Hit the Target: Data and Metrics

Hit the Target: Data and Metrics Mirle A. Kellett,Jr. MD, FACC, FSCAI Chief, Department of Cardiac Services The Maine Heart Center at Maine Medical Center November 9, 2006 Maine Quality ForumIn A Heartbeat

Data and Metrics Committee Members: Mirle Kellett, MD, FACC (Chair), Maine Medical Center Richard Chandler, MD, Penobscot Bay Medical CenterDarlene Glover, RN, MSN, Stephens Memorial HospitalSusan Horton, RN, MSN, Central Maine Heart & Vascular InstituteDoug Libby, RPh, Maine Health Management CoalitionH. Joel Johnson, RN, CCM, ACS, Central & Western Maine Regional PHOKevin Kendall, MD, FACEP, Central Maine Medical CenterSandra Parker, Esq., Maine Hospital AssociationGuy Raymond, MD, Northern Maine Medical CenterKim Tierney, RN, Maine Medical CenterPeter Ver Lee, MD, FACC, Eastern Maine Medical Center Paul vom Eigen, MD, FACC, Northeast Cardiology Associates Dennis Shubert, MD, Maine Quality Forum Christopher McCarthy, Quality Initiatives Administrator, Maine Quality Forum

Common Treatment Guideline Subcommittee Members: Paul vom Eigen, MD, FACC, Northeast Cardiology Associates Larry Hopperstead, MD, Central Maine Medical Center Mirle Kellett, MD, FACC, Maine Medical Center William Phillips, MD, Central Maine Medical Center Peter Ver Lee, MD, FACC, Eastern Maine Medical Center Dennis Shubert, MD, Maine Quality Forum Christopher McCarthy, Quality Initiatives Administrator, Maine Quality Forum Kim Tierney, RN, Cardiac Database Coordinator, Maine Medical Center

In aHeartbeat Mission • Improve the care, quality of life and survival of Maine patients with AMI • Patients will receive the right care at the right time • Establish a system of care to be used by all providers • Continually monitor sufficient indicators of process and quality to maximize the quality of the process.

In a Heartbeat Process • Data and Metrics committee formed to develop indicators across the spectrum of care • Treatment guideline subcommittee formed to establish a common treatment guideline

Treatment Guideline & Data and Metrics • Common treatment guideline report • Data and Metrics Framework • EMS data processes • ED data and process improvement • Post-discharge data

Common Treatment Guideline Subcommittee Members: Paul vom Eigen, MD, FACC, Northeast Cardiology Associates Larry Hopperstead, MD, Central Maine Medical Center Mirle Kellett, MD, FACC, Maine Medical Center William Phillips, MD, Central Maine Medical Center Peter Ver Lee, MD, FACC, Eastern Maine Medical Center Dennis Shubert, MD, Maine Quality Forum Christopher McCarthy, Quality Initiatives Administrator, Maine Quality Forum Kim Tierney, RN, Cardiac Database Coordinator, Maine Medical Center

Common Treatment Guideline Subcommittee Purpose: To develop a common treatment protocol/pathway that PCI Centers have agreed to use in order to streamline the treatment and transfer process for local hospitals with patients that need to be sent to a heart center.

STEMI CLINICALPATHWAY STE/ LBBB Symptoms < 12hours Presentation to Cath Lab Door <1hr * Or Contraindication to Lytic (See table) YES NO Primary PCI Transfer to PCI Center Goal: Door to Balloon 90” Lytic Goal: Door to Drug< 30” Administer MEDS as indicated: ASA Beta blocker Plavix 300mg Heparin ** TIMI Risk Criteria: Previous MI Anterior Infarct SB/P< 100 HR >100 A-Flutter or Fib Age>75 Killip Class>II Post CPR Contraindications to lytic Any prior intracranial hemorrhage Known structural cerebral vascular lesion (e.g. AVM) Known malignant intracranial neoplasm Ischemic stroke within 3 mos (EXC within 3hours Suspect aortic dissection Active bleeding or bleeding diathesis (EXC) menses Significant closed head trauma Uncontrolled HTN (SB/P>175;DB/P>110) Current use of anticoagulants LOW HIGH Stay / Observe Or Transfer to PCI Transfer to PCI Center *For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policy. **Heparin bolus only for patients within 1 hour transport to PCI Facility – 60un/kg max 4,000unit Patient transport over 1 hour to PCI Facility continue Heparin with 12un/kg drip.

STEMI CLINICAL PATHWAY *For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policies should be developed.

Clinical Equipose CurvePCI Time Delay and Outcome Nallamothu, BK AJC 2003

STEMI CLINICALPATHWAY STE/ LBBB Symptoms < 12hours Presentation to Cath Lab Door <1hr * Or Contraindication to Lytic (See table) YES NO Primary PCI Transfer to PCI Center Goal: Door to Balloon 90” Lytic Goal: Door to Drug< 30” Administer MEDS as indicated: ASA Beta blocker Plavix 300mg Heparin ** TIMI Risk Criteria: Previous MI Anterior Infarct SB/P< 100 HR >100 A-Flutter or Fib Age>75 Killip Class>II Post CPR Contraindications to lytic Any prior intracranial hemorrhage Known structural cerebral vascular lesion (e.g. AVM) Known malignant intracranial neoplasm Ischemic stroke within 3 mos (EXC within 3hours Suspect aortic dissection Active bleeding or bleeding diathesis (EXC) menses Significant closed head trauma Uncontrolled HTN (SB/P>175;DB/P>110) Current use of anticoagulants LOW HIGH Stay / Observe Or Transfer to PCI Transfer to PCI Center *For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policy. **Heparin bolus only for patients within 1 hour transport to PCI Facility – 60un/kg max 4,000unit Patient transport over 1 hour to PCI Facility continue Heparin with 12un/kg drip.

