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Creating a Safer System

Creating a Safer System. 24-month national Campaign. For re-evaluation March 2007. To help teams develop skills/capacity to monitor their performance and make Quality Improvements (QI) Focus is harm reduction and improving care processes and outcomes for patients.

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Creating a Safer System

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  1. Creating a Safer System

  2. 24-month national Campaign. For re-evaluation March 2007. • To help teams develop skills/capacity to monitor their performance and make Quality Improvements (QI) • Focus is harm reduction and improving care processes and outcomes for patients

  3. Canadian Adverse Events Study • 7.5% of all hospital admissions are associated with an adverse event (2000) • 36.9% of which were deemed preventable • IE: 70,000 preventable adverse events per year • Possibly contributing to 9,000 preventable deaths in Canada (2000) Adverse Events in Canadian Hospitals (Baker, R. & Norton, P. et al (2004))

  4. The Key focus of SHN: solving the implementation issues that stand between our knowledge of "what works” and our ability to reliably provide this standard of care • Safer Healthcare Now! aims to provide quality improvement ideas, supports and resources to hospital teams with the goal of providing safer care.

  5. 160 healthcare organizations and 470 teams enrolled nationwide (68 teams in Atlantic Canada) • Partners include CMA, CCHSA, DOH, Professional Colleges , Associations of Health Organizations

  6. Six Improvement Initiatives: • Acute Myocardial Infarction (AMI) • Medication Reconciliation • Surgical Site Infection (SSI) • Rapid Response (RRT) • Central Line Infection • Ventilator Associated Pneumonia (VAP)

  7. Cumulative 6-month mortality from ischemic heart disease 25 N = 21,761; 1985-1992 Diagnosis on adm to hosp 20 15 Deaths / 100 pts / month Acute MIUnstable anginaStable angina 10 5 0 0 1 2 3 4 5 6 Months after hospital admission Duke Cardiovascular Database

  8. Endothelial Dysfunction Atherosclerosis Timeline Complicated Lesion/ Rupture Foam Cells Fatty Streak Intermediate Lesion Atheroma Fibrous Plaque From First Decade From Third Decade From Fourth Decade Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104).

  9. Plaque Rupture and Clot Formation

  10. Acute Coronary Syndrome No ST Elevation ST Elevation NSTEMI Myocardial Infarction Unstable Angina NQMI Qwave MI Serum Cardiac Markers Dx: ReinfarctionPrognosisAssess Reperfusion Dx: MIPrognosisSelection of Rx

  11. b-Block ASSENT-2 CCU GUSTO GUSTO-3 GISSI-1 Pre-CCU ISIS-2 Early Mortality After AMI Mortality at 25 - 30 Days SK SK+ASA tPA tPA & rPA tPA & TNK

  12. Definition of AMI • Patients admitted through ER with diagnosis of AMI confirmed by 2 of : • documented symptoms compatible with AMI • ST elevation in 2 contiguous leads or new LBBB • documented enzyme elevation.

  13. Ischemic chest pain 30 min

  14. Ischemic chest pain 30 min Acute Anterior Injury

  15. Ischemic Chest Pain – 30 min

  16. Ischemic Chest Pain – 30 min Acute inferior injury

  17. ST Elevation MI: Management Principles • Achieve early and complete reperfusion of the infarct-related vessel • Primary Percutaneous intervention (PCI) • Thrombolytic therapy • Use evidence-based adjunctive medical therapy • ASA • Beta blockers • Angiotensin converting enzyme(ACE) inhibitors • Statins • Antithrombotic therapy (when indicated)

  18. Primary PCI vs. Thrombolysis PAMI TRIAL: 395 patients Events: Death, recurrent MI or ischemia requiring revascularization 53% event free survival 37 % event free survival From www.uptodate.com . Accessed on July 29, 2003

  19. Fibrinolytic TherapyIs It A Treatment of the Past? • Meta-analysis of 23 randomized trials • Primary PCI reduced Death 7% vs 9% Reinfarction 2.5% vs 6.8% Stroke 1% vs 2% Lancet 2003; 361:13-20

