CRUSADE: A National Quality Improvement Initiative

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. Aspirin Aspirin + Clopidogrel Beta-Blockers Heparin (UFH or LMWH) GP IIb/IIIa Inhibitors For high-risk patients For early cath/PCI Aspirin Aspirin + Clopidogrel Beta-Blockers Statins ACE-Inhibitors Cardiac Rehab Smoking Cessation AHA/ACC Treatment Recommendations Acute Therapies Discharge Therapies

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

4. Inclusion Criteria: High-Risk NSTE ACS • Ischemic symptoms lasting  10 minutes < 24 hours and at least one of the following: • Positive cardiac markers • CK-MB or TnI / TnT above ULN • Positive bedside troponin assay • Dynamic ST-segment ECG changes: • ST-segment depression  0.5 mm • Transient ST-segment elevation of 0.6-1.0 mm (lasting < 10 mins) • Transfer patients - must arrive at CRUSADE hospital within 24 hrs of symptoms

5. Study Design • Nationwide quality improvement initiative • 400+ participating hospitals • Collaborative effort between Emergency Medicine, Cardiology, Hospital QI, Academia, and Industry • Optimize risk stratification for NSTE ACS patients • Promote adherence to ACC/AHA treatment guidelines for NSTE ACS • Implement quality improvement interventions

6. Data Collection • Concise, 3-page data collection form • Retrospective data collection • Payment of $20 per DCF returned • Data collected includes: • Pt risk factors/presenting symptoms • Use of medications/ Use of invasive procedures/In-hospital clinical outcomes • Institutional Review Boards: • Should not require informed consent • Should be viewed by local IRB as QI

7. Quality Improvement Initiative:Primary Endpoints • Effectiveness of QI initiatives measured by changes in adherence to AHA/ACC treatment guidelines • Early / Discharge aspirin and clopidogrel use • Early / Discharge beta-blocker use • Discharge ACE-Inhibitor and statin use • GP IIb/IIIa Inhibitors: Early use and during PCI • Early invasive management - use of cath/PCI/CABG • Appropriate secondary prevention measures • Smoking cessation • Cardiac rehabilitation

8. Patient Identification StrategiesScreening in the Emergency Department • Prospectively identify patients in the ED • Elevated cardiac markers, dynamic ECG changes • Rapid, bedside Troponin I assays in the ED • Review daily ED admission logs • Unstable angina, chest pain, R/O MI, or acute MI • Review admissions to chest pain units • Develop triggers for ED nursing staff to identify patients for CRUSADE • Work with research coordinators who are screening patients for ACS clinical trials

9. Patient Identification StrategiesScreening After Admission • Review daily CCU or telemetry floor admission logs • Unstable angina, chest pain, R/O MI, or acute MI • Review daily cath lab schedule • Unstable angina, acute MI • Develop triggers for CCU / telemetry floor nurses to identify patients for CRUSADE • Screen all patients with elevated cardiac marker levels from local laboratory records

10. Patient Identification StrategiesScreening After Discharge • Review discharge diagnoses for chest pain • Unstable angina, chest pain, R/O MI, or acute MI • New ICD-9 codes for acute MI: + TnT/TnI • Review all patients with elevated cardiac marker levels from local laboratory records • Pull charts after identification of patients to fill out items on the data collection form

11. Quality Improvement Initiatives: • Regional educational meetings • ACC/AHA Guidelines recommendations • Review CRUSADE and QI Initiatives • Site Survey • Understand site beliefs and practice environment • Educational / QI materials • ED Risk Stratification Algorithm/ Sample orders • Guidelines Posters/pocket cards • Discharge MD and patient check lists • Quarterly Feedback Reports

12. Quality Improvement Initiatives:Hospital Survey Component • Baseline understanding of and concurrence with AHA/ACC NSTE ACS treatment guidelines • Is it an education versus adherence issue? • Identify local features which may serve to promote quality improvement initiatives • Survey “structure and culture” of institution • Do institutional characteristics predict improved adherence to guidelines-based care?

13. Quality Improvement Initiatives:Data Reporting to Sites • Quarterly feedback reports to sites regarding their adherence to ACC/AHA treatment guidelines • Focused on AHA/ACC Guidelines treatments • Site confidentiality maintained - data supplied back to sites in a secure fashion • Provides sites with benchmark performance data

14. Sample Quarterly Report:GP IIb/IIa Inhibitor Use in First 24 Hours

16. Site Participants and Responsibilities • Emergency Medicine and Cardiology Co-Advocates • Develop strategies to identify high-risk NSTE ACS patients early during hospitalization • Implement QI tools to promote ACC/AHA Guidelines • QI nurse or research coordinator • Completion of case report forms • Assist in local educational/QI efforts to increase adherence to ACC/AHA Guidelines

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