Acute Myocardial Infarction (Heart Attack)

1. Acute Myocardial Infarction(Heart Attack) Committee Membership: B. Majcher, APRN C. Mulhall, APRN M. Cichon, DO, Director of Emergency Department F. Leya MD, Director Cardiac Cath lab/Interventional Cardiology D. Wilber MD, Director C.V. Institute, Chief Cardiology K. McLean, MD, General Cardiologist M. Jarotkiewicz RRT, MS Director of Cardiovascular Service Line Nursing Staff of 3NEWS, 5 Tower, CCU, Emergency Department, Cath lab, Medical Records Department, IT Department and Center for Clinical Effectiveness. “Confidential: Quality Improvement Material”

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 and the Center for Medicare and Medicaid Services (CMS), examine the care of all AMI patients. • The Core Measures are based on guidelines established by the American Heart Association (AHA) and the American College of Cardiology (ACC). “Confidential: Quality Improvement Material”

3. Opportunity for Improvement • Review of Acute Myocardial Infarction (AMI) Core Measures data has shown that Loyola is meeting, or exceeding, the University Health System Consortium (UHC) and national rates for most measures. • However, LUMC median time of AMI patients with time to Percutaneous Coronary Intervention (PCI within 90 minutes) in patients with ST segment elevation (STEMI) or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time, showed a definite need for improvement. “Confidential: Quality Improvement Material”

4. Opportunity for Improvement • This measure was the only AMI Core Measure within the set of measures where performance was less than 90% • Current performance is below 50%. • Currently the median time for PCI at Loyola is 104 minutes. • The goal is to provide PCI within 90 minutes for all patients. • 42% of Medicare patients treated at Loyola between April 2007and March 2008 received treatment within 90 minutes according to federal data. “Confidential: Quality Improvement Material”

5. Solutions Implemented In March 2009, LUMC announced, Heart Attack Rapid Response Team (HARRT), a new evidenced-based approach for the care of STEMI patients: • Operating 24hours a day, seven days a week (24/7) • In house Board Certified Interventionalist and RN/Tech team • Reducing the “door-to-balloon” time As of April 2009, Loyola University Medical Center is the first Chicago-area hospital and the only hospital in the state of Illinois to have Interventional Cardiologist on site at all times (24/7) • Paramedics performing 12 lead EKGs in the field will call ahead on suspected STEMI cases, (This will save about 15 minutes in clinical outcomes decision making for our high risk patient population) “Confidential: Quality Improvement Material”

6. Solutions Implemented • In June 2007 coordinated accuracy of clock times with Emergency Department, Cardiac Catherization Laboratory and Call Connection Center. In addition the first concept of Code STEMI was discussed. • The AMI Core Measures Committee meets monthly to review and to discuss each STEMI/PCI cases individually and the percentage of STEMI patients receiving PCI during hospitalization. • In January 2007 stage 2 triage initiated in the Emergency Department to expedite ECG process • May 2008 - Loyola’s Center for Heart and Vascular Medicine opened with new model of care designed around every detail concerning the patient’s comfort, convenience, clinical care, recovery and outcome “Confidential: Quality Improvement Material”

7. Solutions Implemented • January 2009 met with IT Department representative to generate weekly report of STEMI patients that would allow expediting care in timelier manner. • Developed outlier reports in order to improve understanding and inform each physician about corrections that need to be made in order to prevent delays in patient’s care. • On a daily basis every newly admitted STEMI/LBBB is reviewed by cardiac case manager. This involves looking at the time of arrival, initial ECG, interventional team notification/response, cath lab report, changes in patient’s severity and planned discharge date.“ “Confidential: Quality Improvement Material”

8. Solutions Implemented • On discharge each AMI patient’s chart and discharge summary has been reviewed and assessed by a cardiac case manager. This evaluation ensures that appropriate inclusion or contraindications to PCI is documented. • Physician review is included on all expired patients or when the conclusion is unclear. • Provided feedback to the Emergency Department staff on their performance. “Confidential: Quality Improvement Material”

9. Outcomes • From Quarter 1 2007 through Quarter 1 2008, the observed percentage of STEMI patients receiving PCI within 90 minutes at Loyola has been below the national average rate. • This appears to be due to: • Travel time of a interventional team • Inability of performing initial ECGs in the field • Relatively large number of chest pain patients being treated at Loyola slightly delays the process of diagnosing STEMI and NSTEMI patients • Patients hospital arrival time - 65% of heart attack patients come after hours • Emergency Department bypass status “Confidential: Quality Improvement Material”

10. Next Steps • Utilize, the newly opened 24/7 operating “Chest Pain Center” • Goal to perform emergency angioplasties within 60 minutes of a patient’s arrival (Door-to-balloon time within 60 minutes) • Continue 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. • To continue performing case level review of AMI cases at monthly AMI Core Measures Committee meeting. And evaluate for additional opportunities for improving the care of AMI patients at Loyola • Continue to evaluate coding criteria of AMI patients. “Confidential: Quality Improvement Material”

11. Next Steps, other AMI Measures • Actively work with interventional team and monitor progress of the new model implemented in relation to saving time-saving lives • Continue to monitor that proper documentation of the AMI process in EPIC is followed by the health care providers • To continue providing in-services for physicians r/t AMI core measures improvements • To work closely with health care providers/cath laboratory/ Emergency Department to create a detail/new plan of care in order to improve PCI time “Confidential: Quality Improvement Material”

12. Definition: Number of AMI patients receiving 100% of indicated care / all AMI patients • Data Source: Original data extracted from LUMC charts by RNs. • Analysis: 91% of LUMC patients with AMI receive all indicated care. • “Confidential: Quality Improvement Material”

13. Definition: Percent of AMI patients with time to PCI under 120 minutes in patients with ST segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time. Patients transferred from another hospital are excluded. Patients with PCI time greater than 24 hours are excluded. Beginning with July 2006, this measure decreased the acceptable timeframe from 120 minutes to 90 minutes. Data source: LUMC medical records abstracted by RNs. Analysis: 48% of LUMC patients receive emergent PCI within 90 minutes. Each emergent PCI case is being actively studied by the PCI Committee. “Confidential: Quality Improvement Material”