  20. Fibrinolysis vs. Transport for PCI • On-site (community hospital) fibrinolysis compared with immediate transport to a regional center for PCI for STEMI • A consistent 40% reduction in AE • Time delay for transport were 10, 30, 43 min (277 min for PCI vs 245 min for fibrinolysis) Odds ratio and 95% confidence intervals for the composite end point of death, reinfarction, and stroke at 30 days ACC Scientific Sessions; March 20, 2002: Atlanta, Ga ESC; September 1, 2002: Berlin, Germany J Am Coll Cardiol. 2002; 39: 1713–1719

  21. Fibrinolytic TherapyIs It A Treatment of the Past? • Resistance to primary PCI • Not enough Primary PCI studies have been performed • Results may not be reproducible in low volume and less experienced centers • Withholding thrombolytic while awaiting PCI may cause harm

  22. Benefits of PCI vs Lysis: The Importance of Timing Kent DM et al Eff Clin Pract 4: 214, 2001

  23. Thrombolytic Therapy: Importance of Early Therapy Benefit Greatest within Two hours of therapy Benefit falls by 1.6 lives per 1000 patients per hour of treatment delay after two hours Data from Boersma,E et al. Lancet 1996;348: 771

  24. ST Elevation MI: Importance of Early Reperfusion TIMI 0=Occlusion TIMI 1= Penetration TIMI 2= Slow Flow TIMI 3= Normal Flow

  25. Thrombolytic Therapy: Ineligible Patients From www.uptodate.com. Accessed July 28, 2003

  26. ST elevation MI • Fibrinolysis – TNK (tPA, rPA, SK) then • Low molecular weight heparin (Enoxaparin) - 30 mg bolus IV under age 75 and - 1 mg/kg sq bid - Age 75 and up – 0.75 mg/kg sq bid. or • Unfractionated heparin for very obese over 145 kg, renal failure

  27. Thrombolytic Therapy: Bottom Line • Earlier (within two hours of symptoms) administration associated with better outcomes but benefit shown up to 12 hours • Overall efficacy in achieving TIMI 3 flow is 50-60% • Risk of Hemmorragic Stroke Low (0.49%-0.72%) • Less with SK than with t-PA or TnK • 40% of patients are INELIGIBLE for thrombolytic therapy • Current Agent of Choice: Tenecteplase (TnK) • Primary PCI better: • Higher rate of TIMI 3 flow (>90%) • Negligible risk of Intracranial Hemmorrhage • Associated with improved outcomes

  28. Summary - STEMI • ST-segment elevation ACS should receive reperfusion therapy (PCI or fibrinolysis) as a medical emergency • Early use of aspirin, b-blockers, ACE inhibitors (in LV dysfunction), antithrombin agents, antiplatelet therapies • Center with invasive facilities have better outcomes

  29. TIMI Risk Score for STEMI Palm Pilot application available at: www.timi.org From www.uptodate.com. Accessed June 28, 2003

  30. Julie Sutton- Team Leader Dr. Jamie Graham- Cardiac Physician Rep. Bonnie Walker- Patient Safety Rep. Dr. Peter Callahan- ER Physician Rep. Maureen Doody- Educator Rep. Brenda Rex- ICU Rep. Suzanne Joseph - 3A Manager Rep. Rhonda Squires- 3A PCC Rep. WMH AMI Committee

  31. AMI Statistics • Prompt ASA reduces risk of death by 15% ; Beta-blockers reduce risk of death in first week by 13% and long term mortality by 23% • RAND study (NEJM) showed only 61% of AMI patients receive ASA and only 45% receive beta-blockers

  32. AMI Key Components • 1. Early administration of aspirin (within 24 hours) • 2. Timely thrombolytic (within 30 minutes) • 3. Aspirin at discharge • 4. Beta-blocker at discharge • 5. ACE-inhibitor at discharge (if systolic dysfunction) • 6. Smoking cessation counseling

  33. Potential Cumulative Impact of 4 Simple Secondary Prevention Treatments "Yusuf S., Unpublished data." CUMULATIVE BENEFITS ARE LIKELY TO BE IN EXCESS OF 75% RRR, WHICH IS SUBSTANTIAL