STEMI CLINICAL PATHWAY *For patients in when the onset of symptoms to presentation is > 3hours, timely reperfusion remains the primary treatment goal. The relative benefits of lytic vs primary PCI are dependent on relative treatment delays and institutional specific policies should be developed.

DATA and METRICS • Why are we measuring this data • Who are we measuring it on • What metrics in the process will we measure • How will we define the elements/metrics • Data collection • Data reporting • Ongoing role

In aHeartbeat Mission • Improve the care, quality of life and survival of Maine patients with AMI • Patients will receive the right care at the right time • Establish a system of care to be used by all providers • Continually monitor sufficient indicators of process and quality to maximize the quality of the process.

Data and Metrics WHY There is concern that patients with acute myocardial infarct are not receiving the appropriate care And That there are significant delays in the care they receive

Data and Metrics • Data collection and analysis will: • tell us what percent of these patients are not receiving • reperfusion therapy and why • show where the delay in treatment lies • give feedback on performance throughout the • system of care • give the tools for process improvement of care.

Data and Metrics WHO Patient Cohort for data measures ECG with ST segment elevation (STEMI) or Left bundle branch block (LBBB) and Cardiac Symptoms (same cohort as JACHO/CMS core metrics)

Data and Metrics Patient Inclusion • Patient Eligibility Criteria: STEMI • STE/ LBBB • ST segment elevation with >1mm/.10mV in two or • more leads. • Documentation of ST- segment elevation or left bundle • branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival. • Using the 12-lead ECG performed closest to the time of hospital arrival. • ECGs done more than one hour prior to hospital • arrival should be repeated.

Patient Inclusion for timeliness Symptoms <12 hours Symptom Onset Onset time for patients reporting symptoms initially intermittent and subsequently constant, the onset time is defined as the time of change from intermittent to constant symptoms. Patients reporting symptoms that were initially mild and subsequently changed to severe, the onset time is defined as the time of change in symptom severity. For patients with both, the change in symptom severity is given preeminence in determining symptom onset time. The REACT Trial definition. Am Heart J 138(6):1046-1057 Patients with symptom onset >12hours are included in the general study but excluded from time measures.

Data and Metrics WHAT Metricsin the Process EMS Emergency Department Transport Demographics PCI Center Process Elements Retrospective Discharge Data

Data and Metrics EMS Data and Metrics Jay Bradshaw

Data and Metrics WHAT Metrics in the Process EMS Emergency Department Transport Demographics PCI Center Process Elements Retrospective Discharge Data

Data and Metrics ED Data and Metrics Rebecca Chagrasulis, MD

Data and Metrics PCI Center/Cath Lab Data Balloon Inflation Time (reperfusion) – First documented balloon time or first documented TIMI flow>2 If patient went to CABG (coronary artery bypass grafting) Mortality (death) in the lab

Data and Metrics Documentation • Reasons for delay in any treatment must be documented: • Patient initial refusal in treatment • Religious reasons • Waiting for family to arrive • No urgent need for PCI

Data and Metrics Discharge Data: • JACHO/CMS Core Measures are already collected by hospitals: • ASA on Arrival and Discharge • Beta blocker on arrival and discharge • Ace Inhibitor • Statin • Smoking cessation • Discharge Instructions

Data and Metrics Retrospective Data: • Same extraction that is done for JACHO/CMS at all hospitals: • Collection of STEMI ICD.9 discharge codes • Primary and secondary diagnosis codes (shock and stroke) • Primary and secondary procedure codes (cath, PCI, CABG) • Disposition at discharge (dead or alive)

Data and Metrics Defining the Elements • Limited data points • Current Data Collection processes e.g. Maine EMS InterfacilityTransport Program • JACHO/CMS Core Measures - Same Metrics and Definitions • ACC/AHA Guidelines and definitions • Consensus of State represented committee • Process data / during point of care – incorporated into current documentation

Data and Metrics HOW Data Collection • Maine Quality Forum has assumed the responsibility for contracting for data collection and reporting. • Collection in the process of care across the spectrum providing tools for adapting into current documentation • Core metrics same as JACHO/CMS extraction • Process improvement metrics

Data and Metrics Data Reporting Maine Quality Forum is committed to providing meaningful analysis on this data to provide actionable information back to providers across the spectrum of care. Critical analysis points –a statewide snapshot of performance on key process points and clinical outcomes. Reports on : timeliness, treatment and outcomes

Data and Metrics Data Reporting Maine Quality Forum Critical Analysis Symptom Onset to medical activation Timeliness In median times EMS activation To patient arrival EMS to 1st Hospital arrival Door to Data Data to Drug Door to Drug GOAL: 30 minutes Transfer to Cath Lab Arrival Door to Cath Lab Arrival GOAL: 60 minutes Lab Arrival to reperfusion Door to Balloon GOAL: 90 minutes

Data and Metrics Data Reporting Maine Quality Forum Critical Analysis Treatment Provided Lytic Lytic and PCI Primary PCI Coronary Artery Bypass grafts (CABG) Medical Treatment or Comfort Measures Only

Data and Metrics Data Reporting Maine Quality Forum Critical Analysis APPROPRIATE CARE METRIC # of STEMI patients receiving reperfusion therapy Total # of STEMI patients-#with contraindications TIMELINESS OF CARE METRIC # reperfused patients treated under goal # of reperfused patients - # with clinically appropriate delay

Data and Metrics Ongoing role Continue to measure and report the system outcomes to improve the global and process improvement outcomes Continue to address barriers to improvement of care within hospitals and across the state Continuously update the care process and protocols with new evidence base science in the treatment of AMI

Hit the Target: Data and Metrics