ • Educational visits (academic detailing using the DMACS information summary card)

  35. After the educational intervention • Collect data on ‘x’ ACS cases (similar to Audit 1): • Evaluate post-intervention (Audit 2) data • Feedback data and compare with baseline and ‘best practice’ • Highlights of achievements in the post-intervention presentation

  36. Acknowledgements Congratulations and thanks to the team involved in this DUE: • Insert name • Insert name • Insert name NPS together with QLD, VIC, NSW, TAS & SA state DUE groups and state DMACS project committees

  37. Questions? Contact your DMACS coordinator for further information if required • Hospital contact person (insert name) • Ph: (insert contact number) • Email: (insert email address) THANK YOU

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