  34. AMI Baseline Data • BASED on Retrospective Chart Review • March -September 2005 • 74 Charts Identified, 20 Excluded • 54 reviewed for compliance and documentation with each of AMI components and overall (Perfect Care)

  35. Acute MI: ASA benefit ISIS-2: 17, 187 patients: Acute MI 23% mortality reduction 42% mortality reduction

  36. Early Administration of ASA Goal: >90% compliance Aspirin 24 hrs before or after hospitalization Exclusions: • Documented contraindications: (ASA allergy, active bleeding, warfarin before arrival) • Transferred in from or out to another acute care facility

  37. ASA on Arrival

  38. Thrombolysis: Decay with Delay

  39. 2. Timely Thrombolysis Goal: >85% compliance Thrombolytic Agent within 30 minutes (door to needle)of arrival Exclusions: • Transferred in from another facility • No ST elevation or new LBBB present • Did not receive a thrombolytic or received thrombolytic more than 6 hrs after arrival

  40. Thrombolytic within 30 min

  41. Aspirin Evidence: Secondary Prevention Category% Odds Reduction Acute myocardial infarction Acute stroke Prior myocardial infarction Prior stroke/transient ischemic attack Other high risk Coronary artery disease(e.g. unstable angina, heart failure) Peripheral arterial disease(e.g. intermittent claudication) High risk of embolism (e.g. atrial fibrillation) Other (e.g. diabetes mellitus) All trials Antiplatelet better Control better 0.0 0.5 1.0 1.5 2.0 Effect of antiplatelet therapy* on vascular events** *Aspirin was the predominant antiplatelet agent studied **Vascular events include MI, stroke, or death Antithrombotic Trialist Collaboration. BMJ 2002;324:71–86.

  42. Odds Ratio for Vascular Events Aspirin Dose No. of Trials (%) 500-1500 mg 34 19 160-325 mg 19 26 75-150 mg 12 32 <75 mg 3 13 Any aspirin 65 23 P<.0001 0 0.5 1.0 1.5 2.0 Antiplatelet Better Antiplatelet Worse Aspirin Evidence: Dose and Efficacy Indirect Comparisons of Aspirin Doses on Vascular Events in High-Risk Patients Antithrombotic Trialists Collaboration. BMJ. 2002;324:71-86

  43. 3. Discharged on ASA Goal: >90% compliance Aspirin prescribed on discharge Exclusions: • Documented contraindications: (ASA allergy,active bleeding, warfarin before arrival) • Transferred out to another acute care facility

  44. ASA at Discharge

  45. Acute MI: Benefit of Beta Blockers 201, 752 patients with MI Mortality reduction: 14.4% vs. 23.9% at 2 years Data from Gottlieb, SS et al. NEJM 1998;339:489

  46. b-blocker Evidence Summary of Secondary Prevention Trials of b-blocker Therapy Phase of Treatment Total # Patients RR (95% CI) Acute treatment 28,970 0.87 (0.77-0.98) Secondary prevention 24,298 0.77 (0.70-0.84) Overall 53,268 0.81 (0.75-0.87) 0.5 1.0 2.0 RR of death b-blocker better Placebo better CI=Confidence interval, RR=Relative risk Antman E, Braunwald E. Acute Myocardial Infarction. In: Braunwald E, Zipes DP, Libby P, eds. Heart Disease: A textbook of Cardiovascular Medicine, 6th ed., Philadelphia, PA: W.B. Sanders, 2001, 1168.

  47. b-blocker Evidence: Post MI with Left Ventricular Dysfunction 1 0.95 n=975 0.9 Carvedilol Proportion Event-free n=984 0.85 0.8 Placebo 0.75 RR 0.77 P=.03 0.7 0 0.5 1 1.5 2 2.5 Years Carvedilol Post-Infarct Survival Control in LV Dysfunction (CAPRICORN) 6,644 patients with LVEF <0.40 after a MI with or without HF randomized to carvedilol or placebo for 24 months The CAPRICORN Investigators. Lancet. 2001;357:1385–1390.

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